Birmingham 20 September 2013

ADCS paper

Care Inquiry report

Nice Collaborating Centre for Social Care

Care options for young peopleevidence to inform commissioning 2013

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Care Inquiry 2013In responding to the needs of all children in care, we must find:

•ways of identifying those children who can go home, and enabling them to do so safely

•ways of increasing the use of kinship care, and providing the right support

•ways of increasing the use of adoption and other legal routes to permanence, and providing the right support

•ways of recognising when long-term foster care can, and is, offering a permanent placement for a child

•ways of ensuring that all these placements are of high quality and likely to last, and ways of ensuring that the benefits of an option for a particular child will endure beyond childhood.

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making not breaking

A ‘fresh’ more flexible response is needed Permanence: ‘security, stability, love and a

strong sense of identity and belonging’ Kinship care needs… should be seen as equal to

adoption in its ability to provide attachment, continuity and identity… its use should be expanded

Long term foster placements also provide a possibility for permanence – ‘foster parenting’ rather than ‘caring’

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making not breaking

Specialist residential settings: this type of provision should be able to demonstrate that there is sound evidence underpinning their practice; that staff are trained, supervised and supported well; and that expert help and advice is available for staff and for the children in their care

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I tend to assign Sundays to be my cleaning day. I got this routine by living in the young people’s home. I took it with me when I left. Having routine gives me a sense of control. That’s something which I feel should be encouraged in young people’s lives.

20-year-old (Days after leaving care)

Children and young people’s views having a perceived choice about their future is

very important (Schofield et al, 2012)

if children do not want to be in a placement then it is unlikely it will be successful (Sinclair, 2005, Selwyn, 2010)

48% of the children and young people interviewed in a recent NSPCC study (2012) about reunification said that they were not consulted at all about returning home and 73% reported they were not ready to return home

International perspectives

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adoption will only ever be the answer for a small number of adolescents

4,600 children on the adoption waiting list 3% of those adopted aged 10-15 (adoption.org)

no children over 9 were referred to adoption register 2011/12

age at entry to out of home care (Thoburn 2009)

placements: international evidence (Thoburn 2009)

alternative models of provision: a continuum of care: examples

Weekday residential settings (Germany)

Respite through self referral (Denmark)

Open access emergency accommodation for runaways

Social Pedagogy in residential care

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Home or care: making the right decisions

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reunification 10000 a year (3050 adoptions) 67% of maltreated children who return home

subsequently readmitted (NSPCC 2012)

growing evidence that maltreated children who remain looked after do better (Wade et al 2010)

where there is strong evidence of serious emotional abuse or past neglect, these children did best in care

most returns = poorest outcomes

Children were less likely to have gone home where

Had experienced neglect

Had a learning disability

Did not want to go home

Birth parent contact was infrequent

Where parental problems at admission were still subject of ‘serious concern’

Most important predictors of return

Risk to child safety assessed as acceptable

Problems that had led to admission considered improved

For older children, wanting to return had some effect

making the right decisions (Wade et al, 2011)

Variation in LA practice was a bigger factor in determining whether a child was returned home than the needs of the child

(Wade et al 2011)

what helps reunions to last?

These factors had continuing resonance for stability at final follow-up, on average 4 years after decision

In addition, stability at 4 years less likely where:

•Serious concerns existed at 6 months

•Children had gone home on a care order

•Parents had continuing problems with substance misuse

•In cases of emotional abuse and neglect

Wade et al (2011)

Reunions more likely to be lasting at 6 months where:

Children had gone home slowly, over longer period of time

Planning for reunion had been purposeful and inclusive

Problems that had led to child’s admission had reduced

More social work support had been provided to the family

Parents had accessed more services to help them with their problems

Children are younger

Wade et al (2011)

Parents who overcame difficulties all did so before child was 6 months old (Ward et al 2010)

care may be the best option Outcomes (stability and well-being) for Wade’s ‘care group’

(maltreated children who remained looked after) were better than for those who went home

Most had settled well, had good relationships, were doing quite well at school and not getting into great difficulty

Many felt safer, were relieved to be away from dangerous homes and well cared for (others more ambivalent)

well-being levels were higher that those who had remained continuously at home

Problems early in reunion predicted poor well-being at follow-up

Those who had experienced one or more breakdowns at home fared worst of all

Where there is strong evidence of serious emotional abuse or past neglect, these children did best if they remained in care

(Wade et al 2011)

Home or care: decision making

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Decision makingtaking the final decision about whether a child should return home

Quality of the assessment can be improved in three ways:

Historical understanding of cases

Validated assessment tools need to be embedded into practice Structured Professional Judgement

Supervision should focus on improving the evidence used in assessments and enabling learning(nspcc 2012: 10)

RiP resources and NSPCC Project Unaided clinical judgment in relation to the assessment of risk of harm, is now widely recognised to be flawedBarlow 2012

Decision making (Brown and Ward, 2012)

At identification

Severe risk: Risk factors, no protective factors and no capacity for change

High risk: Risk factors, protective factors and no capacity for change.

Medium risk: Risk factors, protective factors, capacity for change.

Low risk: No risk factors (or previous risk factors addressed, protective factors and capacity for change. Includes two outliers

Age 3

Permanently separated from parents: two unsatisfactory placements, others showing signs of strain

Medium, high and severe risk: living at home, on-going concerns

Low risk: living at home, no on-going concerns

Almost all decisions were temporary – on average it took 14months for a definitive decision resulting in a viable permanence plan (6months more for this to be completed. Longer for adoption).

Classifying families at risk of harm (Brown and Ward, 2012)

Severe risk: Risk factors apparent and not being addressed, no protective factors apparent

Parents UNABLE to demonstrate sustained capacity for change; ambivalence or opposition to return by child or parent

High risk: Risk factors apparent and not being addressed. At least one protective factor

Parents UNABLE to demonstrate sustained capacity for change; ambivalence or opposition to return by child or parent

Medium risk: Risk factors apparent and not all being addressed. At least one protective factor

Parents ABLE to demonstrate sustained capacity for actual change. Parents and child both want return home to take place

Low risk: No risk factors apparent or previous risk factors fully addressed, protective factors apparent

Parents ABLE to demonstrate sustained capacity for actual change. Parents and child both want return home to take place

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Kinship care needs… should be seen as equal to adoption in its ability to provide attachment, continuity and identity… its use should be expanded

Kinship care

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Kinship care 173,200 children living in kinship care although 90 per

cent not technically ‘looked after children’ (Selwyn and Nandy, 2012)

no system of registration for these children

kinshsip care can enhance sense of belonging: pre-existing relationships and high level of commitment of kinship carers (Farmer, 2010) and stability (Cuddeback, 2004)

carers under much pressure – poverty, no or little financial or other support from children’s social services especially around contact with birth parents

risk that use of SGOs divert children from welfare system and support?

Kinship care: strengthening stability

recognise high rates of poverty and lack of support

Commission for family support for kinship carers

improve advice to informal kinship carers on benefits and contact with birth parents

some children experience stability but also stigma and isolation

ensure SGOs do not further penalise kinship carers

adolescent graduates and entrants (Stein 2007) different issues – different approaches (p14-15).

But underlying issues may be very similar

child protection/family breakdown

stability all need consistency and stability

all types of placement are challenged by adolescent developmental factors

however - 54% of moves are initiated due to delayed and precipitate entry or over-optimistic expectations of swift reunification (not relationship breakdown with carers) (Ward 2009)

3+ placements in a year down from 13% in 2007 to 11% in 2009-2010. 2012 still 11%

movement is avoidable and supporting stability is cost effective

stability age: Farmer and Lutman’s ‘unstable group’ were

the oldest (mean 11.5 years)

proactive case management: ‘unstable group’ characterised by passive case management

changes at home: if the child was returned to a changed household odds of stability increased by a factor of nearly 3.5

local authority performance: those not in the poorest performing LA were 10 times more likely to be in stable placement (Farmer and Lutman 2010)

evidence-based interventions

implementation issues – Wiggins et al checklist

need for robust evaluation in English settings

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long term foster ‘parenting’

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long-term foster care 75% of looked after children are cared for in a

foster placement (DfE, 2012)

stable long-term foster care can have very similar outcomes to stable adoption (Biehal et al, 2010)

offers a route to permanency for those who want to maintain a strong sense of identity and contact with their birth families (Ward et al, 2004)

problems associated with long-term foster care

may not ‘feel’ very permanent – always possibility of legal challenge or change of care order

Special Guardianship Orders (SGOs) introduced 2005 to enhance stability but reduction of financial and other supports is major concern for many foster carers and deterrent to their take-up (Schofield and Ward, 2008)

Some local authorities provide financial support with SGOs but this appears to be rare and is currently discretionary (Wade, 2011)

Children often have highly complex needs but despite this, lack of mental health and therapeutic services (Selwyn et al, 2006)

Leaves young people vulnerable at the time of transition to adulthood

strengthening stability in long-term foster care

reduce unplanned placement moves through: reduction in the use of emergency placements improving decision making concerning reunification more recognition and support for the complex needs

of children increasing the pool of foster carers to avoid over-

stretching existing carers

NICE Collaborating Centre for Social Care

The new role of NICE

From April 2013 developing guidance and quality standards for social care in England

Topics referred by the DoH and DfE

apply an evidence-based system to decision-making in social care, similar to that provided for the NHS

guidelines and standards, based on best evidence ensuring quality and value for money for those responsible for commissioning and professionals

promote better integration between health, public health and social care services

Planned topics Health and Well-being of Looked After Children

and Young People (Publ. April 2013)

Transition between children’s and adults’ services (Publ. March 2016)

Abuse and neglect of children and young people (Publ. May 2016)

How does it fit in the sector? Not mandatory - aspirational and examples of best

practice

NICE is in discussion with OFSTED about how social care quality standards might inform and support the inspection of children’s social care services

Stakeholder consultation for each guideline

Involvement during guidance development groups: invitation for expert evidence

commissioning a continuum of services

permanence as the focus

be informed by children and young people

Local needs analysis

from:

care as last resort

emergency placement

repeated returns home

towards:

planning for stability and wellbeing

Support to overcome consequences of earlier experiences - building therapeutic alliances

support to 18+

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planning

support packages

therapeutic alliances

evidence-based models

step down from intensive support

transitions

Counting what counts Beyond existing data collection, what else

would you want to know to understand whether you are achieving improved stability/permanence?

Where might savings be made/costs avoided if placement stability / permanence was improved?

research in practice resources Evidence Matters in Family Justice (Erlen

and Lewis 2012)

Engaging resistant, challenging and complex families (2012)

Analysis and critical thinking in assessment (Brown et al 2012)

Children experiencing domestic violence (Stanley 2011)

Safeguarding in the 21st century (Barlow and Scott 2010)

Parental Mental Health Problems: research review (Tunnard 2004).

Signposts

Frontline briefings

Parental substance misuse (forthcoming 2013)

West Midlands Research in Practice Partners Birmingham

Coventry

Dudley

Herefordshire

Sandwell

Solihull

Staffordshire

Stoke-on-Trent

Telford & Wrekin

Walsall

Wolverhampton

Worcestershire

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