Mapping mental health services for looked after children in London aged 0-5 years

June 2016

Jo Moriarty, William Baginsky, Sarah Gorin, Mary Baginsky and Jill Manthorpe

About the Policy Institute at King’s

The Policy Institute at King’s College London acts as a hub, linking insightful research with rapid, relevant policy analysis to stimulate debate, inform and shape policy agendas. Building on King’s central London location at the heart of the global policy conversation, our vision is to enable the translation of academic research into policy and practice by facilitating engagement between academic, business and policy communities around current and future policy needs, both in the UK and globally. We combine the academic excellence of King’s with the connectedness of a think tank and the professionalism of a consultancy.

About the Social Care Workforce Research UnitThe Social Care Workforce Research Unit (SCWRU) at King’s College London is funded by the Department of Health Policy Research Programme and a range of other funders to undertake research on adult social care and its interfaces with housing and health sectors and complex challenges facing contemporary societies.

Acknowledgements and disclaimerWe thank the NSPCC for funding this research and for the advice and support received from Jessica Cundy, Richard Cotmore, Matt Forde and Lucy Morton. We are very grateful to the people who gave up their time to be interviewed and to provide information. The Social Care Workforce Research Unit receives funding from the Department of Health Policy Research Programme. The views expressed in this report are those of the authors and not the Department of Health nor the NSPCC.

Scope of the report 4

Policy background ........................................................................................................ 4

Study aims .................................................................................................................... 4

Background 6

Mental health of looked after children ......................................................................... 6

Mental health of children aged under five years old .................................................... 6

Mental health of looked after children aged under five years old ............................... 6

Interventions to improve the mental health of looked after children under five years old .................................................................................................................................

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Access to child and adolescent mental health services (CAMHS) .............................. 8

Looked after children in London ................................................................................. 4

Findings 9

Commissioning and funding......................................................................................... 9

CAMHS services .......................................................................................................... 10

Better identification of looked after children under five years old with mental health difficulties ......................................................................................................................

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Mental health services for looked after children aged under five years old ................ 12

Perinatal and infant mental health services ................................................................. 13

Help for birth parents and foster carers ....................................................................... 13

Out of borough placements .......................................................................................... 14

Discussion 15

Appendix: methods ...................................................................................................... 16

References..................................................................................................................... 18

Contents

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Scope of this report

There are rising levels of concern about the mental health of children and young people in general (Frith 2016) and that of looked after children in particular (Bazalgette et al. 2015). Experiencing abuse and neglect heightens the risk that children will develop mental health difficulties (Johnson et al. 2002, Éthier et al. 2004) but there is growing consensus that early intervention can minimise these damaging effects and improve outcomes for children’s social and emotional development.

Policy backgroundThe government has made it clear that it supports the early identification of mental health problems in looked after children and the provision of appropriate treatment. Joint Department for Education and Department of Health (2015) statutory guidance for local authorities, clinical commissioning groups and NHS England on promoting the health and wellbeing of looked after children states that the:

‘… corporate parenting responsibilities of local authorities … include having a duty … to safeguard and promote the welfare of the children they look after … [This] includes the promotion of the child’s physical, emotional and mental health and acting on any early signs of health issues.’

(Department for Education/Department for Health 2015: 6)

The government also intends to reduce what it sees as unsatisfactory delays in the adoption system:

‘Where birth parents cannot meet a child’s basic needs it is one of the state’s most important responsibilities to step in and ensure that children can have a childhood which keeps them safe and enables them to flourish.’

(Department for Education 2016a: 5)

At the same time, the House of Commons Education Committee (2016) has expressed concern about the variability in looked after children’s access to mental health services and the degree to which services are properly co-ordinated. It has also criticised the lack of recent, reliable data on the frequency of mental health problems among looked after children and called for better assessments of their mental health needs to become a priority.

Study aimsThe NSPCC commissioned the Social Care Workforce Research Unit to undertake a short mapping exercise to find out more about mental health services in London for children under the age of five who are looked after1 by their local authority as a result of maltreatment. The NSPCC itself has been working with health and social work partners to establish pilot schemes in Glasgow (Minnis et al. 2010, Pritchett et al. 2013) and Croydon (Baginsky et al. 2016 forthcoming) to test the effectiveness of the New Orleans Intervention Model (NIM). This is the name given to a service approach that provides an intensive mental health intervention for children in foster care aged 0 to 5 which informs recommendations to the court about permanent return to birth families or adoption (NSPCC 2016).

Our aim was to help the NSPCC consider where the New Orleans Intervention Model fitted within the wider health and social care system in terms of budgets, commissioning structures, and service provision. As well as highlighting gaps in provision for young looked after children in care, birth

1 InEnglandandWalestheterm‘lookedafterchildren’isdefinedinlawundertheChildrenAct1989.Achildislookedafterbyalocalauthorityifheorsheisintheircareorisprovidedwithaccommodationformorethan24hoursbytheauthority.Lookedafterchildrenfallintofourmaingroups:childrenwhoareaccommodatedundervoluntaryagreementwiththeirparents;childrenwhoarethesubjectofacareorderorinterimcareorder;childrenwhoarethesubjectofemergencyordersfortheirprotection;andchildrenwhoarecompulsorilyaccommodated(RoyalCollegeofGeneralPractitioners/RoyalCollegeofNursing/RoyalCollegeofPaediatricsandChildHealth2015).

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parents and foster carers, it was hoped that the mapping exercise could identify other promising practice examples of services intended to help looked after children under the age of five.

Mapping what is happening ‘on the ground’ is one way of helping to reduce the ‘implementation gaps’ that can arise between the development of new approaches and their wider adoption. They exist for a number of reasons, including the length of time and amount of resources needed to demonstrate effectiveness, different funding streams — especially where funding is insecure and temporary — that lead to the closure of a service or programme before it has been fully evaluated, and a sense of exceptionalism that hampers effective interventions developed in one setting or location from being implemented in another. It provides an updateable overview of local developments within a comparatively short space of time. The results can be standalone or used to help plan future research proposals.

The report is divided into three parts. The background section outlines what is known about the mental health of looked after children aged under five years old in the context of information on the mental health of children and young people and looked after children aged 0-16 years. The findings section presents the results from the mapping exercise. It ends with a preliminary discussion that reflects the exploratory nature of the findings.

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Background

Mental health of looked after childrenResearch carried out in the UK and internationally shows that the mental health of looked after children is considerably poorer than that of their peers in the general population (Ford et al. 2007, Luke et al. 2014). Secondary analysis of data from four nationally representative surveys undertaken by the Office for National Statistics (ONS) in Great Britain (Meltzer et al. 2000), England (Meltzer et al. 2003a), Scotland (Meltzer et al. 2003b) and Wales (Meltzer et al. 2004) suggested that around 45 per cent of looked after children aged 5-16 years had emotional or behavioural difficulties that were serious enough to be defined as a ‘mental disorder’.2 By comparison, results from another ONS survey using almost identical questions found that around 10 per cent of children in the general population experienced these difficulties (Green et al. 2005).

Since then, a series of studies has found similarly high levels of mental health problems among looked after children (Stanley et al. 2005, Sempik et al. 2008, Goodman and Goodman 2012, Ratnayake et al. 2014, Bazalgette et al. 2015). It is thought that these raised prevalence rates stem from the complex inter-relationship between the adverse circumstances that led to these children becoming looked after in the first place and the experience of being looked after itself (Stanley et al. 2005, McAuley and Davis 2009, Golding 2010, Luke et al. 2014, Bazalgette et al. 2015).

Mental health of children aged under five years oldDespite increasing recognition of the importance of the early years as a focus for early intervention, there has been very little research into the profile and rates of mental health problems in children

2 Thereportusedtheterm‘mentaldisorder’,asdefinedbytheICD-10[InternationalStatisticalClassificationofDiseasesandRelatedHealthProblems]toimplyaclinicallyrecognisablesetofsymptomsorbehaviourassociatedinmostcaseswithconsiderabledistressandsubstantialinterferencewithpersonalfunctions(MentalHealthFoundation2015:9).

aged under five (Murphy and Fonagy 2013), even though many emotional and behavioural difficulties experienced by children aged 5-16 years have become apparent much earlier (Carter et al. 2004, Wichstrøm et al. 2012). This is partly attributable to the reluctance to label very young children (especially when a problem may be temporary) and partly because standardised screening and assessment tools validated for use with very young children are a comparatively recent development (Carter et al. 2004, Murphy and Fonagy 2013, Luke et al. 2014).

The few published studies that have attempted to diagnose the frequency of mental health difficulties in children under five years old in the general population – none of which were undertaken in the UK - have reported varying prevalence rates. These range from 16-24 per cent of children under five years old in the United States (Earls 1982, Lavigne et al. 1996, Keenan et al. 1997, Lavigne et al. 1998, Egger and Angold 2006) to seven per cent in Norway (Wichstrøm et al. 2012).

In practice settings, the level of observational skill needed to identify signs of emotional difficulties and trauma in very young children, especially if they are not seen as behaviourally difficult, has also been highlighted (Wakelyn 2011).

Mental health of looked after children aged under five years oldUp to date UK data on the mental health of looked after children under the age of five years is similarly lacking. Sempik (2010) reported that three local studies undertaken in England (Sempik et al. 2008), Scotland (Minnis and Del Priori 2001), and Northern Ireland (Monteith and Cousins 2003) suggested that around one in five looked after children aged 0-5 years showed signs of emotional and behavioural difficulties. On the basis that, at the time he was writing, there were 12,000 looked after children under the age of five years old, he

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estimated that as many as 3,000 of these could have mental health difficulties that affected their lives and those of their carers. There are currently 13,830 looked after children aged 0-4 years (Department for Education 2016b). Assuming these estimates were broadly correct and rates have remained unchanged, this could mean that 3,458 looked after children aged under five years old experience mental health difficulties.

Interventions to improve the mental health of looked after children under five years oldThe consequences of developing mental health problems early in life are serious, with almost half of mental health problems experienced by all adults (not just those who have been looked after) pre-dating back to their time as a child (Murphy and Fonagy 2013). While some children and young people recover from mental health difficulties; others do not. Another group develop problems as they reach adolescence (Parry-Langdon 2008). Care leavers appear to be at particular risk of experiencing mental health difficulties compared with other young people (Lamont et al. 2009).Overall, 70 per cent of children and young people who experience mental health problems consider that they have not had appropriate interventions at a sufficiently early age (Children’s Society 2008, cited in Mental Health Foundation 2015).

Interventions aimed at improving the mental health and wellbeing of looked after children have attracted considerable policy and political interest (Luke et al. 2014, House of Commons Education Committee 2016). However, the vast majority of these appear to have been tested with older rather than younger looked after children (for example, McDaniel et al. 2011) or with children aged under five but who are not necessarily looked after (Holmes et al. 2015).

Access to child and adolescent mental health services (CAMHS)The involvement of child and adolescent mental health services (CAMHS) in the mental health of looked after children aged under five years old has been patchy. Most referrals accepted by CAMHs are for older children and young people, with a focus on those causing concern with serious self-harm (Hinrichs et al. 2012) or presenting with symptoms of psychosis (Cratsley et al. 2008).

Increased demand for services has led to many CAMHS teams raising their ‘thresholds’ for accepting referrals. This makes it less likely that support will be provided at an early stage and may mean that serious indicators of distress and trauma in very young children may not be picked up, or if they are, do not trigger an immediate response. Even when children aged under five years old do get access to treatment, they may wait a long time. Average waiting times for non-urgent referrals for all children and young people can be as long as 26 weeks while urgent referrals wait around four weeks to be seen (Frith 2016).

Traditionally, CAMHS services tended to regard child abuse and neglect as a social problem, requiring a social care solution (Shaw and De Jong 2012). The expansion of therapeutic posts and services for looked after and adopted children, often through joint commissioning and organisational arrangements, created a better climate for joint working between services but many such initiatives are believed to be under threat in the current socio-economic climate (Ratnayake et al. 2014).

Research has suggested that looked after children have particular problems accessing CAMHS. Some services want children to be living in stable placements before they can work with them but this may not be possible for some looked after children. Children placed ‘out of area’ of the local authority in which they live seem to at an even greater disadvantage. Moves out of area can lead to looked after children being placed on the bottom of waiting lists in their new placement, irrespective of how far up a list they have previously moved in their home authority. In addition, referrals can be lost or delayed and case notes not transferred with children in a timely manner (McAuley and Davis 2009, Golding 2010).

Local annual expenditure on CAMHS services varies considerably. When funding from all sources (clinical commissioning groups, local authorities, and NHS England) is combined, the average expenditure in London per child aged 0-17 years is £85. This is slightly more than the average per England of £78 but is less than the £103 spent in the north of England (NHS England 2016). These figures are based upon the number of children aged 0-17 years in the population and not on the prevalence of mental health problems locally.

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Looked after children in LondonDepartment for Education figures show that at the end of March 2015, there were 10,000 looked after children in London. Of these, 410 were under the age of one year while 950 were aged between one and four years. In contrast with the rest of England, where there has been a rise in the number of looked after children over and above increases in the number of 0-18 year olds in the population as a whole (Department for Education 2016b), the trend in London has been downwards – despite recent increases in the number of unaccompanied children seeking asylum which disproportionately affects boroughs such as Hillingdon and Croydon (Wilding and Dembour 2015). Senior managers in Children’s Services attribute this to greater efforts to reduce ‘drift’ in terms of permanency decisions and the active encouragement of alternatives, such as kinship care (Chamberlain and Ward 2013). Despite this, the number of looked after children still varies considerably by borough mainly because of the extreme variation in levels of deprivation, population size, and fertility patterns.

While there has been a downward trend in the number of looked after children, London boroughs are still more likely to use out of area placements than other regions. A study of out of borough placements identified that this could reflect shortages of foster carers and of residential homes (particularly if the borough had a policy of only placing looked after children in children’s homes with good or outstanding Ofsted ratings) or to achieve a specific purpose, such as placing a child with a kinship carer living in another borough or to match a looked after child with a foster carer of the same ethnicity. It also found that while access to universal health services was generally good in out of area placements, obtaining support from CAMHS services was more problematic (Brodie et al. 2014).

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Findings

Commissioning and fundingThe Children and Young People’s Mental Health Taskforce was set up by the government to consider the way that children’s mental health services were organised, commissioned and provided could be improved. Its Future in Mind report recommended that every local area should develop a local five-year Transformation Plan:

… cover[ing] the whole spectrum of services forchildren and young people’s mental health and wellbeing from health promotion and prevention work, to support and interventions for children and young people who have existing or emerging mental health problems, as well as transitions between services.

(NHS England 2015: para 9.8)

It assumed that local clinical commissioning groups would draw up these plans, ‘working closely with Health and Wellbeing Board partners, including local authorities, to ensure that services were jointly commissioned in a way that promoted effective joint working and established clear pathways’ (para 9.9).

Camden Multi Agency Liaison Team (MALT)

Camden MALT is a health led team that is jointly managed by health and social care. It is made up of social workers, psychologists, child and adolescent psychotherapists, family therapy and child and adolescent psychiatrists. It works closely with family services and social workers to support families facing complex problems that are affecting their children’s emotional wellbeing and development. The team provides consultation, assessments, and brief therapeutic interventions and will refer on to appropriate services.

Unlike many parts of England, clinical commissioning groups and London boroughs are, with two small exceptions,3 coterminous. This brings advantages in terms of planning and commissioning services. Almost every clinical commissioning group appeared to have drawn up a transformation plan in conjunction with local partners and many informants pointed out that the way mental services for looked after children under five would develop in the future was dependent on the extent to which their needs had been identified in the local transformation plan. There seemed to be variation in the extent to which these plans addressed the needs of looked after children and children under the age of five, with some making specific reference to their needs while others focused more on support for older children and young people.

Informants also offered examples where services for looked after children were jointly commissioned or worked in services that were jointly commissioned and managed, such as the Camden Multi Agency Liaison Team (MALT) (Camden Council Undated).

Perhaps because so many informants were employed in clinical roles, it proved difficult to obtain information on overall funding levels for services for looked after children under five in each locality. The extent to which services had been affected by cuts in expenditure appeared to be variable. One person described the service in her area as ‘hugely under-resourced’. Some looked after children teams in children’s social care departments had been merged into social work teams for all children. In another instance, a large multidisciplinary looked after children team had been reduced to three team members, including the loss of a family therapist post. While some new

3 CityofLondonandHackneyarejointlycoveredbyHackneyCCG.WestLondonCCGcoversalloftheRoyalBoroughofKensingtonandChelseaandasmallpartofWestminster.TheremainderofWestminsterisinCentralLondonCCG.

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sources of funding, such as the Adoption Support Fund (ASF) could be used to help long term mental health outcomes for previously looked after children, these had not necessarily made up for cutbacks across services as a whole.

As well as the impact of more recent funding cuts, some differences in funding for services for looked after children seemed to reflect historical patterns of spending. While referring to a ‘bleak environment’ of cuts, one informant with experience of working across different boroughs also noted that services for looked after children had always been better resourced in some boroughs than others.

It’s worth noting that, many informants were employed in the NHS where funding has been protected in terms of inflation (although not enough to cover the growth in demand for services as a whole). It is possible that a more negative picture of funding might have emerged had we been able to talk to more people in children’s social care and voluntary organisations.

CAMHS servicesCAMHS services have historically been conceptualised as a 4-tier model (House of Commons Health Committee 2014: 19), as shown below. Some CAMHS teams were based in the NHS while others were located in children’s social care departments. On the whole, CAMHS teams

based in social care were generally described as being Tier 2 services.

One informant was particularly critical of the CAMHS tier model, arguing that it tried to fit children into boxes, rather than adapt the service around the child’s needs. This viewpoint is in keeping with a report from the former Children’s Commissioner (Atkinson and Owen 2015). The Tavistock and Portman NHS Trust and the Anna Freud centre were also reported to be working on developing a new model for CAMHS (Wolpert et al. 2015).

In keeping with the wider trend towards jointly commissioned and/or jointly managed health and social care services, several CAMHS services were jointly funded and/or managed. This was generally thought to promote early intervention for looked after children with mental health problems and reduce delays in assessment times. An alternative approach to encouraging joint working was co-location, with one team funded and managed by the NHS based in the same building as children’s social care. In Waltham Forest, the local authority commissioned a dedicated CAMHS ‘fast track’ service for looked after children so that referrals of looked after children could be dealt with as quickly as possible (Waltham Forest Clinical Commissioning Group Undated). However, more difficult relationships were reported in another separately funded service with referrals going from one team to another for long periods before

Figure 1:ModelforCAMHSservices

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agreement could be reached on which team would accept them.

While there were several examples of CAMHS services with a dedicated looked after children team and some examples of teams for children under five, it did not seem as if any borough had established a CAMHS team that only worked with looked after children under five. By contrast, in a trend that mirrored some looked after teams based in children’s social care, several CAMHS looked after children teams were reported to have been disbanded in order to achieve savings and their workers had been redeployed into other parts of the service.

As mentioned earlier, without better prevalence data, it is difficult for commissioners to predict how many looked after children under five years old might need CAMHS services. One CAMHS worker specialising in support for children under five years in an outer London borough said that she had only had one looked after child on her caseload during the previous year. By contrast, another informant from a looked after children’s team in a much larger outer London borough reported that there were ‘at least’ 10 looked after children under the age of five years on its books.

On the whole, most informants estimated that few looked after children under the age of five were accessing CAMHS services. Hardly anyone suggested that it was too complex, or undesirable in terms of labelling, to diagnose mental health problems in children in this age group. Instead, there was broad agreement that looked after children under five would not be referred to CAMHS unless they were ‘presenting with mental health difficulties’ or ‘showing signs of distress.’

Islington Community CAMHS

Islington Community CAMHS works with colleagues in children’s social care, children’s centres, primary and secondary schools to train and support them in the identification of children with mental health problems. The service for children aged under five has a CAMHS worker in all 16 Children’s Centres for half a day a week. They offer early identification and intervention with parents/carers of children aged 0-5 years.

As one informant pointed out, in practice this meant that very young children experiencing trauma or depression but not presenting with behavioural problems would be very unlikely to meet the referral criteria.

Exceptionally, an informant working for a CAMHS service in an inner London borough explained that the local clinical commissioning group had made it clear that it wanted ‘referrals accepted regardless of distance [meaning that looked after children living out of borough could continue to be treated] and thresholds’. More typically, informants reported long waiting lists and high thresholds to access Tier 3 (and sometimes Tier 2) services. There seemed to be considerable variation in waiting times between areas, with one informant reporting that waiting times for an appointment with CAMHS were around four weeks while another spoke of waiting times as long as a year. Another said that while looked after children under the age of five years in her area could access Tier 1 services (such as parenting support or play therapy) within a few weeks of being referred, these might be insufficient for their needs.

Other CAMHS services were reported to operate age limits, not accepting referrals of children under the ages of seven or eight years. In one area, children under the age of five years presenting with emotional or behavioural difficulties were reported to be seen by paediatric services rather than be referred to CAMHS.

While the description that CAMHS services were engaging in ‘responsive rather than preventative’ work seemed to apply to many services, there were examples such as the Islington Community CAMHS team (Whittington Health 2002-2016a) where CAMHS services were adopting a more proactive approach. In this instance, the service is for all children under the age of five years old, not just those who are looked after.

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Better identification of looked after children under five years old with mental health difficultiesResearch (Sempik et al. 2008, Jee et al. 2010) has suggested that the identification of mental health difficulties in looked after children under five years can improve with the used of standardised screening measures. Since April 2008, all local authorities in England have been required to provide information on the emotional and behavioural health of children and young people in their care through Strengths and Difficulties Questionnaire (SDQ) (Goodman et al. 2000, Goodman and Goodman 2012). Informants saw this as a largely positive development, although delays in completing forms could sometimes happen. In Haringey, the First Step service (Tavistock and Portman NHS Foundation Trust 2016) service uses the SDQ to screen looked after children when they come into care and then annually. There has been a large increase in the number of referrals to the team but it remains small with only 2.2 full time equivalent staff.

Two informants highlighted the need for better training for social workers, social care workers and foster carers in recognising the early signs of mental health difficulties and problems in attachment among very young children. One was of the opinion that this helped to contribute to the relatively low numbers of children under the age of five using CAMHS services. She also pointed out the negative effects of frequent staff turnover in establishing where children were experiencing mental health difficulties.

Debates about social workers’ knowledge about child development have been longstanding (for example, Brandon et al. 2011, Munro 2011) and are contested. What is certain is that much of this discussion has focused on qualifying education without enough consideration of the role of continuing professional development (Moriarty and Manthorpe 2014). One informant explained that they were using the Reclaiming Social Work model (Forrester et al. 2013) where a therapist is part of the social work team to help improve social workers’ knowledge in this area. Several more referred to advice sessions run by psychologists at which social workers would discuss children on their caseload. In one borough, all the workers in

First Step

First Step has been commissioned by Haringey Children’s Social Care to provide a psychological health screening for looked-after children and young people in Haringey. Where needed, children are offered up an extended assessment of up to six sessions. The service has also developed an intervention for foster carers called Watch Me Play, which is intended to help foster carers in developing child led play. The service also provides a family rehabilitation service to help children and their families when they are going back home to live with their birth parents after a period of time in care.

children’s centres had been trained in the Five to Thrive programme (Kate Cairns Associates (KCA) Undated) to help them recognise signs of attachment difficulties in the children they saw.

Mental health services for looked after children aged under five years oldThe only three specialist mental health services that we identified specifically providing services for looked after children under the age of five were the London Infant and Family Team (LIFT) in Croydon (Baginsky et al. 2016 forthcoming), SUSI in Southwark (Hardy et al. 2015, ClinicalTrials.Gov 2016) and a pilot scheme in Waltham Forest.This last example has been running for almost a year to assess the mental health of all looked after children under the age of five years old. It is a dedicated service with a clinical psychologist who provides a full report on the child’s mental health on the basis of observations and assessments undertaken at the first Review Health Assessment when the child becomes looked after.

There were other mental health services for children aged under five years, such as Growing Together in Islington for parents experiencing mild to moderate anxiety, stress, depression or relationship difficulties which are impacting on their parenting but this service is not restricted to looked after children.

In the same way, the Croydon and Enfield Parent Infant Partnerships (PIP) are part of the wider PIP UK partnership (Parent Infant Partnership UK Undated). There provide services in local communities to babies

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SUSI

SUSI (Social-emotional Under 4’s Screening & Intervention) is a follow on study from a pilot study developed in response to concerns in Southwark about the difficulty of identifying neglect and engaging very isolated and marginalised families who usually only came to services when the family was at the point of breakdown and the children were presenting with significant behavioural, emotional and mental health problems. The current study has targeted children new into care; children of parents who are open to the Southwark Parental Mental Health team; and children who are the subject of child protection plans.

who are struggling to develop a secure attachment relationship with their primary caregiver (generally the mother), and to provide a range of therapeutic interventions that can promote positive interactions within the infant-parent relationship. An evaluation of this approach is currently being undertaken by Northumbria University.

A range of services are also provided at the Anna Freud Centre. These include the Parent Infant Project (Anna Freud Centre Undated-c), which offers a range of psychotherapeutic interventions for parents and their babies, and an early years parenting unit for parents with personality difficulties whose children are on the ‘edge of care’ (Anna Freud Centre Undated-a). They were also reported to be working on an adaptation of the New Beginnings Programme (Baradon et al. 2008), which originally worked with mothers in prisons to help them become more aware of attachment relationships but which has been adapted for mothers in the community.

Perinatal and infant mental health servicesThe government has promised to invest £290 million in perinatal and infant mental health services over the next five years (Gov.uk 2016). All informants reported that they had access to in-patient services for women experiencing mental health problems during pregnancy and shortly after birth. However, in comparison with this, the perinatal parent infant mental health service (PIMMHS) provided by NELFT (2016) appeared to offer support for a much longer period.

Perinatal Parent Infant Mental Health Service

NELFT (North East London) NHS Foundation Trust provides a perinatal parent infant mental health service (PIMMHS) to Barking and Dagenham, Havering, Redbridge and Waltham Forest boroughs. It is a specialist psychiatric and psychological service. The psychiatric component of the service works with women with mental health problems during pregnancy and up to a year postnatally. The psychological component of the service works with parents and children up until the age of three to address attachment difficulties to prevent complex mental health problems when the babies and toddlers become older.

Help for birth parents and foster carersOutside of specific services for looked after children, parents were also able to access different types of parenting programmes. There seemed to be an increasing trend towards using evidence-based parenting programmes, such as the Incredible Years (Webster-Stratton and McCoy 2015) or the Solihull Approach (Undated) rather than programmes developed in house.

Waltham Forest was one of 18 sites included in the evaluation of the Family Nurse Partnership scheme (Family Nurse Partnership 2015). While the research team evaluating the programme did not recommend its continuation (Robling et al. 2016), others (Barlow et al. 2016) have suggested that the scheme has potential, particularly for children’s socio-emotional development. A follow on study is due to report in 2018.

There is international concern about the population of birth mothers who experience repeat court-ordered removals of children (Broadhurst et al. 2015) and this seemed to be reflected in greater attention to ongoing support for birth parents who have had a child removed. In most instances, this was arranged through social work services. The work of Pause (2016) in helping women to break this cycle and develop new skills and ways of responding to difficulties in their lives has attracted considerable publicity (for example, Hill 2014). The original pilot in Hackney is being extended to Greenwich, Islington, Newham, and Southwark as well as other areas outside London.

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Family Nurse Partnership

Waltham Forest runs a Family Nurse Partnership programme which provides ongoing, intensive support to young, first-time mothers through pregnancy and until the child’s second birthday. Help is also provided to fathers and other family members if mothers would like them to take part. Among other aims, the scheme aims to help mothers build positive relationships with their babies and understand their needs.

Several boroughs were reported to use Fostering Changes (Pallett et al. 2002) to help foster carers improve their relationships with children and manage difficult behaviour.

Out of borough placementsConsistent with the picture presented by Brodie et al. (2014), out of borough placements of looked after children represented an additional challenge, even if the out of borough placement was in the best interests of the child – for example, so that he or she could be placed with kinship carers. In one borough, following a serious case review, it had been decided that the home borough would continue to provide all CAMHS services until a decision about permanent placement had been reached. In others, limits were set on the distances that CAMHS practitioners could travel in order to see children placed out of borough.

If children are placed too far away for their own CAMHS team to continue to see them, any treatment they receive has to be agreed by the clinical commissioning group and this is another layer of gatekeeping that could potentially delay access to treatment. Some informants from clinical commissioning groups reported that they bought in specialist treatment privately for looked after children placed out of borough when the child’s home CAMHS could not be involved but others did not seem to have the mechanisms set up to do this. Some local authority provided services were also reported only to be provided to children living within their home borough.

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It is important to begin by recognising the limitations of this mapping exercise. Although we interviewed 53 people (and need to make a considerable number of telephone calls and send many emails to identity contacts), this only represents a very small proportion of practitioners, managers, and commissioners working in mental health services for children and young people in London.

Overall, the mapping exercise suggested that there was increasing awareness of the importance of early intervention for looked after children under the age of five years but the extent to which different services were able to respond was very variable. In some places CAMHS and looked after children services appeared to be stretched. In others, a decision seemed to have been taken to prioritise services for this group. This implies that there is considerable variation in provision across different boroughs that reflects the interplay between historical levels of provision and current funding arrangements. However, there was a high level of interest among informants in finding out what services were being developed in other boroughs and for the opportunity to learn from their experiences.

There were a number of jointly commissioned and managed services, which reflects the complex and multiple needs of this group of children. However, information from the interviews suggested that while we were offered many examples of mental health services operating at Tier 1, there was comparatively little provision at Tiers 2 and 3. Services such as New Beginnings (Anna Freud Centre Undated-b), Growing Together (Whittington Health 2002-2016b), LIFT (Baginsky et al. 2016 forthcoming) and SUSI (Hardy et al. 2015) offered examples of emerging approaches but they are localised.

Interestingly, the LIFT team in Croydon and the Perinatal Parent Infant Mental Health Service

(PIMMHS) in Barking and Dagenham, Havering, Redbridge and Waltham Forest provided rare examples of specialist mental health interventions in outer London boroughs where services sometimes appeared to be very stretched with increasing numbers of children and young people of all ages needing mental health services.

The provision of specialist mental health services offering intensive treatment for looked after children under the age of five years appeared to be very limited. Most of it appears to be centred on the South London and Maudsley NHS Trust and the Anna Freud Centre. It is striking that many of the services identified in this mapping exercise are pilot schemes or clinical trials. The extent to which effective types of support can be brought into the mainstream is likely to have important consequences for the provision of mental health services for looked after children under five years old in London.

Generally, it appeared that looked after children aged under five currently comprise a small proportion of those on CAMHS caseloads. A combination of high thresholds and waiting lists in CAMHS and under recognition of emotional and behavioural problems in looked after children under five years were offered as explanations for this. However, without research investigating prevalence rates and current screening practices, it is impossible to comment any further on the extent to which mental health problems among looked after children under five years old are being missed.

Discussion

15

This was a small scale project that had to be undertaken in a very short time (April 2016). A sampling frame of children’s social care departments, clinical commissioning groups, CAMHS services, and other NHS trusts providing mental health services for children and young people was drawn up. We then attempted to identify people in managerial and leadership positions within each service to request them to take part in a telephone interview.

It was not always easy to identify the right person to take part in a telephone interview as names and contact details were rarely recorded on websites. Given the demands on services, it was unsurprising that many telephone calls and emails requesting an interview went unanswered. However, it must also be acknowledged that many people went to considerable efforts to share their knowledge and expertise. Overall, given the relatively short time available to gather the information and the variation and complexity of services from one borough to another, the efforts needed to identify the right person to approach

(and who was also willing to take part in the mapping exercise) were considerable.

Table 1 shows the number of interviews from each sector. Informants were promised confidentiality and many were speaking as individuals rather than as representatives of their service so we cannot provide a list on individuals interviewed. However, we were able to talk to a range of people from different types of organisation.

Table 2 shows that, despite the challenges in setting up a sampling frame and needing to contact so many organisations, we manged to identify an informant in every London borough. In some instances, it was possible to talk to someone commissioning services, a member of a CAMHS team or other NHS, and somebody from children’s social care, generally someone responsible for the children and family service or the manager of a looked after children team. However, we did not achieve this in all areas. The level of information that people were able to provide was also variable, with some informants providing considerable amounts of additional material.

Appendix: methods

Type of service Number Per cent

CAMHS 21 40

ClinicalCommissioningGroup 8 15

Children’ssocialcare(generallylookedafterchildrenteam) 10 19

NHSTrust 7 13

Voluntaryorganisation 2 4

JointLA/CCGcommissionerorjointlycommissionedservice 5 9

Total 53 100

Table 1:numberofinterviewsfromeachsector

16

Borough Interviews

BarkingandDagenham √√√√

Barnet √

Bexley √√

Brent √

Bromley √√

Camden √√√

Croydon √

Ealing √√

Enfield √√

Greenwich √√

Hackney √

HammersmithandFulham √√

Haringey √

Harrow √

Havering √

Hillingdon √

Hounslow √

Islington √√

KensingtonandChelsea √√

KingstonuponThames √√

Lambeth √

Lewisham √√

Merton √√√

Newham √

Redbridge √√√

RichmonduponThames √√

Southwark √√

Sutton √√

TowerHamlets √

WalthamForest √√

Wandsworth √√

Westminster √

Total 32 (53 interviews)

Table 2:numberofinformantsacrosseachborough

17

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