Therapeutic Services in Gloucestershire

COVERING SHEET FOR THERAPEUTIC SERVICES SECTION OF EMOTIONAL HEALTH & WELLBEING COMMISSIONING STRATEGY FOR CHILDREN & YOUNG PEOPLE

The Attached is one of several workstream documents which support the overarching Gloucestershire Emotional Health & Wellbeing Commissioning Strategy for children and young people which is being developed during 2007.

This strategy has several work streams, namely: universal services, parenting support, behaviour support and therapeutic services.

It is intended that each of the work streams will develop their own stand alone document, and the attached therefore acts as this document for the therapeutic services work stream.

For the purposes of the consultation, it may be used separately and/or with the overarching introductory document but should always be seen in the broader context which includes the other work streams. Some references within it therefore refer to these other documents and sections.

All of the documents can be found at:- http://www.gloucestershire.gov.uk/index.cfm?articleid=13009

Simon Bilous 21 May 2007

1 THERAPEUTIC SERVICES IN GLOUCESTERSHIRE (draft v8) Therapeutic input can be defined as approaches and interventions aimed at contributing towards improving the mental health and psychological wellbeing of children, young people and families from levels 2-4* (see also Overarching strategy document for explanation of ‘levels’). This includes identification of problems, assessment, intervention, treatment and longer-term management when necessary.

The development of this strategy involved a review of current therapeutic services from targeted interventions through to child and adolescent inpatient provision. An analysis of the gaps in service provision and areas for service development were identified. Young Minds was also commissioned to support this review.

A comprehensive health needs analysis was undertaken in 2005, which is summarised in this document. The full needs assessment is available at: http://www.gloucestershire.gov.uk/index.cfm?articleid=13009 and informs all parts of the overall strategy, including this workstream. See Appendix 2 to this document for a summary.

1. Overview of current therapeutic service provision in Gloucestershire

In Gloucestershire a number of services and initiatives have been developed to improve the emotional health and well being of children and young people. These services are delivered through a number of agencies, both statutory and voluntary.

At level 2, (for explanation of service levels see Appendix 3 of Overarching Strategy document) voluntary agencies and a recently developed team of primary mental health workers provide therapeutic support to children and young people. There are a number of schools who employ their own school counsellor or, in at least one case, a registered nurse to provide support in the school. It is not known how many schools or clusters of schools have employed this model.

Spanning across level 2/3 there are a range of teams, including the intervention team, the youth inclusion and support team, the best futures team. They offer anger management; self esteem building; support to other staff; and a range of practical support.

Specialist child and adolescent mental health services (CAMHS) at level 3 are provided by Gloucestershire Partnership NHS Trust (GPT) in five locality teams around the county. Many of the specialist CAMHS staff work across organisational boundaries and some are seconded into other agencies eg Youth Offending Service.

As far as highly specialist services are concerned, only a small number of young people in Gloucestershire require hospitalisation or placement in a specialist residential therapeutic environment**. Currently, this level of care is provided mostly out of Gloucestershire by a mixture of NHS and private providers. Some 16 and 17 year olds are admitted to adult mental health beds in Gloucestershire.

*Tiers/Levels – CAMHS is typically described within the NHS in terms of ‘Tiers’ of service/need. The CYPSP in Gloucestershire has developed a multi-agency description of need and service that uses the term ‘Levels’, in an attempt to achieve a common language between agencies. This is explained in detail in Appendix 3 of Overarching Strategy document. **Therapeutic communities and specialist residential schools offer group-based treatment in a community setting. These placements are used when other treatments are not working and there is considerable instability in a person’s life eg due to mental illness

2 2. Messages from research regarding therapeutic services

This research evidence not only underpins the priority groups identified but also informs the recommendations for commissioners.

The most recent national survey of child mental health carried out in 2004 revealed the impact of mental health problems in childhood, with 1 in 10 children between the ages of 5-16 years identified as having a clinically diagnosed mental disorder. Many child psychiatric disorders persist into adulthood and have profound effects on the child, their family and wider society1.

Despite the plethora of data available on aspects of childhood mental wellbeing it has been recently highlighted that there is a lack of data on the health of the most vulnerable groups of children in our society. This is despite the fact that these children are likely to be in greatest need of service provision. The report goes on to recommend an urgent review of available child and adolescent data sources at national, regional and sub regional level and to develop a common model of routine outcome evaluation and analysis of the data collected. This work is currently being undertaken by CAMHS outcomes research consortium (CORC).2

Goodman3states that a large number of well conducted clinical trials have clearly demonstrated the clinical and cost effectiveness of some specific interventions. These include cognitive behavioural therapy for anxiety and behavioural therapy for phobias. There is a poor evidence base for some interventions although the National Service Framework (NSF) clearly states that a full range of evidence based interventions should be available.

“There is insufficient research based evidence to draw conclusions about the effectiveness of child psychotherapy in the treatment of most disorders, but some..evidence of its effectiveness for young people who self harm, those with eating“There disorders is considerable or hard scope to control for obtaining diabetes. more However, effective there services is a growing and better body ofvalue case for work money evidence by diverting that suggests available psychodynamic resources away theories from treatments can be effective of 4 fordubious certain value groups and of into young treatments people thatand havefor infant been mental shown health to work” work”.

This point is also made by Young Minds4:

. A study by Sinclair5provides compelling evidence for investment in infant mental health services and mental health promotion among pre-school children, arguing that

1 Maughan B , Brock A, Ladfa G (2004) chapter 12 in Mental health in the wellbeing of children and young people London: ONS 2 Ferguson,B et al (2006) Indications of public health in the regions. 5:child Health, Association of public health observatories 3 Goodman R (2005) Child and adolescent mental health services: reasoned advice to commissioners and providers London: Maudsley discussion paper No 4 4 Mason J, Morley D, Smith P (2007) Review of the emotional health and well being development in Gloucestershire Young Minds

3 dysfunctional parenting and violence causes the economy to lose £billions as children become damaged and unable to contribute economically. Recommendations include: screening of pregnant women for health and social risks, with the development of appropriate interventions to encourage the development of secure attachments and good parenting; and a national public health approach to addressing the root causes of violence. He argues that investment at this stage is more cost effective than at other stages:

Fig 1: Rates of return to human capital investment initially setting investment to be equal across all ages. Source Sinclair 2007

A report from the Commission for Social Care Inspection6 has shown that high thresholds in health and social care can mean that:

• Some families’ problems are allowed to escalate before they can be addressed • Intervention is crisis-driven rather than providing lower level, on-going support • Parents who ask for help are turned away if their needs are not sufficiently high • Children on the child protection register said their parents got too little help, too late

A recent Government discussion paper7 identified that prevention and early intervention is key to enabling all children to realise their potential. It highlights the need for improvements in preventive services and parenting support, as well as the need for more work to reduce the obstacles to inclusion for young people. Two vulnerable groups are identified as needing considerably more attention: disabled children and families caught in a cycle of low achievement.

5 Sinclair A (2007) 0-5: How small children make a big difference Provocation series 3 (1) The Work Foundation

6 Supporting parents, safeguarding children. Meeting the needs of parents with children on the child protection register, Commission for Social Care Inspection (CSCI), February 2006 7 HM Treasury/DfES (2007) Policy review of children and young people: a discussion paper 4 A study commissioned by NASUWT 8found that teachers felt unable to differentiate between mental health problems and emotional/behavioural problems, and they needed more training to be able to recognise the nature of pupils’ problems. Teachers described current interventions as too little too late, with poor liaison between service providers and schools. School based interventions were more acceptable and less stigmatising and teachers requested better consultation and support from CAMHS and educational psychologists and better coordination between professionals.

A recent report from Young Minds 9 highlighted serious concerns about young people admitted to adult psychiatric wards. While some young patients reported positively to their experience for many this was not the case. The lack of age appropriate in-patient facilities prevented CAMHS from meeting these young patients’ needs. Young people themselves reported feeling unsafe, bored and uninformed about their care plans, and they also reported poor discharge planning. Recommendations include stopping the use of adult wards for young people; addressing the shortage of emergency beds in tier 4 provision; develop alternatives to inpatient care; and develop transition services to meet the needs of 16 and 17 year olds. Developing alternative provision by providing a specialist intensive mental health service at home and/or using day facilities has resulted in sustained reduction in inpatient beds by approximately 80%10

While children and young people in the care system have had their right to advocacy enshrined in law, less progress has been made for those using specialist mental health provisions. Recent policy drives have highlighted the existence of good practice in participation and advocacy in this field11

“Advocacy is about empowering children and young people to make sure that their rights are respected and their views and wishes heard at all times” 11

Witnessing domestic abuse is the cause of considerable morbidity among children and adolescents, affecting every aspect of development, and resulting in severe emotional, behavioural and social difficulties (eg conduct disorders; PTSD symptoms; anxiety, depression and suicidal feelings; risk taking behaviour; difficulties in making and maintaining relationships; difficulty in paying attention, and falling behind with school work). Very young children are particularly at risk because traumatic experiences can have adverse effects on brain development leading to permanent brain dysfunction with up to 25% fewer synapses formed. The effects of witnessing domestic abuse may

8 NASUWT 2006 Identification and management of pupils with mental health difficulties: a study of UK teachers’ experience and views 9 Young Minds (2007) Pushed into the shadows: young people’s experience of adult mental health facilities London: The Children’s Commissioner for England http://www.library.nhs.uk/mentalhealth/ViewResource.aspx?resID=236097&tabID=290 10 Worrall-Davies, A and Kierman K. (2005) Evaluation of an intensive home treatment approach for Bradford CAMHS. University of Leeds Research Report. University of Leeds. 11 Welsh Assembly Government (2003) National Standards for the provision of Children’s Advocacy Services, Cardiff, Welsh Assembly Government. 5 persist into adulthood and is certainly the single biggest risk factor for males becoming perpetrators of domestic abuse. It is important to stress that these effects are not seen in all child witnesses, although some effects may be sub-clinical. Other factors need to be considered such as resilience. In general the more severe the violence witnessed, the more severe the problems young witnesses face12.

It is not certain how many children and adolescents in the UK witness domestic abuse. The Department of Health estimates 750,000 children per year, but evidence suggests that this may be an underestimate: Alexander, McDonald and Paton found 32% of secondary school pupils were witnessing domestic abuse, and the 2006 Gloucestershire on-line pupil survey reported that 48% of year 8 and year 10 pupils either witnessed or were victims of domestic abuse12.

3. National Guidance - Key drivers for change

For many years CAMHS performance was not monitored at a national level. This has begun to change with a Department of Health (DH) Public Service Agreement (PSA) target “to substantially reduce mortality rates by 2010 from suicide and undetermined injury by at least 20%”. This is in addition to the existing DH target “improve outcomes of adults and children with mental health problems by ensuring that all patients who

12 Newell G (2007) MPH dissertation (not yet published). 6 need them have access to crisis services by 2005 and a comprehensive CAMHS by 2006”13

The elements of a ‘comprehensive CAMHS’ are measured by the use of three proxy measures as follows:  24 hour/seven days a week cover to meet the urgent mental health needs of children and young people  A full range of CAMHS for children and young people who also have a learning disability.  A full range of CAMHS for 16 and 17 years olds, appropriate to their age and level of maturity.

In 2005, Local Authorities began to be measured on CAMHS performance via a new indicator. This corresponds to the three indicators reported on by health, but includes a fourth measure – whether protocols are in place for partnership working for children and young people with complex, persistent and severe behavioural mental health need.

This target was reinforced in the Priorities and Planning Framework 2003-200614 which identified CAMHS as a key area for expansion. All Local Authorities are expected to provide comprehensive emotional wellbeing services, including mental health promotion and early intervention. Underpinning these objectives is the ‘national capacity assumption’ that services would grow by at least 10% each year until 2006, according to agreed local priorities. This would be demonstrated by increased staffing, patient contact and/or investment. £300 million of additional funding has been invested nationally into the development of CAMHS between 2003/06 via the local authority CAMHS grant and via central funding through PCTs.

One further DH target is to develop the early intervention in psychosis (EIP) teams to ensure that 7,500 new patients aged 14-35 year olds receive support in 2006/07.15 This target obviously includes young people.

In 2004 the Government issued major new policy guidance in relation to children’s emotional wellbeing within its National Service Framework (NSF) for Children, Young People and Maternity Services16. Standard 9 sets out the vision for “an improvement in the mental health of all children and young people”. This vision is to be achieved through appropriately skilled practitioners working in partnership to provide effective, evidenced based and accessible care across all tiers from mental health promotion through to highly specialised care. It provides 10 markers of good practice to be achieved over a 10-year period. The National CAMHS Support Service (NCSS) has also been established to facilitate the development of CAMHS across England.

In 2006 the DfES and the DH produced a progress report highlighting both achievements in CAMHS in recent years, and areas on which service providers and commissioners will need to focus to ensure the NSF standard is to be achieved17 The three PSA target proxy indicators (see p7) are those which need to be reached and maintained in the short term.

13 Healthcare Commission. Performance Indicators for Assessment 2006/2007 http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsP olicyAndGuidanceArticle/fs/en?CONTENT_ID=4008430&chk=lXp8vH 14 DH (2002) Improvement, expansion and reform - the next 3 years: priorities and planning framework 2003-2006. 15 Healthcare Commission. Performance Indicators for Assessment 2006/2007 16 DH (2004) The National Service Framework for Children Young People and Maternity. 17 DFES/DH (2006) Report on the Implementation of Standard 9 of the National Service Framework for Children, Young People and Maternity. 7 This progress report17 sets out medium term goals to be achieved by 2009:

1. Partnership Working Including good links between agencies, training for staff to understand each other’s roles and the support that can be provided by partner agencies, and a non- stigmatising, child and family centred approach

2. Early Intervention and Primary Care Improving waiting times for level 2 and three interventions and planning and commissioning level 4 services to avoid continual spot purchasing and out of county stays.

3. Paediatric liaison Providing a bridge between acute paediatrics and psychiatric and psychosocial care.

4. Services for Children with Complex, severe and persistent conditions Agencies have to show effective partnership working to provide appropriate care for children with social, educational and health needs, wherever possible avoiding the disruption of in patient or residential care. Intensive ‘wrap around’ therapeutic and multi agency approaches are seen as examples of good practice in this area.

5. Looked After Children Continue to improve services to meet the mental health needs of looked after children

6. Young Offenders Following assessment, all young offenders receive therapeutic intervention; and improved links between therapeutic programmes commenced within a secure setting to continue after release.

7. Routine Outcome Monitoring This is a key element of ensuring clinical practice is founded on evidence and that commissioning results in positive outcomes for children

8. Evidence based practice There is an emphasis on ensuring NICE guidance is implemented (which often recommends using cognitive behavioural therapy) whilst also commissioning a range of evidence based approaches such as family therapy and child psychotherapy.

9. Information Systems Ensuring adequate information systems are in place.

10. Delivering Race Equality Using “Delivering Race Equality in Mental Healthcare” to guide the commissioning and delivery of services in order to address inequality and exclusion. This includes the new workforce role of the BME community development worker.

A recent Government White paper called for a shift towards integrated, accessible, health and social care services provided in local communities, ensuring greater prevention, better treatment of long term conditions and greater involvement of the public in the planning of services18

Continuous improvement and evidence-based interventions have been major national themes across health and social care in recent years. Whilst there is debate regarding 18 DH (2006) Our Health, Our Care, Our Say. A new direction for Community Services. London. The stationary Office 8 the evidence base for some therapeutic interventions for children and adolescents, there are clear expectations for practitioners to operate within a framework of managed quality and to ‘adhere to the best available evidence’19. National bodies are in place to support the implementation of practice and management standards. The National Institute of Health and Clinical Excellence (NICE) has published guidelines on a number of conditions affecting children and adolescents including:  Depression in children and young people (2005)  Self harm (2004)  ADHD (2006)  Obsessive compulsive disorder and body dismorphic disorder (2005)  Eating disorders (2004)  Conduct disorders (2006

The 10 High Impact Changes for mental health services20 provide a framework to underpin service improvement. Based on evidence from practice, this aims to improve quality and efficiency of care, outcomes, service users’ experience by making the best use of resources to benefit service users. Examples include  Treat home based care as the norm  Increase the reliability of interventions by designing care cased on what is known to work

These key messages and drivers must be embedded in Gloucestershire’s approach to commissioning and delivering mental health services for children and adolescents.

19 DH (2004) The National Service Framework for Children Young People and Maternity 20 National Institute for Mental Health in England.(2006) 10 High Impact Changes for Mental Health Services. Care Services Improvement Partnership. 9 4. Market Analysis (including Financial Position)

Underpinning this commissioning strategy is the absolute requirement for NHS organisations to ensure that all activity conforms to the financial imperatives identified in the DH National Operating Framework. This presents a challenge for the Gloucestershire health community who must conform to this framework, while at the same time participate fully with the Change for Children Programme, which includes this strategy.

In Gloucestershire the health community deficit was assessed at £40m at the beginning of 2006. In order to help address this, the budget for specialist CAMHS in 2006/2007 was reduced by £394,000. This has resulted in a significant loss of nursing staff from this service. However, the pre-existing plan to use some of the central PCT funding for CAMHS provided new investment of £250,000 recurring went ahead, allowing for the development of a countywide Primary Mental Health Worker (PMHW) Service for children and young people. This new service will operate in the community, in between universal and specialist services, providing consultation and training to staff and some targeted direct work with children and young people.

The Children and Young People Directorate (CYPD) within Gloucestershire County Council faces similar resource constraints; it is obliged to consider political imperatives eg levels of council tax increases.

No funding increases are anticipated through the CYPD or PCT commissioning routes in the next three years; this reinforces the need to consider what can be achieved within existing resources.

Information from service providers and stakeholders shows that the majority of CAMH services have developed historically, as a result of a complex mix of national drivers, and initiatives from individual clinicians or teams to establish services in their locality. This has resulted in provision that is neither uniform nor equitable, and not based on need or agreed priorities.

“It is clear that services are distributed unevenly across the county. Its rurality contributes to this but we found projects are funded to work in some areas only, which …….means that young people in other areas have little or no access”21

21 Feedback from service providers and stakeholders indicates that inter-agency working could be greatly improved (eg there are insufficient care pathways) and there are gaps in level 2 services (for explanation of levels see Appendix 3 of Overarching strategy document). These gaps have resulted in some children and young people not receiving the support they need. This has led to strained working relationships across agencies, as practitioners at level 1 feel frustrated at the lack of level 2 provision. Therefore, a disjointed set of services has emerged, linking well together in some areas (most likely due to individuals working well together rather than processes) and not in others, and in some cases leading to overlapping services.

“Many of these services overlap and/or work with the same young people sometimes at the same time and sometimes at different stages”. 22 21 Mason J, Morley D, Smith P (2007) Review of the emotional health and well being development in Gloucestershire Young Minds

22 Mason J, Morley D, Smith P (2007) Review of the emotional health and well being development in Gloucestershire Young Minds

10 There is a need for clear pathways between services so that professionals are aware of each others roles. This will also promote more effective and positive interagency working.

Interagency collaboration was identified in the Young Minds review as lacking, with a number of myths surrounding, particularly regarding access to and provision of the Specialist CAMH service. Professional working relationships between social care and specialist CAMHS are cited as needing improvement.

The Young Minds review also highlighted the skills gap in mental health for front line workers in general, and this was particularly noted in residential emotional behavioural schools, children’s homes, services for children with learning disabilities, in paediatric wards and adult mental health wards.

Level2/level 3 Need Market Analysis

 Voluntary and community sector

In 2005/2006 the CYPD funded two counselling services with a total of £35,000, part of which was specifically for looked after children with emotional needs. A third counselling service received grant funding from the County Council. Although Gloucestershire PCT intended to fund the counselling services, financial constraints prevented this. Further joint funding between health and the CYPD of the voluntary sector has taken place in 06/07.This has been for the same three charities, who operate at level 2 of need. These three counselling services alone helped over 1000 children and young people in the year 2005/2006.The Young Minds review2 identified that voluntary sector provision could be expanded to bridge important service gaps identified in BME services and those with learning disabilities and children in care.

 Primary Mental Health Workers

A recent analysis of referrals to Specialist CAMHS indicated that 40% of children and young people could have received a service from a less specialist provider. These inappropriate referrals have contributed to the long waiting times experienced by some children and young people. This must be addressed to ensure that those needing services are receiving support in a timely manner and at the lowest level of intervention possible to meet their needs.

This finding reflects the fact that services designed to meet needs at level 2 are underdeveloped; this is a national as well as a local issue. In Gloucestershire steps have been taken to address this problem with the development of a Primary Mental Health Worker (PMHW) service (see p 10). Other services are becoming aware of the benefits offered by PMHWs, which could lead to inclusion of PMHWs in other teams. Even with potential additions, this service will be below the levels of staffing recommended in the literature26 & 22 and it is important that the demand on and effectiveness of the team are carefully monitored.

It has been£106,000 identified that supervision for school counsellors is crucial and that improved£47,000 links need to be made between Specialist CAMHSMainstream (SCAMHS) and schools. It is envisaged that the PMHW service will address this. £518,410 Drug and Alcohol  Specialist CAMHS Therapy Sure Start The expectation of the SCAMH service growing year on year by 2006 has not been achieved in Gloucestershire and it is currently in the process of adapting to the loss of Youth Offending nursing posts in 2006/07 through to 2007/2008. Team 11 £3,638,000

Fig 2: Overview of Gloucestershire health community expenditure on CAMHS (figures based on 2005 CAMHS Mapping)

The locality teams described in fig 2 as mainstream CAMHS have grown organically and are not weighted to areas of deprivation or need (see appendix 1). The service saw 1440 children and young people in 2005-2006 and received 1613 referrals during this time. Waiting times for SCAMHS are often reported as being too long. There has been improvement in waiting times which have reduced from a maximum wait of 70 weeks down to 54 weeks and the majority of children are seen within 13 weeks.

The Forest of Dean locality has the longest waiting times, the largest population but the smallest team. A key task will be to organise the locality teams to address these issues. This should be possible with the implementation of the work flow management system ‘Choice and Partnership Approach’ and the implementation of a new IT system which will enable the relevant information to be gathered in order to inform commissioning.

An analysis of provision indicates that some specialist services are only available in certain parts of the county, notably the Infant Mental Health Service and the Gloucestershire Recovery in Psychosis team (GRIP). There is currently no specific provision within SCAMHS for therapeutic interventions in response to sexual abuse. As abused children are a priority group (see section 5 p 16) a commissioning priority will be to improve care and support for this vulnerable group of children and young people - see also para 6.10 page 20. 26 York A, Lamb C (eds) 2006 Building and sustaining specialist child and adolescent mental health services Council Report CR 137 Royal College of Psychiatrists http://www.rcpsych.ac.uk/files/pdfversion/CR137.pdf created June 2006 accessed 18.4.07 The recent review from Young Minds23 indicates that treatment practices are not consistent across the county for the same presenting symptoms and recommends that clear evidence based pathways are established in order to utilise resources effectively and provide the greatest benefit for children and young people.

£45,000 of the allocation to mainstream CAMHS in 2006/2007 has been to fund paediatric liaison and this has been used in the past to fund a pilot psychology liaison post to both community and acute paediatrics. The funding is currently used to provide assessments of children and young people admitted to hospital for deliberate self harm.

2323 Mason J, Morley D, Smith P (2007) Review of the emotional health and well being development in Gloucestershire Young Minds 12 CAMHS Grant*

“ The core CAMHS Grant in 2005-06 is given to Councils with Social Services Responsibilities (CSSRs) to enable them to carry forward their joint strategies with the NHS and other agencies to develop CAMHS.” Grant Conditions

 The core grant should be used to improve CAMHS, in accordance with local needs and priorities, as set out in the local CAMHS Development Strategy.  Plans for spending the grant should be agreed between CSSRs, Primary Care Trusts (PCTs), education and other partners. Local agencies should work in partnership at all levels of service planning and delivery. Joint commissioning arrangements and/or use of Health Act flexibilities should be used wherever possible”.

Fig 3 shows how the grant has been spent.

CAMHS Grant Expenditure for 05/06

C Fw /d to 06/07 £182k 25% Intervention Team £380k Task Foster Care £10k Intervention Team Agency £380k Agency Placements £162k Placements £162k 52% 22% C Fw /d to 06/07 £182k

Task Foster Care £10k 1%

Fig 3: CAMHS grant allocation 2005/06

The majority of the grant has been on funding the Intervention Team (see Fig 3). The team’s caseload is approximately 20 children and young people per year, a few of whom have been supported over a sustained period, which has resulted in children and young people staying in county and/or in a placement.

* Department of Health (2004) Child and Adolescent Mental health Service (CAMHS) grant guidance 2005/6 http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Healthservicecirculars/DH _4098628

This service needs to be jointly and explicitly commissioned across CYPD and health, with clear guidelines (including working relationships) and specified outcomes in order to monitor efficiency and effectiveness when providing services for Looked After Children (LAC) with complex needs.

Over 25% of the grant was used to provide one out of county agency placement for a child with complex learning emotional and behavioural difficulties. There is not enough information available to know what mental health needs have been met from this section of the funding.

This reinforces the need for a clear and transparent joint decision-making process, using appropriate outcome measures, to demonstrate that the funding is used effectively to meet mental health needs. 13 The CAMHS grant has not been fully used, as funding has been carried forward since 2004, with a total of £182,000 being carried forward to 2006-07 from 2005-06.

Level 4 Needs

 In Patient Provision

Fig 4 shows the inpatient bed days, the provider split and the cost for inpatient services during 2005/06. Gloucestershire commissioned two NHS in-patient facilities on a block contract basis. A small contract with one provider provided excellent value for money; however, the main NHS in-patient block contract did not represent value for money, as the unit was unable to provide the capacity that had been commissioned. This contract has now been renegotiated to reflect actual use and activity and thereby provide better value for money. There is also an over representation of eating disorder patients being catered for within the private sector. There are no specific CAMHS in-patient beds provided within Gloucestershire.

Because of these issues, the PCT has been forced to “spot purchase” the majority of in-patient beds from private providers. In some cases these have been over 100 miles away from Gloucestershire. This means that whilst children are cared for in an age appropriate environment by appropriately skilled staff, they are often a great distance from home, away from the security of their parents and carers. In a minority of cases this has been due to the need for very specialist therapeutic care that could not be provided closer to home. The costs of these placements are extremely high and it is felt by commissioners that resources could be used more effectively by commissioning services differently so that children and young peoples’ needs are met closer to home.

306, 6% 16/17 Yr Olds in Adult Wards = 14 Patients (£Unknown)

1753, 35% NHS Adolescent Wards = 15 Patients 2989, 59% (£1,192,871)

Private Placements = 25 No of providers = 15 Patients (£1,829,535.97) No of patients = 51 Total bed days = 3,583 Total Cost = £3,022,406.97

Fig 4: In-patient bed days by provider and cost 2005/06

A significant number of children aged 16/17 are admitted to adult psychiatric beds within Gloucestershire. The number of bed days ranges from 1-101; in terms of the total number of bed days these stays represent a minority of total bed usage and concern a largely transient group waiting for more appropriate provision to become available. An audit in Gloucestershire over an 18 month period in 2004-06 found that the majority of young people in this category were admitted as an emergency, with most spending a short time in the adult wards. This practice of emergency admission is in line with the NSF, which states that adult beds may be used when it is essential for the welfare and safety of the user and others; however minimum standards in terms of safeguarding for these facilities should be developed. The national review of the NSF states that services and the environment should be appropriate to older adolescents and the use of adult beds should be stopped within the next five years.

14 There is an ad hoc advocacy service for young people in inpatient units that is provided by Gloucestershire Independent Advocacy service and some children and young people are given the ‘Headspace’ self advocacy toolkit but no formal system of advocacy is commissioned.

 Specialist Residential Schools and Therapeutic Communities (see footnote p 1)

Gloucestershire has a considerable number of Emotional and Behavioural Difficulties (EBD) residential and day school places. The Young Minds review24 expressed concern at the lack of therapeutic support and input available to these schools, which are managing extremely challenging pupils (see p9 Complex BESD document).

Despite the relatively high number of special school placements, compared to comparator authorities (see appendix 3 BESD document), in 2005/2006 Gloucestershire PCT and the CYPD jointly funded 17 children with complex needs (including mental health needs) who were cared for in specialist residential settings, mostly out of the county. The cost of the therapeutic input for these specialist placements totalled £324,000 in 2005/6 and has risen in 2006/2007. Nationally, commissioning of specialist placements has not been done systematically or cost effectively with clear needs, outcomes, monitoring and exit strategies identified.25 Gloucestershire is working with other authorities and across agencies to develop a clear process in commissioning these placements and to explore opportunities to pool budgets in the future.

5. Gloucestershire’s Priority Groups

Alongside the overall needs assessment (summary at Appendix 2; full assessment at weblink page 2), we have identified three priority groups within Gloucestershire as described below. Further detail on the reasons for identifying these groups can be found at Appendix 3 of this document.

5.1Looked after children (LAC), including children on the child protection register and those who have been adopted

The intervention team provides therapeutic services for LAC whose foster placement is in danger of breaking down due to severe emotional and behavioural needs. The team is planning to provide consultation to children’s homes. The educational psychology service provides behaviour management support to children’s homes. However, these

24 Mason J, Morley D, Smith P (2007) Review of the emotional health and well being development in Gloucestershire Young Minds

25 Audit Commission (2007) Out of Authority Placements for Special Educational Needs. Audit Commission Publishing. 15 children are amongst the highest in terms of mental health need with the added complexity of an estimated 20% having a learning disability.

The Young Minds review24 states

“As a result of poor inter-agency working between LAC and SCAMH services, LAC in residential care are reported to receive almost no SCAMHS service despite their very high level of mental health needs and distress”

The review goes on to state that staff working in the children’s homes feel poorly equipped to deal with the mental health issues that arise, eg self harm, and recommends that urgent support and assessment should be provided.

Other specific gaps identified in Gloucestershire for vulnerable LAC included:  Those with learning difficulties, particularly as they transfer to adult services  Adopted children as they reached adolescence  Sexually abused LAC  LAC not in stable placements  Children in private foster placements, particularly BME children  Children on the child protection register

5.2Children and young people who offend or are at risk of offending

The Youth Offending Service (YOS) is performing well in relation to meeting Government targets in assessments for mental health issues in young offenders and also in terms of early intervention. The YOS has strong links with SCAMHS and has good access to SCAMHS for their clients. This needs to be extended to the Youth Inclusion Support Team (YIST) project to strengthen the early intervention approach.

Gloucestershire YOS screens the mental health of all young people who receive a substantive outcome. This can lead to assessment by a specialist CAMHS nurse so that mental disorders are identified promptly and the young offender offered timely access to the appropriate services with CAMHS. This process works extremely well. However, there has been no increase in funding over the last three years despite the considerable increase in the numbers of young people coming through YOS. YOS mental health provision is at full capacity with no contingency to cover the specialist nurse when he is away.

Gloucestershire YOS also have a part-time clinical psychologist who assists the specialist nurse with assessments. The psychologist often prepares detailed reports on young people with complex needs, which has reduced the amount of psychological reports requested by the Courts, therefore helping to ensure the criminal justice processes are not unnecessarily delayed. A significant gap in the service YOS offers has been identified around Learning Disabilities. National research has indicated that a large proportion of young offenders have a learning disability. There is no provision for the identification or on-going service within YOS for young people with a learning disability. YOS intends to start screening young people for learning disabilities to gather some local information; however the limited capacity within the current mental health team makes the start date of this project uncertain.

5.3Children and young people with Disabilities

16 The Young Minds review found the national picture of unmet need for children with disabilities was reflected in Gloucestershire, particularly with reference to services for children and their families who were o Receiving palliative care o LAC in residential care with learning disabilities o Parents of premature and very ill babies on the special care unit. o Patients with sensory disabilities.

At the lower levels of need, both the voluntary sector and some individual professionals carry out interventions, but this is uncoordinated, is patchy across the county and may not be evidence based. There needs to be more uniform emotional support for children with disabilities across the county. There is a lack of knowledge amongst the workforce in Gloucestershire with regard to disability and mental health of the fact that their disabilities put them at greater risk of mental disorders, and this needs to be factored into workforce training and should be reflected in assessments and care packages . There is also concern regarding lack of access to and provision of Specialist CAMHS. In order to strengthen access to therapeutic provision for children with a learning disability, a clinical network coordinator is being appointed and a care pathway agreed. It is envisaged that this post will increase access for all disabled children and provide some training.

Other Emerging Issues

 Black and other minority ethnic (BME) Communities

There has been some cultural competency training across agencies but the general lack of workforce awareness around cultural issues was highlighted in the Young Minds review. There is a lack of targeted services for BME communities and poor collection of ethnicity data. This is coupled with a lack of activity to improve access to service provision, such as information in different languages, interpreting services, culturally appropriate foster carers and SCAMHS workers, so that Gloucestershire CAMHS is fully compliant with anti-discriminatory legislation.

Monitoring arrangements

Specialist CAMHS are currently part of the CAMHS Outcome Research Consortium. This includes evaluation of interventions from the child and parents before and after the intervention and standardised measures of improvement including the strengths and difficulties questionnaire. It is not clear how or if at all other services monitor the effectiveness of interventions or treatments.

6. Changing the Focus of Services

We want to change the focus of services over the course of the five years 2007/08 – 2011/2012 so that they are:

17  Planned and commissioned across the PCT, the CYPD and other partners through the Emotional Health and Wellbeing Partnership.  Needs led rather than service driven and catering for our vulnerable priority groups.  Accessible and acceptable to all who need help, particularly those from more vulnerable or marginalized communities, so that services are available when children and young people need help and are delivered in less stigmatizing places and ways.  Evidence based and consistent in their approach to interventions  Provide a consistent journey for children and young people in a coordinated way across disciplines and agencies.  Are cost effective and clinically effective, as measured by improved outcomes for children and young people. How will this be resourced?

We have already acknowledged (see p 10) that there are not likely to be any significant increases in funding within the statutory sector for these services in the foreseeable future. Our plan for change therefore requires better and more effective use of the existing resources. This will require the development of a resource plan, which will need to identify how change will be implemented. The implications of this resource plan would be subject to the scrutiny processes of individual partner organisations affected by them.

If we do this, it will mean

 More children having their mental health needs met more quickly and at a lower level of intervention with fewer children needing highly specialist services.  More children receiving an appropriate service and a smooth planned journey across services to meet their needs  More children having their mental health needs met closer to home, reducing the number receiving care out of Gloucestershire  Gloucestershire’s vulnerable priority groups getting the support that they need, including working towards reducing inequalities amongst BME groups  An overall improvement in the emotional health and wellbeing of all children and young people in Gloucestershire

How will this be achieved?

6.1 Redirect funding so that more is allocated to lower level interventions to benefit more children and to enable effective early intervention; also to enable services are delivered to meet needs promptly while maintaining choice and flexibility

 Invest in level two/three Primary Mental Health Workers to meet the demand. The new service will require careful monitoring over 07/08 to assess effectiveness and ensure accurate future planning.  Ensure an effective pathway to gain consultation and advice for all practitioners working at level 2 to enable them to become more skilled in addressing mental health difficulties.  Ensure allotted time is commissioned within work schedules of Specialist CAMHS and PMHW to allow for consultation and advice to practitioners operating at lower levels of need  Embed the common assessment framework in care pathways to ensure that needs are met via a multiagency approach before they escalate  Work with the voluntary and community sector to increase access to short term evidenced based therapeutic interventions.  Ensure all commissioned services include processes to ensure that children and young people are seen within national target time limits

18  Ensure all services are commissioned to provide flexibility about appointment times, therefore minimising missed appointments  Commission targeted level 2 interventions to be delivered in a variety of settings in the community that provide a less stigmatising environment and facilitate access

6.2 Reduce the number of children placed in out of county in-patient units or specialist residential placements, by funding the development of appropriate interventions within Gloucestershire

 Over the next three years gradually decommission the majority of out of county inpatient beds  Invest in ‘wrap around’ services to meet the highly specialist needs of children and young people at home or in local day facilities.  Develop provision of emergency in patient beds within Gloucestershire in age appropriate environments

6.3 Develop an effective joint commissioning process to address the needs of the very small number of children who require highly specialist interventions that are not available locally.

 Commissioning will include the identification of clear treatment plans, outcome measures and exit strategies so that children can return to in county mainstream provision as soon as is appropriate . 6.4 Ensure agencies work together to provide a structured approach to mental health problems

 Develop a programme of team building and multiagency training particularly across SCAMHS and social care to improve interagency working and communication

6.5 Involve children and young people in developing, monitoring and evaluating services

 Develop a programme of participation, consultation and involvement through the CYPSP utilising the ‘Hear By Right’ standards  Work collaboratively with service users to identify needs and commission effective interventions

6.6 Ensure an appropriately trained workforce in line with recommendations from national guidance in order to ensure practitioners respond promptly at the appropriate level of intervention

 Appoint a joint training coordinator across health and CYPD to provide a training programme consistent with national guidance and individual agency requirements, and utilising existing expertise.  Training will include attachment, the needs of vulnerable and marginalised children eg BME communities and those with disabilities.  Adult mental health staff caring for 16 and 17 year old in patients should be included in training, and should be subject to Criminal Records Bureau (CRB) checks.

6.7 Ensure interventions are effective and evidence based

 Commission services to provide interventions that are known to work. 19  Decommission interventions not grounded in sound evidence.  Develop a performance framework across agencies providing therapeutic services

6.8 Ensure services are available consistently and equitably across the county

 Over the next three years invest in a county wide infant mental health service.  Work with adult mental health service to ensure we are meeting needs with regard to the early intervention in psychosis team (GRIP team)

6.9 Improve support offered to young offenders or those at risk of offending

 Sustain and enhance service provision in order to meet the NSF standards  Increased SCAMHS input to YOS  Provide earlier intervention by supporting the YIST through consultation and training with SCAMHS  YIST to develop improved community links to enable better support for marginalised adolescents, especially those from BME communities

6.10 Improve services for LAC, adopted children and those on the child protection register

 Because of the research evidence showing the association between abuse/neglect and brain dysfunction, children in care and those on the child protection register (or heading that way) should have their mental health needs assessed and offered appropriate intervention as early as possible  Develop clear pathways into SCAMHS for LAC in residential care, foster care, including unstable placements  Develop services to address identified mental health needs of children on the child protection register, those on the edge of care, children in private foster placements and those in transition to adult services  Monitor the progress of the budget holding lead professional pilot to examine if this could be a model of meeting the mental health needs of LAC

6.11 Improve services for children and young people with disabilities

 Ensure that children with disabilities have equity of access to appropriate CAMH services  Continue the work already in place to ensure that children and young people with learning disability have equity of access to all CAMH services  Monitor the number of children with disabilities accessing all therapeutic CAMH services  Develop voluntary sector services for children with disabilities to ensure needs are met at the lowest level possible. This will include providing any necessary training  Develop countywide multi-agency care pathways for children who require coordinated support across health, education and social care (eg ADHD, autistic spectrum disorders and conduct disorders)  Parenting support should be offered to parents whose children attend special schools

6.13 Improve services for Children and Young People from BME communities

20  Develop links with voluntary and community organisations, to improve provision of therapeutic services at lower levels of intervention and to improve access to SCAMHS.  Develop systems and processes to disseminate accessible information regarding therapeutic services to BME communities.  Develop a programme of recruitment to therapeutic services that better reflects the local population in order to improve cultural competency amongst the workforce and encourage uptake of services by BME communities  Develop links with the voluntary and community sector to provide training to schools and health professionals to improve an understanding of cultural issues and the skills needed to work effectively with BME groups

21 Professional Distribution - Central Team 6.19 wte Profession Distribution Pop 124578 Tewks/Chelt

Occ Therapy Occ Therapy Nursing Nursing Psychotherapy Psychotherapy Consultant Psychology Consultant . Art Therapy Psychology Profession Distribution - North Medical Art Therapy Glos/Forest Family Tharapy Medical Family Tharapy Occ Therapy . Nursing Psychotherapy 7.105 wte Consultant Pop. 108765 Psychology Art Therapy Medical Family Tharapy . 5.1 wte Pop.136740

Profession distribution - Cirencester/Chelt

Occ Therapy Nursing Psychotherapy Consultant Psychology Art Therapy Medical . Family Therapy 7.315 wte pop. 135008

Profession Distribution - Stroud

Occ Therapy Nursing Appendix 1: Specialist CAMHS team Psychotherapy Consultant configuration per locality team with Psychology identified population and high Art Therapy Medical 5.24 wte deprivation areas within Gloucestershire Family Tharapy Pop. 124578 . 22 Appendix 2 Population Needs Assessment Summary

Epidemiological information:

The NHS Health Advisory Service1 defines mental health problems as:

“Disorders of emotions, behaviour or social relationships which may cause distress or disturbances in the family or community, or risk to optimal development in the child. They are relatively common and encompass mental disorders which are more severe or persistent.” National data (table 1) shows that although approximately 10% of children have a mental disorder, boys are more likely than girls to be affected and the prevalence of mental disorders increases with age.

Condition 5 to 10 year olds 11 to 16 year olds All children 5-16 year olds Boys Girls All Boys Girls All Boys Girls All Any mental 10.2% 5.1% 7.7% 12.6% 10.3% 11.5% 11.4% 7.8% 9.6% disorder Conduct 6.9% 2.8% 4.9% 8.1% 5.1% 6.6% 7.5% 3.9% 5.8% disorders Emotional 2.2% 2.5% 2.4% 4.0% 6.1% 5.0% 3.1% 4.3% 3.7% disorders Hyperkinetic 2.7% 0.4% 1.6% 2.4% 0.4% 1.4% 2.6% 0.4% 1.5% disorders Autistic 2.2% 0.4% 1.3% 1.6% 1.1% 1.4% 1.9% 0.85 1.3% disorders, tics, mutism, eating disorders Table 1: Prevalence of mental disorder children aged 5-16 in Great Britain, 2004. Source: The mental health of children and adolescents in Great Britain, ONS 2005

It has been estimated that 10% of children aged 2-5 years may be experiencing mental health problems such as anxiety or depression2. A 2005 ONS report3 identified other socio-economic factors associated with increased prevalence of mental disorders eg poverty, unemployment, housing type.

The psychiatric morbidity of young people aged 17 & 18 has also been estimated (details in full needs assessment).

1. Health Advisory Service (1995) Child and Adolescent Mental health Services: Together we stand London: HMSO

2. http://news.bbc.co.uk/1/hi/health/4478428.stm . Created 28.11.2005; accessed 26.6.0006

3. ONS (2005) The mental health of children and adolescents in Great Britain London: ONS

23 These rates have been adjusted for age and gender in order to provide a local estimate which suggests that in there are over 13,000 children aged 0 -18 who may have mental health problems in Gloucestershire:

Persons Age group Gloucestershire Males and females 0-4 years 2361 Males 5-10 years 2140 11-16 years 2976 17-18 years 1054 6170 Females 5-10 years 993 11-16 years 2325 17-18 years 1773 5091 13,622 Table 2: Locally Adjusted Estimated Numbers of Children and Young People aged up to 18 years with Mental Health Disorders in Gloucestershire

This estimate is supported by findings from the 2006 pupil on-line health and lifestyles survey where 8-13% of respondents stated that they were (a) unhappy most of the time/quite unhappy; (b) not at all confident/not very confident about their future; (c) unsatisfied or quite unsatisfied with their life.

We know that the population of children and young people is currently on a downward trend, and it has been estimated that between 2001 and 2021 it is expected to decrease by approximately 8% .This should be balanced against the rise in children with disabilities, including learning disabilities and very complex needs and those with life limiting conditions who are at greater risk of developing mental health difficulties (ref Gloucestershire PCT(2006) Our Health: Our Say Report of the Public Health Directors for Gloucestershire 2005-2006).There are also a range of other risk factors which make some children and young people more vulnerable to mental health difficulties, and these are described in the full needs assessment in more detail - deprivation is known to be a significant risk factor.

The numbers of children and young people identified in the needs assessment and the priority groups identified in table 3 should be viewed with caution as Gloucestershire is a relatively affluent area. Although there are a significant number of children and adolescents with severe behavioural difficulties (the NICE/SCIE guidance on conduct disorders estimates 3964, with 392 new cases per year), many of these children will also fall into the other priority groups identified in table 3.

24 The following priority groups have been identified using the epidemiological information and the known risk factors:

Risk factor for mental health Estimated number of problems and percentage likely to Gloucestershire children likely have mental health needs to be affected Learning disabilities (30-50%) 945-1575 Physical disabilities (30%) 47 school age children Chronic physical illness (8-11% 10-15 693-954 year olds) Young offenders (42% substance 333 (substance misuse service) misuse; 44% mental/emotional health 349 (mental health needs) needs) Looked after children (42% 5-11 yr olds; 29 (5-11) 49% 11-15 yr olds) 67 (11-15) On child protection register/ Child abuse 32-48 children aged 2-16;1 child (20-30% 2-16 yr olds; 18-48% 17-18 yr aged 17-18 olds) (If witnessing domestic abuse is (40,998 – 65,000) included an estimated 30-50% of children witness domestic abuse – some of these may be included in the group with severe behavioural problems) Table 3: Risk factors, prevalence and estimates of number of children and adolescents with mental health problems

Looked after children (LAC) in residential homes, children awaiting long term foster placements, and looked after children who have been sexually abused are all amongst the most vulnerable in the county, with a very high risk of mental health problems. Many LAC and young offenders also have a learning disability, which compounds their vulnerability and risk of mental health problems. These are also the groups who often experience the greatest difficulty in accessing Specialist CAMHS4.

Although Gloucestershire has a larger white population than the average for England as a whole, young people from black and minority ethnic (BME) are over-represented amongst those in contact with looked after children’s services, the Youth Inclusion and Support Team (YIST) and the children with disabilities service. This reflects national evidence that BME and mixed race children and adolescents are over- represented in the vulnerable groups, and they experience more violence in the home and school exclusion4.

Table 4 shows the percentage of black and minority ethnic (BME) groups in Gloucestershire. ONS ethnic group No of people % of county % of England population population White British 530,790 94.02% 85.72% White minorities 13,350 2.37% 3.93% White Irish 4,340 0.77% 1.27% Total White 548,480 97.16% 90.92% Mixed heritage 4,840 0.85% 1.31% Asian/Asian British 5,520 0.97% 4.57% Black/Black British 3,310 0.58% 2.3% Chinese 1,340 0.24% 0.45% Other 1,070 0.19% 0.44% Total BME 16,080 2.84% 9.07% Table 4: Gloucestershire/England population by ONS ethnicity classification4 25 The distribution of BME families within the county gives rise to the following concern:

“50% of BME communities live in Gloucester and 23% in Cheltenham. The other districts have less than 10% BME population. Whilst access to CAMHS needs to be developed in the two major towns, it is likely that psycho-morbidity will be higher amongst BME communities in the more rural areas and smaller towns, where there are less well established, or non-existent, community organisations to support them” .4 4. Mason J, Morley D, Smith P (2007) Review of the emotional health and well being development in Gloucestershire Young Minds

Supporting information

(a) Service user perspective The consultation of the Children & Young People’s Plan in 2006 identified emotional health and wellbeing as a priority.

In addition, a consultation with a small number of service users was carried out in 2006. Findings from this included:  Most service users and their parents commented positively on the support given, particularly being listened to and the context of the interventions (eg environment, content, mode of delivery). Some service users did not identify any positive comments about the interventions offered.  A small number of service users felt that the interventions had not resulted in any improvements in their situation, but more reported that they were satisfied with the interventions.  Most service users could not identify ways in which interventions could be improved, but some suggested that support offered could be more focussed on specific issues, and more regular.  Parents wanted support earlier and in times of stress.

National consultation research5-8 shows that: Children and young people want  their first point of contact to be well informed about child mental health and available services.  Confidentiality to be respected.  Consideration given to the environment in which support is given.  Professionals to be transparent in informing them about all aspects of interventions.  Flexibility around appointment times and where they are seen.  A range of interventions offered, including practical help.  To be treated with respect and empowered.  Services to work in close collaboration.

In addition to these common themes, BME children and young people -  Want Practitioners to have the skills to work within the context of the young persons ethnicity  Feel they lack awareness, particularly amongst parents, of when and where to seek help  Would like the services of an interpreter  Have concerns around the stigma attached to using ‘mental health’ services9,10

26 Although there are some well functioning focus groups, there is difficulty in maintaining service user groups specifically linked to the CAMHS experience. There is a need for much improved participation from parents, carers and young people, and this has been acknowledged in the incorporation of participation into commissioning standards across all services for children and young people. It is intended that this development will lead to improved involvement of service users not just in service evaluation but also in the wider commissioning process.

(b) Organisational perspective

There are two aspects to consider – the views of service providers and those of commissioners. Service providers were included in the 2006 consultation, and their responses are summarised here:  Although many respondents made positive comments about the support offered to children and adolescents, some concerns were raised including: lack of coordination across agencies; long waiting times for interventions; difficulties of children going through care proceedings in accessing specialist CAMHS; lack of awareness of other services for children and adolescents.  Improved referral systems and the use of care pathways are needed  Increased CAMHS staffing capacity is needed, particularly in tier 3

Commissioners are concerned with ensuring that resources are used wisely so that interventions are both clinically effective and cost effective. Figures from the financial year 2005/6 show that a substantial proportion of resources were used on level 4 out of county placements for a small number of patients (see market analysis section for full details).

Implications and analysis

Poor outcomes do not occur randomly. They have their roots in the risks and experiences that children are exposed to from before birth and throughout childhood. Correlations between indicators of risk and poor outcomes – which show children’s vulnerability to adverse social and economic circumstances – is well established and Sinclair’s graph (Fig 1) illustrates this.

Estimating the costs of poor outcomes is difficult. However, an example of some poor outcomes gives an idea of their scale in terms of costs to society and consequences for individuals.

 If attainment of all children in care could be raised to that of all children, there might be a gain to society of around £6 billion in terms of increased productivity over these children’s lifetimes  A place in a Young Offender Institution costs over £50,000 per year and the Audit Commission estimated that if effective early intervention had been provided for just one in ten of those young people sentenced to custody each year, public services alone could have saved over £100 million annually

1. Health Advisory Service (1995) Child and Adolescent Mental health Services: Together we stand London: HMSO

2. http://news.bbc.co.uk/1/hi/health/4478428.stm . Created 28.11.2005; accessed 26.6.2006

3. ONS (2005) The mental health of children and adolescents in Great Britain London: ONS

4. Mason J, Morley D, Smith P (2007) Review of the emotional health and well being development in Gloucestershire Young Minds

27 5. Buston, K. (2002). ‘Adolescents with mental health problems: what do they say about mental health services? Journal of Adolescence, 25 (2)p 231-42. 6. Gibson R, & Possami A. (2002). ‘What young people think about CAMHS’, Clinical Psychology 18 p 20-24 7. Baruch G, & James C (2003). The National Framework for Children, Young People and Maternity Services: The Mental Health and Psychological Well-being of Children and Young People. Report from Consultation with Users of Children and Adolescent Mental Health Services London: Department of Health. 8. 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. London: Young Minds9. Kurtz Z and James C (2005) What’s new:learning from the CAMHS Innovation Projects London: DfES. 10. Kurtz Z, Stapelkamp C, Taylor E, Malek M and Street C (2005)Minority Voices- A guide to Good Practice in planning and providing Services for the mental health of black and minority ethnic young people London: Young Minds.

28 Appendix 3 Reasons for choosing our priority groups Our priority groups are looked after children (LAC), including those who have been adopted; young offenders (especially first time offenders) and those at risk of offending; and children and young people with disabilities, including learning disabilities.

Looked after children

This group is numerically small but has high levels of need and demonstrably poor outcomes. A 2002 survey1 of looked after 5-17 year olds found that 45% had a mental disorder, 37% had clinically significant conduct disorders and 12% had emotional disorders – see figs 1 and 2. Fig

Fig 1: Prevalence of mental disorders among 5-10 Fig 2: Prevalence of mental disorders among 11-15 year olds; looked after and private household children

The same survey found that mental health problems were most common among children in residential care – see fig 3 below.

Fig 3 Presence of any mental disorder by placement type

National data shows that children who are looked after by the local authority have worse outcomes than children who remain in the family home. After leaving care, they are more at risk of: becoming teenage parents, being homeless, being unemployed and of drug and alcohol dependency2. The Social Exclusion Unit’s Report3 identified five main reasons why looked after children have poor educational outcomes including “children in care need more help with their emotional, mental or physical health and well being”.

In addition: 29  40% of girls leaving care will become pregnant before their 20th birthday  In 2005-06 looked after children were 2.5 times more likely to be given a final warning reprimand or conviction than the overall population of children over 10  60% of looked after children have some degree of difficulty with reading, spelling or numeracy1  14% of looked after children have been in trouble with the police1

Local evidence of educational attainment clearly illustrates the difference in outcomes between looked after children and non-looked after children:

Year LAC Gloucestershire 2002-03 5.7% 62.1% 2003-04 7.0% 62.2% 2004-05 3.4% 62.1% 2005-06 3.0% 63.3%

Table 5: Percentage of young people leaving care (LAC) aged 16 or over with 5 or more GCSEs at grade A*-C or a GNVQ compared to Gloucestershire overall. Source Gloucestershire County Council

Children who are looked after, or who have been adopted, may have suffered permanent psychological and emotional damage as a result of their experiences, especially if they have been abused or neglected from a very young age. This is because high stress levels can lead to “hard wiring” of maladaptive responses, and to the development of disordered attachments4. This damage may manifest itself in many ways eg lack of empathy, inappropriate sexual behaviour.

The experience of abuse or neglect can adversely affect all areas of development and lead to social, emotional or psychiatric problems that persist into adulthood. Evidence shows that 45% of looked after children had some form of mental health problem (compared with 10% of non-looked after children), and that the actual experience of being looked after can exacerbate mental health problems or lead to the development of new difficulties5.

Many adopted children come from the LAC population and are more likely than the rest of the LAC population to have suffered abuse and neglect6. For some families adoption carries an additional stigma in society. Their emotional needs stem from early abuse/neglect/ and sometimes rejection by birth parents. Whilst being looked after they are likely to have had at least 3 placements and waited some time before an adoptive family was found and they take this legacy with them into their new family. Adopted children have to develop new relationships with adoptive parents, siblings, extended family, and peers. Sometimes children need help with:

 Developing attachments in the new family  Issues of identity - who am I and why am I here? This can be particularly prevalent during adolescence7  Managing contact (especially managing multiple families)

Young offenders

This group is also numerically relatively small yet has high needs and poor outcomes. The prevalence of mental health problems among young offenders is approximately 40%; problems include conduct disorder, autistic spectrum disorder. There is a high suicide rate for those in young offenders’ institutions. They are also more likely to have a learning disability. A survey of psychiatric morbidity among imprisoned young offenders aged 16-20 was carried out in 19978. This found that 30  Almost 10% of females had been admitted to a psychiatric hospital  84-88% of males had a diagnosable personality disorder  4-6% of males and 9% of females had a diagnosable psychotic disorder  41% of males and 67% of females scored highly on tests to ascertain neurotic disorders  20% of males and 33% of females had attempted suicide at some stage in their lives  7% of males and 11% of females had self harmed  The average score on IQ testing was lower than in the general population  62-70% of males and 51% of females had high scores on a test to ascertain alcohol misuse  More than 70% of all respondents reported using drugs in the 12 months prior to being imprisoned

Although there have been some improvements in service provision for this group, a Healthcare Commission Report recommended that greater improvements were required for 16-17 year olds, as this age group is responsible for most of the crimes committed by young people, including the more serious crimes, but they have the greatest difficulty accessing child and adolescent mental health care9. In 2006, 793 assessments were carried out in Gloucestershire among 1500 young offenders (those who were not assessed may have been fined or cautioned and not referred to the Youth Offending Service (YOS).

Children and young people with disabilities (including learning disabilities)

This is a numerically large group with relatively high needs and poor outcomes. It includes those with chronic health problems such as cystic fibrosis. The prevalence of disabilities is likely to increase as more pre-term babies survive (with the consequent risk of learning disability), more children survive serious trauma or illness, and more children with life limiting illness (eg cystic fibrosis) survive into adulthood. It is difficult to quantify exactly how many disabled children and adolescents live in Gloucestershire because of difficulties in defining disability but data from both the local authority and the primary care trust show that:

 The 2001 Census showed that 4,458 0-18 year olds reported a long term illness  3% of school children have a statement of special educational needs  13,913 children attending mainstream schools in the county and 792 attending special schools have an identified primary need that adversely affects their functioning and learning  2,316 children attending mainstream schools and 233 attending special schools have identified emotional, behavioural or social disorders, and many of these also have learning disabilities

Mental health disorders affect 30% of children who are physically disabled10 – see table 1 below. Risk factors and prevalence differ between conditions. Disabled children are at greater risk of abuse, and being abused increases the risk of mental health problems.

Risk factors in child Impact on rate of mental disorders Physical illness 3 times increase in rate 31 Chronic health problems Brain damage 4-8 times increase in rate of disorder in young people with cerebral palsy, epilepsy or other disorder above the brainstem Sensory impairments 2-3.5 times increase in rate Hearing impairment (4 per 1,000) No figures but rate of disorder thought to be Visual impairment (0.6 per 1,000 increased Learning difficulties 2-3 times increase in rate, higher in severe rather than moderate learning difficulties Language and related problems (2%, but 4 times increase in rate of disorder improved identification needed)

Table 1: Prevalence of specific child and adolescent mental health risk factors and impact on rate of mental disorder . Source Young Minds10

Mental health problems are more prevalent among children and adolescents with learning disabilities. Data from two large surveys by the Office for National Statistics were combined11 and the following results were obtained:

 3.5% of all children were identified as having learning disabilities (LD)  Children with LD were more likely to have poor general health, live in a poorly functioning family and have been exposed to a variety of adverse events eg abuse, domestic abuse  36% of children and adolescents with LD have a diagnosable mental disorder  Children and adolescents with LD are 33 times more likely to have autistic spectrum disorder, 8 times more likely to have ADHD, 6 times more likely to have a conduct disorder and 4 times more likely to have an emotional disorder  Children and adolescents with LD are more likely to have multiple mental health disorders

References

1. Meltzer H, Corbin T, Gatward r, Goodman R, Ford T (2003) The mental health of young people looked after by local authorities in England: summary report http://www.statistics.gov.uk/downloads/theme_health/Mental_health_children_in_LAs.pdf accessed 21.3.07

2. http://findoutmore.dfes.gov.uk/2006/10/lookedafter_chi.html created October 2006; accessed 23.11.06

3. http://www.socialexclusionunit.gov.uk/downloaddoc.asp?id=42 created 2003; accessed 20.11.06

4. Hosking G, Walsh I (2005) The WAVE report 2005: violence and what to do about it Croydon: The WAVE Trust

5. BMA Board of Science (2006) Child and adolescent mental health; a guide for healthcare professionals London: BMA

6. PIU (2000) Prime Minister's Review of Adoption. London: Department of Health. 7. Brodzinsky The psychology of adoption

8. Lader D, Singleton N, Meltzer H (2000) Psychiatric Morbidity among Young Offenders in England and Wales

32 http://www.statistics.gov.uk/downloads/theme_health/PyscMorbYoungOffenders97.pdf accessed 21.3.07

9. Commission for Healthcare Audit and Inspection (2006) Let’s talk about it: A review of healthcare in the community for young people who offend

10. Young minds (2001) Guidance for Primary care trusts child and adolescent mental health: its importance and how to commission a comprehensive service http://www.youngminds.org.uk/camhs/index.php accessed 21.3.07

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