Children and Young People Committee
Inquiry into Arrangements for the Placement of Children into care in Wales
Response of the Association of Child Psychotherapists’ Regional Group for Wales
Introduction
1. The Association of Child Psychotherapists
(ACP) is the main professional body for psychoanalytic child and adolescent psychotherapy in the UK (see appendix for more information). We welcome the opportunity to contribute to the inquiry of the Children and Young People Committee into examining the effectiveness of systems for placing children and young people in care. This response is informed by child psychotherapists’ extensive experience of work with children, young people and the professional networks around them.
2. People systems.
Placing children and young people with foster carers is a complex process which demands that systems are durable and resilient enough to manage this complexity. We believe that crucial to Wales’ better management of this complexity is the continued recognition that in dealing with systems we are dealing first and foremost with people. A focus on systems in our view would therefore need to retain sight of the individuals they consist of and in particular the child whose needs at the roots of the systems influence the character, operation and structure of the system at all levels.
3. Distress as communication
We have observed that all people systems involved either directly or indirectly in the care, treatment, management or planning of looked after children are affected by the unique stressors that have caused a serious breakdown of healthy family functioning. In considering how to design more effective systems for dealing with the distress of looked after children, the people that the systems consist of need the opportunity to better understand that children and young people under stress communicate through action rather than words. A system of people that cope with the child’s communications of distress is a system that will function better at all levels. We firmly believe that if the distress of the child or young person in care is not emotionally understood and contained at a grass roots level, the distress moves up through the system: child to foster carer to social worker and teacher to heads of service, eventually sapping time and resources from managers, planners, commissioners and ministers.
4. Maximising personal resilience
. In our experience the success or otherwise of professional systems (including schools) to function in a way that helps prevent family breakdown depends almost entirely upon the capacity of the hosting family and first tier system of professionals to help the child understand and emotionally contain his or her experience of family breakdown. This original experience is sometimes voiced but more usually acted-out in the form of disturbing, rejecting or provocative behaviour fuelled by unresolved fears, anxieties and expectations shaped by previous experience. In this respect, we believe that creating healthy systems involves the better preparation of its personnel to maximise their personal resilience in the face of severe distress communicated by children and young people through their behaviour. Better preparation of foster carers and tier one professionals will help minimise the potential for serious patterns of disturbance to become re-established within the foster home. As a consequence of better emotional containment at the child’s level, there will be less of a need for severe distress and anxiety to find its way up through the various tiers of an organising system.
5. What are we dealing with
Two-thirds of looked after children and young people enter care suffering the effects of abuse and neglect. The symptoms presented by this group of children are serious. Mental health problems amongst children in care are four times higher than in the general population (3). They include chronic depression and anxiety, attachment disorders, low self esteem, obsessive-compulsive disorders, soiling or smearing of faeces, sexualized preoccupations and sexual activity, volatile mood changes, aggression and defiance. A third of children in care have a statement of special educational needs compared with three per cent of all children (18). Children who have been in care form up to a third of rough sleepers and a quarter of adults in prison (4). Childhood conduct disorders cost the economy in excess of £3,000 (5) per year per child and this escalates to £70,000 as the young person reaches adulthood (6).
6. Many children and young people survive adverse early experiences by forming psychological defences (7). They may retreat behind a protective shell, becoming withdrawn and cut off from emotional life and development; or they may become hyperactive, too busy to think or feel. Many looked-after children reject help, leaving their carers feeling helpless and useless. This can be linked with multiple placement breakdowns, which have a profound impact on their development (1, 2). Some children become identified with the person who hurts or deprives them. This can lead in turn to future abusive behaviour. These maladaptive defences, if untreated, can make it impossible to trust, accept help, or learn.
7. The more disturbing the child’s experience of distress, the greater the risk of repeated placement breakdown. ÒThe largest category of need for children starting to be looked after in the year to 31 March 2008 was ‘abuse or neglect’ at 52 per cent of the total.Ó (CYPC correspondence May 2009). Of the 4,633 looked after children, 11 per cent had three or more placements during the financial year 2007-08 (ibid). These figures are worrying. They point towards three simple truths:
That the experiences of abuse and neglect are the biggest cause of natural family breakdown in all categories related to looked after children
That amongst children who are looked after, those who have experienced abuse and neglect are over represented in terms of experiencing further, repeated family breakdown
That simply changing the family does very little to alter the underlying experiences which are the root cause of unbearable behaviours and the subsequent repeat breakdown.
8. The majority of looked-after children in Wales do not receive the treatment they need. In our experience, the multiple breakdown of family systems is exacerbated when professionals with the specialist skills to support children, foster families and social workers in understanding and working through the home-breaking effects of abuse and neglect are not available on an equitable basis throughout Wales. Child and adolescent psychotherapy is only partially commissioned in Wales,meaningthat the majority of children, young people and families in Wales do not have access to this vital service.Only three of the eight Welsh Health Boards currently commission child and adolescent psychotherapy. Most mainstream CAMHS cannot provide treatment for children during court proceedings or while awaiting long-term placement, adoption or rehabilitation. This is a period when a therapeutic intervention can make a crucial difference. The ACP believes that there should be 1.3 child psychotherapists per 100,000 of the general population or 1 per 10,000 of the under-19 population.
9. There can be lasting and damaging consequences for the emotional and mental health of those children who do not have access to appropriate services.
It has been estimated that 90 per cent of children who have experienced sexual abuse receive no substantial support (23). Untreated children who suffer from abuse – up to 60 per cent of those who enter care – can be at increased risk of depression, post-traumatic stress disorder, relationship difficulties and attachment disorders, risky behaviour and negative self-image and attitudes towards other people (24).
10. Complex needs require specialist services.
The support required to make a placement work needs to be intensive, long term and provided by skilled professionals. The use of killed professionals in work with this client group saves on emotional distress and therefore financial resources too, as a well contained foster family requires less input from social services, medical care (self harm and heavily monitored pharmacological programmes of care), police, probation, drug and alcohol misuse services and educational resources. Intensive work for these purposes may be as little as one or two hours per week of a specialist’s input, which compares favourably to the many hours of other services that are often required in the absence of specialists who are formally trained to emotionally contain severe distress.
11. The complex mental health needs of children in care are best met by specialist multi-disciplinary teams of highly qualified, experienced professionals working alongside social services and mainstream CAMHS. In the Hywel Dda Trust, 1.2 wte child psychotherapists provided more than 1,500 direct
consultations to children and young people. Approximately 90 per cent of these sessions were provided to children and young people who were looked after, the majority of which were maintained within their foster placement. (Hywel Dda, CAMHS, Child Psychotherapy Service).
12. Following the recommendations of Lord Laming, our English counterparts in many local authorities have set up designated multi-disciplinary mental health teams for looked-after children (28). In order to meet the complex needs of this vulnerable client group, these services provide multi-systemic interventions in line with findings from child development research and attachment theory that childrens’ paramount need is for secure, continuous and stable relationships. These services provide fast response multi-disciplinary assessment; placement support; treatment including psychotherapy for children in transition; consultation to carers, social workers and professional networks; training, audit and research (29) These specialist services are responsive to local contexts and work within or alongside social services. The emerging evidence for good practice in this area needs to be gathered and built upon in Wales (30).
13. Specialist CAMHS provision should also be developed for ‘children in need’ or children on the edge of care. Resources need to be made available so that these vulnerable children and families are not denied services. Specialist assessment is needed to identify children who can safely remain with their family given the right support, and those children whose emotional or physical welfare can only be ensured by taking them into care. Currently, specialist services for this high-risk population are under-developed or non-existent. These families struggle to access mainstream CAMHS but rarely have the opportunity of specialist help.
14. Support and training needs to be ongoing and fit for purpose.
A common misconception in our experience is the notion that quick fixes for these children and young people exist and consequently that quick fix trainings can suffice. This belief in Wales has led to a re-defining of the term ‘specialist’ within the context of providing a service to the most vulnerable groups. Wales’s specialists now include people with no formal child mental health or child psychotherapy qualifications even though ‘specialist psychotherapy’ has been cited in recent W.A.G. documentation as an ‘indicated service’ of need. (National Action Plan to Reduce Suicide and Self Harm in Wales Consultation
). As a result, we are now seeing a rapid growth in the market for child psychotherapists in Wales who have no formal child psychotherapy, child counselling or even child mental health qualifications. There are no short cuts to providing specialist psychotherapy for children and there are no short cuts in training child psychotherapists that are specialised in working with our most vulnerable people. As such, we ask that the Children and Young People’s Committee review the availability of qualified child psychotherapy professionals and professional child psychotherapy trainings in Wales, and compare the results to the rest of the UK.
15. Emotional understanding is central to care.
Critical to addressing children’s mental health issues is a thorough understanding of the psychological processes at work. Understanding the detail of each child’s history helps to make meaning of their disturbed behaviour. For many children, the process of finding meaning is like a lifeline that allows them to connect with others and to reconnect with their own minds. Research in neuroscience and attachment shows how making meaning is central to emotional and cognitive development (8, 9, 10). For children and young people who have experienced family breakdown, the professionals working with them in different areas of their lives have to join together like parents to carry out their responsibilities. Unless these complex dynamics are recognised and addressed, the disturbance and distress of family breakdown can impede effective working between professionals and agencies around the child. From this perspective we recommend that social workers have substantial experience and training from mental health professionals, including child psychotherapists, in understanding the complex dynamics around broken families and mental health difficulty.
16. Research shows that disturbance which has been internalised by a child within the first two years of family life tends to remain. Whilst sounding bleak, this is a fact which needs to be taken on board by service planners and commissioners. Without a full appreciation of this, and a knowledge of how to work with the resulting effects, unrealistic expectations, goals, treatment methods, training packages and service pressures will result, adding to the stress and impacting on the operation of looked after children’s systems of care. Children who have internalised abuse and neglect will naturally bring their life experience with them. This experience will inform their expectations, hopes and fears about other people they meet, however different these people are.
17. This we find is often one of the most corrosive elements in a foster home which is trying its best to provide a loving environment. In our experience foster families break down when the foster parents feel they are up against an unchangeable mind, a child who finds it hard to recognise that what is on offer is very different to what they have previously experienced. In the worst cases this ‘expectation’ can be so great that without adequate support it can re-create abusive and neglectful conditions within the foster home. With individual specialist treatment from a child psychotherapist, children and young people can be directly
helped to see the difference between their expectations and what is being provided. Foster parents are also helped to understand that their role is to continue to provide what is different and to bear with the often long process involving the understanding and reduction of a child’s resistance towards internalising an alternative provision of care.
18. The individual emotional and developmental needs of children and young people should be central to placement planning.
While for many children, in-borough placements may offer continuity, there is a proportion of children for whom a move away from warring or enmeshed birth-family relationships may offer their only realistic chance of developing their own identity and potential. Other children may need specialist residential care. It is important that there is careful assessment of placements to ensure that they best meet each child’s emotional and developmental needs. Whilst the needs and wishes of the child should be paramount in care planning, we also know from clinical experience that children who have been subjected to severe neglect, deprivation and abuse are often unable to make informed decisions about their care. Many children cling to abusive carers and would not choose to leave them. Only when they have been able to settle in foster care are they able to recognise that a different kind of life is possible. Financial, therapeutic and social work support for kinship carers should be on a par with that for non-related carers, to enable them to care for children who would otherwise be the responsibility of the local authority (21).
19. Whilst ethnic and cultural matching is desirable for all children, individual needs and circumstances should be assessed on a case-by-case basis. Children at risk of later mental health and emotional difficulties have a primary need for emotional continuity. Important as ethnic and cultural factors are, they should not be the prime basis for placement decisions for children vulnerable to attachment disorders (22).
20. Stable and continuous services are needed to provide a context for audit, follow-up and research to add to the evidence base for therapeutic work with looked-after children. and young people, thus ensuring continuous service development and improvement. Investment is needed in high-quality, experience-near research, audit and follow-up studies to further develop a robust and relevant evidence base.
21. Matching children and young people.
We experience much misunderstanding over this process and have witnessed some expensive therapy packages being bought-in by Welsh statutory and voluntary services because of a lack of trained child psychotherapists in Wales. Much confusion exists as to what a good match is and the professional skills and on-going responsibilities involved in how to maintain a ‘good match’. In our view, a good match is made-up of several key factors. These include:
A thorough assessment of the child/young person, where the particular features and qualities of his or her experiences and expectations are known.
Careful consideration given as to the relevance of sharing important information whether substantiated or unproven. This, we feel, needs to be taken on a case by case basis. With specialist support from qualified child psychotherapists, social workers and foster carers could be helped to make better judgements as to the relevance of available information but more importantly could benefit from specialist support in helping understand and
emotionally manage
the ongoing implications of the historical information available and any new information that arises in due course.Emotionally managing unproven information as a potential risk whilst also providing an environment where such information does not negatively influence a child’s potential is, we feel, paramount to the success of a placement but it is one of the most complex elements to work with successfully. Though draining for foster families and stressful for social workers this dual capacity has to be developed otherwise risky gaps in provision and support will exist. In our clinical experience this support is best offered in the form of a regular supervision or discussion group with specialists.
22. The meeting of two fundamentally different systems.
Good matching necessarily involves the understanding that a fostering placement involves the meeting of two very different family systems. With this understanding, the task is one that paradoxically prepares, supports and maintains the integration of two systems that are at first,
and however well hidden, incompatible at a fundamental level. Abused children tend to cling to their abusers and their ways and do not often welcome the new form of care being offered. Getting to know what a child expects, is attached to, and helping him or her sort through the confusion in such a way that allows for a greater acceptance of care, is a highly complex and task that needs returning to at every developmental milestone in a child’s life.
23. Children and their carers need stability.
The ACP believes that stability and predictability in relationships are fundamental to ensuring positive outcomes for children in care. We need to ensure that children have stability so that they are able to form supportive emotional attachments with their carers and make use of educational provision and opportunities. The quality and continuity of children’s relationships with carers and social workers is central to their recovery and future development.
24. Poorly qualified private service development in rural areas of Wales.
We have been made aware of the setting-up of several private residential therapeutic centres in country dwellings catering for looked after children who have suffered chronic sexual abuse. Our advice has been asked for to look at the therapeutic services being offered and their suitability for the client group in question. In our view, the qualifications of staff employed in two residential facilities were not of a suitable standard for working with the level of disturbance typically encountered in child sexual abuse victims. In one institution the therapy on offer was in part the invention of its founding director and included the offer of an Òorgasmic re-shapingÓ schedule which we were told has had some success in America with adult prisoners. Thankfully, in this instance the extremely dubious practice was questioned and halted before it had a chance to begin. In another, the ‘therapists’ were taking up a short term, adult-focussed training but advertising it in such a way as to give the impression that the individuals concerned were experienced and qualified in therapy with abused and abusing children.
25. To help prevent such risky developments continuing, we think that the current local authority inspectorates need to mandatorily
include a formally qualified child mental health specialist amongst their assessment team when the institution in question is claiming to provide therapeutic work or therapy to vulnerable children. This is especially important as in the current climate anyone can call themselves a ‘psychotherapist or counsellor working with children’ and those not well versed with the various levels of child mental health qualifications will not be in a position to spot the difference between qualified and unqualified therapists. Such establishments also tend to sound attractive to professionals referring from out of county where the links to the child’s social work team can be reduced due to the distances involved and links to local health compromised due to poorly co-ordinated referral and communication systems between referrer, residential establishment and local health provision.
26. The combination of cheap property in rural Wales, lack of regulation of psychotherapies for children and the apparent ease with which therapeutic services can set themselves up in places of rural isolation create serious risks for the safety of children and young people in Wales. We do not know how big a problem this may be in Wales but to have even one such example occurring is worthy of serious concern. To prevent such risks occurring we suggest the following measures:
The introduction of far more stringent guidelines on what constitutes a qualification in child psychotherapy.
Care & Social Service Inspectorates need to be multidisciplinary task forces that include a children’s mental health specialist, especially when an establishment claims to offer therapy or therapeutic work to vulnerable children. As part of this regulating responsibility, residential therapeutic establishments need to provide regular reports to a multi professional panel where the clinical provision of the establishment can be continuously monitored. It is vital that these reviews use a rigorous face to face format rather than relying on written submissions only to monitor and regulate.
More robust systems designed to ensure out of county referrers link to health professionals GP’s and local CAMHS as part of their responsibility when referring to residential establishments that are out of their county/country.
Appendix A: How do child and adolescent psychotherapists improve outcomes for looked-after children and young people?
1. Support for carers and teachers: child psychotherapists support foster carers and teachers to understand and manage the range of difficulties that children in care bring to family and school life. This facilitates more stable placements and reduces school exclusions. We know from research that the more stable foster placements are, the better the outcomes in all areas of life (11).
2. Facilitating understanding of difficult behaviour:
distorted ways of responding to carers are often repetitions of patterns developed in earlier neglectful and abusive situations. Child psychotherapists use their training in observation, child development, and psychodynamic theory and practice to help carers understand the emotional meaning behind a defiant or dismissive front and to reach the vulnerable child behind the defense (12).
3. Work in schools:
child psychotherapists carry out observations and consultations in schools, and work with teachers to find ways of supporting children so that they can manage the classroom setting. This reduces school exclusion and facilitates take-up of educational opportunity.
4. Assessment and treatment:
child psychotherapists assess children’s individual needs for treatment and provide psychotherapy which can last between six months for children in transition to up to two years or more. This slow, careful work allows children gradually to find new ways of coping that allow them to learn, trust and form new relationships (13).
5. CAMHS and specialist CAMHS:
child psychotherapists are core members of multidisciplinary CAMHS teams in three Local Health Boards in Wales, providing specialist assessment and treatment for children and young people in care. About a third of the children referred to child psychotherapists have already received other interventions that have failed to lessen their distress or change their behaviour (14). Specialist CAMHS work closely with related professionals such as looked-after children’s nurses to coordinate care for conditions where physical and mental health needs are interconnected, such as eating disorders, wetting and soiling, risky acting-out, alcohol consumption and substance misuse.
6. Training and supervision:
Along with colleagues in adult psychiatry and psychotherapy, psychology and social work, child psychotherapists provide training and reflective supervision for staff in social work, schools, residential care. They can help professionals to cope with the impact of their work with disturbed and disturbing children on a day-to-day basis, by offering psychological support and reflective consultation (15). Retention of quality staff who are emotionally invested in their work and are able to tolerate and respond effectively to young people’s needs helps to provide the continuity that children in care need.
7. Research: child psychotherapists carry out research in order to continuously develop and extend the wide range of clinical applications of child psychotherapy (16).
8. Child protection and court work:
Child psychotherapists play an important role in assessing children and families where there are serious child protection issues and providing treatment once children are in new placements (31). Increasingly child psychotherapists are playing a role as expert witnesses in specialist assessments for court where complex issues to be investigated include the degree of significant harm suffered by the child, the child’s emotional, social, psychological, educational and therapeutic needs, the relationship between the child and each birth parent and other family members, the relationship between the siblings. Often these children are caught in a conflict of loyalties, and whilst they may state in words their wish to return to their birth family, what lies beneath the surface is communication (often in the form of play or drawings) that contradicts the words. They can show how they are only too aware that, sadly, their parents are not able to prioritise their children’s’ needs over their own (32). As a result, children’s expressed wishes should be acknowledged and taken into account, but should not determine care planning.
Child psychotherapists make recommendations that can be useful for making decisions about permanency for judges in the family courts and also for adoption panels when matching takes place. They also advise on issues relating to contact with family members, and can consult to family centre workers who supervise contact sessions so that the effect of the contact on each child can be carefully thought about. Contact sessions can have a destabilizing effect on placements, but can also, when they go well, be of benefit to the child. Social services colleagues often need help assessing the quality of the contact in terms of its effect on the child – leading up to contact visits, as well as the effects after the contact. More resources and specialist training are needed to develop and extend this work.
Appendix B: About the Association of Child Psychotherapists
The Association of Child Psychotherapists (ACP) is the main professional body for psychoanalytic child and adolescent psychotherapy in the UK. Founded in 1949, it has just under 800 members who work mainly within the NHS as part of Child and Adolescent Mental Health Service (CAMHS) teams, as well as in social services, schools, hospitals, specialist clinics, the voluntary sector and in private practice.
Child and adolescent psychotherapists work with children and young people as well as their parents, families and wider networks. They also play an important role supporting other professionals who work with children and young people, including teachers, social workers, youth workers and other mental health professionals. They do this through training, supervision and consultation.
The six-year practice-based doctoral level training of child and adolescent psychotherapists gives them a unique insight into the emotional and psychological world of children. Their training is based on the detailed observation, study of child development and of conscious and unconscious communication. Their work is informed by a broad evidence base, multi-disciplinary teamwork and specialised clinical experience.
For more information, please visit: www.childpsychotherapy.org.uk
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