© Rebecca Sng. 2008. Yes, But What Works with kids with high needs? The Alternate Care Clinic...

© Rebecca Sng. 2008.

Yes, But What Works with kids with high needs?

The Alternate Care ClinicTherapeutic support for kids in care

Presentation by:

Dr Rebecca Sng - Unit Head, A.C.C. and

Dr Megan Chambers - Director, Redbank House


After Entry Into Care• The data we have suggests that

children in OOHC have ongoing, unmet mental health needs(Bundle, 2001; Williams, Maddocks, Cheung, Love, & Hutchings, 2001)

• Some studies suggests that the rates of psychopathology in the High Needs population are comparable to the rates in Juvenile Justice facilities and Psychiatric Inpatient Units.

• Yet NSW did not have a single multidisciplinary unit dedicated to the mental health needs of this population.


Core Question

How to deliver child and adolescent mental health

services to children in care?


Introduction to the Alternate Care Clinic


What is the ACC?• A joint project b/t DoCS and Dept of Health• Services children/young people in long-

term out-of-home care (OOHC) with a high level of complex needs

• Provides flexible and comprehensive interventions with open time frames

• Seeks to co-ordinate and support services involved with the client to ensure the highest possible standard of care.

• Works on systemic, attachment based framework.


Who are the staff?

• Department of Health staff– Psychiatrists– Social Worker– Clinical Psychologist– Clinical Neuropsychologist

• Dept of Community Services staff– Psychologists– Psychology internship programme


Therapeutic Model

Improve Safety

Improve Reflection

Improve Functioning

Child Medication to decrease arousal

Coherent narrative development

Problem Solving, Affect Regulation, Interpersonal skills

Carers Build empathy/ decrease misunderstanding

Putting things in developmental/ historical context

Training the carers to teach the skills.Inc skills of carers

Wider System

Decrease anxiety in the system

Long-term planning (not crisis driven)

More coherent system, clearer communication etc


Question 1

• How to deliver those services to high needs young people who:– Never attend appointments– Are not “customers” for therapy– Are emotionally and behaviourally

unstable– Periodically substance abusing– Periodically in detention


Psychiatrist Only Model

Example 1


The Casual AttenderProblem:There are a number of

adolescents in care who are a source of high anxiety to their DCS case managers.

• These adolescents may– present to hospitals with psychotic

symptoms– may be heavy substance users– may be prescribed a range of

medications by multiple practitioners who see them in multiple settings

– are high risk takers, impulsive and potentially self-destructive.


The Casual Attender• Classically they are:

–Frequent absconders–Have extensive trauma histories

–Come into care late – Have difficulties with affect

regulation in multiple contexts, with resulting police and juvenile justice involvement.


The Casual AttenderIn terms of relationships they:

•Have very few stable relationships.

•They are often in peer groups which are alienated from adults.

• They usually do not tolerate intensive intimate involvement with adults.


Is there any point referring these young people for mental health assessment and treatment??

What would be the purpose?• After missed appointments• Unavailability at crisis times• Missed/abused/chaotic dosing of

medications• The risk of alienating the young

person because of pathologising experiences.


HOWEVER…..

There are potential benefits if these difficulties can be

managed…..


1. Decreasing anxiety in the carers

HOW? • By predictable, and informed

involvement of the mental health professional. – This comes from regular appointments with

the key staff involved, which proceed whether the young person is there or not.

• This can also be a risk management/risk sharing strategy with case plans, including mental health plans, and opinions which are proactive rather than reactive.


2. Improved ownership/coherence in the health system

This can lead to• Better crisis management• Improved communication• Less reactive prescribing • Monitoring of compliance and

effectiveness of medications(via staff)

• More accurate diagnoses based on longer-term assessments.


2. Improved connection with the young person (sometimes…)

This can lead to:• Decreased anxiety • Less pathologising• Some openness to other contacts• Familiarity with the place and the

process and (hopefully) not too much reactivity to them

• Hopefully thoughtful listening to their concerns.


To do these things, a mental health service

must….• Manage missed appointments,

sometimes not seeing the identified patient for some time

• Manage being the focus of frustration from other services

• Manage feeling relatively impotent, and knowing that they can only contribute a small ingredient of the young persons case plan.


HOWEVER…

It is a systemically

coherence-aiding and

anxiety-reducing ingredient…

and hence can assist the young person significantly.


Question 2• How to promote therapeutic

relationships with multiple carers– Who have no background in

attachment and trauma frameworks – Who are presented with extremely

challenging behaviours– Who have unpredictable changes to

their work settings– Whose agencies are operating in an

uncertain environment.


Residential Care Worker Training

Example 2


Building a new house of Behaviour Management

I have a good relationship with my carer

My feelings are OK I am a “good kid”

I trust adults to be in charge

I can make mistakes safely.


RCW Training Programme

• 7 sessions of two hours each• Made up of modules and concepts from

a wide variety of sources, as well as original material.

• Based on the model that improvement in functioning is based on improvement in emotional/physical/relational safety and an increased capacity to reflect and process.


RCW Training Programme

• Presentation of content material is not enough.– Training includes a variety of

experiential exercises.– Most importantly, staff must be given

time to apply the concepts with adequate support. One off workshops are not effective in this way.


How is different to training Foster Carers?

• Often more complicated team dynamics

• Consistency is harder to achieve• RCW’s often have had their

relationship with the child minimised

• Misunderstanding of professional boundaries


So why is it important?• Pivotal to achieving

emotional/relational safety for clients. Without this, functional improvement is impossible.

• This safety will only be achieved by:– Attachment-based, sophisticated, well

understood behaviour management – Complex comprehension of the young

person’s experience – Emotional capacity to provide the

relationship environment that allows not just management but also recovery.


References

Bundle, A. (2001). Health of teenagers in residential care: comparison of data held by care staff with data in community chid health records. Archives of Diseases of childhood, 84, 10-14

Williams, J., Maddocks, A., Cheung, W-Y., Love, A., & Hutchings, H. (2001). Case-control sudy of the health of those looked after by local authorities. Archives of Diseases of childhood. 85, 280-285

© Rebecca Sng. 2008. Yes, But What Works with kids with high needs? The Alternate Care Clinic...

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Transcript of © Rebecca Sng. 2008. Yes, But What Works with kids with high needs? The Alternate Care Clinic...