Stability & positive long term outcomes for Looked after Children Efun Johnson Designated Doctor for...

Stability & positive long term outcomes

for Looked after Children Efun Johnson

Designated Doctor for Looked after Children, Lambeth

Dr Efun Johnson November 2013

Introduction

“The need for good quality health assessments to enhance services that give stability and positive long term outcomes for Looked After Children.” - Dr. Efun Johnson


Overview of workshop

• Children’s Rights -UNRC articles• Looked after children – the background and

context • Placement stability -importance• Guidance for health of Looked after Children• Action points for practitioners


UNCRC• Ratified in UK in 1991

• 42 articles

• What the convention says about keeping looked after children safe


UNCRC• Article 19 – Governments should ensure that

children are properly cared for, and protected from violence, abuse and neglect by their parents, or anyone else who looks after them.

• Article 25 – Children who are looked after by their local authority, rather than their parents, should have their situation reviewed regularly.


Definition of “stability”

The state or quality of being stable, or firm. The strength to stand or endure.

Merriam Webster Dictionary

Definition of “resilience”Process of, capacity for, or outcome of successful adaptation despite challenging or threatening circumstances.

Masten, Best Garmezy (1990)


Placement Stability

• The short term stability indicator measures the number of placements a young person has in a year.

• The long term stability measure identifies those young people who have lived in the same placement for two years, if they have been looked after for two and a half years. National Indicator 63.


National and Local Themes

• It is generally agreed that it is damaging for children to be moved often and is known to have an adverse affect on their emotional stability and security. It also has a considerable impact on their education and learning.

• NICE/SCIE guidelines for LAC (2011) Encourage warm and caring relationships between child and carer that nurtures attachment and creates a sense of belonging so that the child or young person feels safe, valued and protected. Emphasis on multi-agency working.

• Every Child Matters - "Stability can make a positive difference to their [children's] lives, giving them the opportunity to form strong attachments with carers and friends, maximising their resilience, and improving their chances of achieving positive outcomes".


Why is placement stability important?

• Attachment• Importance of Relationships• Child Development (social, emotional, cognitive,

physical) • Educational achievement• Interests and enjoyment• Community • Developing identity


Why is it important that children form secure attachments?

– Attain his/her full potential– Have a blue print for relationships– Think logically - executive functioning– Develop social emotions and conscience –Theory

of mind– Trust others– Become self-reliant– Cope better with stress and frustration– Reduce feelings of jealousy– Overcome common fears and worries– Increase feelings of self-worth


What is known to contribute to instability – Child factors

• Child aggression• Mental health problems• History of maltreatment/abuse• Child’s perception that the placement is

temporary• If been in residential care previously.


Local factors - child

• Gang involvement/affiliation• Offending• Absconding / missing from care• Substance misuse• Risk of sexual exploitation• Not in education • Non-engagement with services


Birth family risk factors

• Parental substance misuse or alcohol abuse• Parental criminality• Death of a parent


Birth family – local factors

• Internet/ social networking• Loyalty to birth family• Unconscious manipulation/ sabotaging of

placement• 14+ years safeguarding plans may need to

be reassessed• Parental mental health• Siblings at home • Parental relationships with new partners


Placement risk factors

• Siblings placed separately• Younger foster children in placement or

recently moved in• Foster carer’s own children within similar age

range


Placement – local factors

• Good matching• Timing – e.g. moving placement as transition

to secondary


Carer risk factors

• Carer having unrealistic expectations (e.g. expecting gratitude/respect; challenging behaviour)

• Carer stress – difficult life events


Carer - local factors

• Lack of flexible/adaptive parenting skills• Single/pair of FCS• Lack of family network• Carer life experience – unresolved trauma/abuse/life

experience• Own extended family history of mental health problems• Language barriers


Relationship risk factors - attachment

• Child - SW • Carer - SW – clear communication• Child – Carer, e.g. eating, boundaries, seeking

help• Child - birth parent


Relationships – local factors

• The match• Splitting of the roles: FC needing more support

and SW hearing they can’t cope• System is feeling stuck, feeling hopeless• IRO consistency


What promotes stability?

Child factors: • Placements that support intellectual/educational

development• Meaningful friendships • Activities - consistent


Local factors - children

• Resilience and adaptive• Able to seek support when hurt• Ongoing Life story work to promote a

coherent narrative• Emotional regulation/intelligence• Pro-social skills


Protective carer factors

• Carer with good family support – long-term partnership

• Social support – friends, neighbours, colleagues, respite

• Carer parenting ability - strong parenting skills


Local factors- carer

• Genuine interest in children• Warmth• Humour• Patience• Energy• Open to novelty • Emotionally resilient/emotional intelligence• Good cook….


Protective relationship factors

• Role models• SW continuity• Positive child - SW relationship• Positive child - carer relationship• Managed contact with birth family • Education • Positive peer relationships• Sense of community


What are the outcomes of instability on child and psychological

development?

• Impact on an already disrupted attachment pattern• Emotional development- delay or dysregulation• Social development –theory of mind• Cognitive development – executive functioning• Behavioural problems – tantrums, challenging

behaviour, aggression, oppositionality• Low resilience


Social Care Perspective

• Thorough assessment by SW

• Informed intervention plan• Identification and matching

of appropriate F/C• Need for multi-agency

working and clear communication

• Impacted on by varying standard of assessment

• Lack of FC recruitment?


Looked After Children

Background, Outcomes , Pathways and

Guidance


How Many Children?

• Nationally – children in England• CLA in UK

England Lambeth Southwark Lewisham


Context

•Child altogether in England - 11 million•Lambeth, Southwark, Lewisham - 600,000•Over 91,000 looked after children in the UK

•England - 67,050 children looked after (31 March 2012)•Northern Ireland - 2,644 children looked after(31 March 2012)•Wales - 5,725 children looked after (31 March 2012)

•Scotland - 16,248 children looked after ( 31 July 2012)

•3,400 adopted


Trends

Significant •Fall in the No. of CIC over past 30 years, then

– ↑ between 2008 - 2009 (overall increase almost 3%)

•Increase in the No. of care proceedings in England following Baby P Inquiry (CAFCASS, 2009).

•Children remaining in care for longer periods,– 13% staying in the care system for more than 5 years

(House of Commons, 2009).


Who are the looked after children?

What are the reasons for being LAC?


Reasons for being LAC


Reasons for being LAC• Abuse or neglect• Child’s Disability• Parent’s illness or disability• Family in acute stress• Family Dysfunction • Socially unacceptable behaviour• Poverty• Assent parenting/Child abandonment


What is fostering?

• Fostering is a temporary arrangement

• Allows a child to live with a family until circumstances enable the child to:

Return to their own familyLive independently or Be placed for adoption.

• Can be for a few weeks, months, or even years


Foster carers are:

• Always given an allowance towards the cost of keeping the child

• Share the responsibility for the child with the agency


Private Fostering

• Looked after by an adult who is not a relative for more than 28 days

• Child under age of 16 (18 if disabled)• Private arrangement between parent and carer• Not Looked after by LA• Carer does not hold PR• Carer has legal obligation to inform their Local

council of intention & when child leaves care• Most children are black and most carers white


Private Fostering

• Often lack of information on child e.g. name• Lack of medical histories• Frequent moves• Abuse can occur• There can be cultural problems• Often it is with carers that have been turned

down for fostering!

Children need to be safeguarded


What is adoption?

• Legal procedure

All parental responsibility is transferred to the adopters

• Once an order has been granted,

It cannot be reversed

• An adopted child

Loses all legal ties with the birth family Becomes a full member of the new family


Adoption- pattern changed

Changes in social support has encouraged new thinking about:

• which children are eligible for adoption • who is eligible to adopt.

ChildrenAdoptersContact


Who can adopt?

• Must be over 18

• Show that they can give a child the care needed

• Be able to afford to take in the child

• The requirements vary from agency to agency

• Focus is on needs of the child


Adoption- who can adopt now

• Married couple • Unmarried couple living in an enduring family

relationship, same or different gender

• Single person over 18• Married person where spouse cannot be found, separated, likely to be permanent spouse incapable of applying due to physical or mental illness

• Partner of parent of child


Why adoption fails

• Information not clear or realistic• 36% positive• 33% negative• 13% mixed

• problems not fully recognised by agencies• anticipating the wrong problems• being deliberately misled increased

disruption


Outcomes


Attainment snapshot• On average 58% of those LAC in the appropriate age group

achieved level 2 at Key Stage 1 & 51% achieved level 4 at Key Stage 2.

• The comparable %ages for all children were 85% & 82% respectively.

• 68% of LAC obtained at least 1 GCSE or GNVQ compared with 99% of all school children who achieved any qualification.

• 29% of LAC did not sit an examination of this type


Continuing education, employment & convictions

At the end of school year 11, •73% of children remained in full-time education •14 were unemployed the September after leaving school.

•9% of LAC aged 10 or over, were cautioned or convicted for an offence - 2½ times the rate for all children of this age.


Health outcomes

• 84% of LAC had immunisations that were up-to- date

• 86% had a dental check, • 85% had an annual health assessment • 5% of LAC were identified as having a

substance misuse problem (60% received an intervention)


Cautions and Convictions

• 9.6% of looked after children aged 10 or over, were cautioned or convicted for an offence during the year, almost 3 times the rate for all children of this age.

• This rate has been similar over the past 3 years.


In summary

LAC have poor outcomes for:• Health • Education• Employment opportunitiesTherefore • We need to provide a coordinated and

comprehensive package of care to improve the outcomes for these children & YP


Issues/Risks for LAC

• Mental health (30-50%)• Education• Learning difficulties (20-30%)• Risk taking behaviours• Maltreatment• Criminality• Poor outcomes


Health issues

• Information collation• understanding of vulnerability and needs• Factoring in birth parents - inheritance• Information sharing • Consent and confidentiality • Seeing ourselves as corporate parents


Why such problems?


Before Birth

• Genetic– Parental learning difficulties, mental ill-health– Physical health – heart disease, sickle cell…

• Antenatal– Maternal substance abuse– Infection, ill health, poor nutrition


After Birth

• Poor Care• Poverty• Abuse and Neglect• Parental ill-health, substance abuse, • Social exclusion, prejudice


Where are they Looked After?


Placements(2011-12)

• 76-79% in foster care (LSL)• 26% placed in Southwark (Lew 40%)• 60% < 7 miles of home address• 83% <20 miles of home address

• 69, 12.6% moved > 3x in last year• 21, 4% adopted in last year


Guidelines and Legislation

• Adoption and children’s Act 2002• National standards for Adoption• Intercountry adoption Health issues for Children• Promoting Health of Looked after children• Every child matters• Promoting quality of life of LAC (NICE/SCIE)


Longstanding Legislation/Practice Guidance

• Children Act (1989/2004)• Quality Protects (1998)*• Leaving Care Act (2002)• Every Child Matters (2003)• Healthy Care standards(2003)• Raising the educational attainments of Children in

care (SEU 2003)• Working Together to Safeguard Children(2010)• “Care Matters” (2007)


PHLAC (Statute)-LAC health role

• Principles of Good Health Care

• Health Assessment, Planning, Intervention and Review

• Roles and Responsibilities of Councils

• Roles and Responsibilities of the NHS

• Health Promotion - Planning• Provision for Mental Health• Confidentiality, Information

Sharing and Consent


Role of Designated Professionals

• Advisory role • Policy and procedures• Annual report• Clinical governance and audit• Training• Liaison• Monitoring and information management


NICE/SCIE – Promoting quality of life

• Qualitative review • Published in October 2010• Identified research on the

views, experiences and preferences of children and young people about the care system.

• 10 databases searched• Data extracted from 50

studies


Principles and values

• Put the voices of C/YP and their families at heart of service design and delivery.

• Tailor services to the individual and diverse needs of C/YP by ensuring effective joint commissioning and integrated professional working.

• Develop services that address health and wellbeing and promote high-quality care.



• Encourage warm and caring relationships between child and carer– nurture attachment – create a sense of belonging – C/YP feels safe, valued and protected

• Help C/YP to develop a strong sense of personal identity (maintain chosen cultural & religious beliefs)



• Ensure YP are prepared for and supported in their transition to adulthood.

• Support the C/YP to participate in the wider network of peer, school and community activities– build resilience & sense of belonging

• Ensure C/YP have a stable experience of education – encourage high aspiration


NICE Guidance –LAC/YP needs

Evidence statements suggest they need:• Love & affection (often lacking in their lives)• A sense of belonging• To be supported• someone to talk to• continuity in their relationships with

professionals


Can we safeguard?

Through service provision & design for :1. Children on edge of care

– Keeping children on the radar & – keeping in contact with agencies

especially in neglect2.Children in care

– Listen to children, and– look out for the signs / access to children


Keeping LAC/YP safe

Using•UNCRC and advocacy•NICE /SCIE guidance, ‘Promoting quality of life for looked-after children’. and•Statutory guidance – Promoting Health of LAC•Publications e.g. Munroe review


UNCRC• Ratified in UK in 1991• Rights of the C/YP

• 42 articles

• What the convention says about keeping looked after children safe


UNCRC• Article 19 – Governments should ensure that

children are properly cared for, and protected from violence, abuse and neglect by their parents, or anyone else who looks after them.

• Article 25 – Children who are looked after by their local authority, rather than their parents, should have their situation reviewed regularly.


UNCRC

• Article 20 – Children who cannot be looked after by their own family must be looked after properly, by people who respect their religion, culture and language

• Article 22 – children who come into a country as refugees should have the same rights as children born in that country


UNCRC

• Article 39 – Children who have been neglected or abused should receive special help to restore their self-respect.

• Article 31 – All children have a right to relax and play and to join in a wide range of activities


UNCRC

• Article 12 – Children have the right to say what they think should happen, when adults are making decisions that affect them, and to have their opinions taken into account

You need • To involve C/YP in decisions• To seek their wishes and feelings• To be aware of their rights


Munro Review

• Published 10th May 2011Noted -‘Spending time with

children is given too low a priority’

C/YP told the review that what they value most are:

• good relationships with professionals they can trust and practice that focuses on their needs, and

• Continuity


Messages for practitioners

• Spend time with C/YP • Treat C/YP respectfully • Provide continuity• Build relationships with C/YP• Provide services that focuses on C/YP needs• Maintain services beyond ‘crisis’• Advocacy services can be critical • C/YP may need to talk about abuse and harm• Remember C/YP have rights.


Intercollegiate Framework

Definition of COMPETENCE :

“ A set of abilities that enable staff to effectively safeguard, protect and promote the welfare of children and young people in care”


Intercollegiate LAC Competence Framework - 5 levels

•Level 1: Non clinical staff working in any healthcare setting

•Level 2: Clinical staff with contact with C/YP/parents/carer

•Level 3: All staff working with LAC/carer/parent

•Level 4: Specialist roles Medical/Nursing/health advisors for LAC

•Level 5: Designated professionals for LACDr Efun Johnson November 2013

Levels 1/2• Level 1 – nonclinical

staff in healthcare settings

• Level 2 - staff with contact with Children/YP/parents/

carers

• Aware of terminology• Aware of some

legislature

• Same as level 1• Understand

consent/confidentiality• Specific LAC staff

needs additional training


Level 3 - All health staff working with Looked After Children

Staff groups: Universal services: HV, midwives, school nurses, children’s general and specialist nurses, CAHMS staff, paediatricians, CASH services, GPs, LD, forensic nurses/doctors


Level 3 - core competence• Achieve levels 1 and 2• Able to respond to to impact of adverse life events• Apply knowledge of holistic health needs• Able to initiate interventions to improve resilience• Recognises impact of parental health concerns on

C/YP• Understands interagency working & can contribute• Recognises own limitations and seeks advice from

specialist• Able to share info appropriately• Empathic and supportive


Assessments


Statutory Health Assessment

– Identify unrecognised health needs– Identify mental health, behavioural and

emotional problems– Recognise developmental or learning

concerns– Plan appropriate action and ensure

recommendations are carried through– Discuss life style issues– Plan follow up


Statutory Health Assessment

Different Categories of assessment in guidance• Children less than 5 years old• 5 – 10 years old• 11 – 18 years old

4 different types of forms• IHA-C and YP• RHA- C and YP


Health Care Plan

• Written report and health plan for 1st review (4 weeks after coming into care)

• Brief description of identified health issues– Clearly headed action points– Time-scales for action– Person expected to act

• Statutory review at health assessments– Twice yearly for under 5s– Once yearly for over 5s

• Integration in care plan


Is care good or bad?:

• There are limits to what Care can achieve. Some children will always carry the scar tissue of their heredity, gestation and early experience

• Nevertheless on balance Care contributes much to the happiness of those in it

• There is reason to think that it could work better and more cost effectively but not that it requires root and branch reform


Evidence:

• Sinclair I. Fostering Now: Messages from Research, Jessica Kingsley 2006

• Beecham J. and Sinclair I., Costs and Outcomes in Children’s Social Care, Jessica Kingsley, 2006

• Sinclair I., Baker C., Lee J., and Gibbs I.: The Pursuit of Permanence, A study of the English Care System Jessica Kingsley, 2007


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