Introduction
This summary provides an overview of evidence relating to:
Care experienced children and young people’s mental health.
About the evidence presented below
We searched for academic research and grey literature using a wide range of search terms including: care experienced, looked after, care leavers, children, young people, mental health, trauma, child and adolescent mental health services, trauma.
There is also a brief overview on how the Covid-19 pandemic and approaches to dealing with it have affected care experienced young people.
The complexity of care experienced children’s mental health problems and difficulties with engagement can mean evidence around this topic is limited. A lack of evaluation and rigorous data means there are significant limitations on which interventions and support systems are seen to be effective or working.
Accessing resources
We have provided links to the materials referenced in the summary. Some materials are paywalled, which means they are published in academic journals and are only available with a subscription. Some of these are available through The Knowledge Network with an NHS Scotland OpenAthens username. The Knowledge Network offers accounts to everyone who helps provide health and social care in Scotland in conjunction with the NHS and Scottish Local Authorities, including many in the third and independent sectors. You can register here. Where resources are identified as ‘available through document delivery’, these have been provided to the original enquirer and may be requested through NHS Scotland’s fetch item service (subject to eligibility).
Where possible we identify where evidence is published open access, which means the author has chosen to publish their work in a way that makes it freely available to the public. Some are identified as author repository copies, manuscripts, or other copies, which means the author has made a version of the otherwise paywalled publication available to the public. Other referenced sources are pdfs and websites that are available publicly.
Background
Care experienced young people (also referred to as looked-after young people), include those in foster care, residential care, kinship care, hostels or independently, or with their parents or relatives while under the supervision of social workers. Foster care is most common (ScotSen, 2018; Scottish Government, 2019).
Around half of mental health problems (excluding dementia) start before 15 years of age, and 75% before 18. Nine out of ten children who have been abused or neglected at a young age will develop a mental health problem by the age of 18. 65% of young people who have a mental health need are not currently receiving any statutory service support. Despite this Child and Adolescent Mental Health Services (CAMHS) make up less than 1% of the NHS budget (NYAS, 2019).
Care experienced young people
Care experienced children and young people have consistently been found to have much higher rates of mental health difficulties than the general population, including a significant proportion who have more than one condition (The Mental Health Foundation, 2002). They are approximately four times more likely to have a mental disorder than children living in their birth families (NSPCC, 2015). Almost half (rising to three quarters in residential homes) meet the criteria for a psychiatric disorder (NSPCC, 2014; Coram Voice, 2015; Social Market Foundation, 2018) compared to 10% of general population (Who Cares? Scotland, 2016).
The latest measure of the emotional and behavioural health of looked after children using the Strengths and Difficulties Questionnaire (SDQ) found that 37% had scores considered a cause for concern, compared to 12% of children in the general population (Alliance For Children In Care And Care Leavers, 2017).
Barnardo’s surveyed care leavers and found that 46% were identified as having mental health needs, with 65% of them not receiving any form of statutory support (The Care Leavers’ Association, 2017; Social Market Foundation, 2018) and are between four and five times more likely than their peers to attempt suicide (NYAS, 2019).
Types of mental health difficulties
Carers report often having to manage a range of significant emotional and behavioural difficulties in the young people they care for (Hiller, 2020). Almost two out of every five children have a diagnosed behavioural disorder. Research suggests children with disruptive and hyperactive behaviours are at particularly high risk of placement breakdown, as their carers can struggle to cope.
Common mental health diagnoses among children in foster care include disruptive behaviour disorders and attention deficit / hyperactivity disorder, post-traumatic stress disorder, anxiety and mood disorders (Hambrick, 2016).
A Care Inspectorate report (2020) found long-standing mental wellbeing needs a consistent feature, with self-harm, suicidal thoughts and suicide attempts from an early age. A study undertaken by Glasgow City Council in 2004 suggested around 50% of young people in their Children’s Units had self-harmed at some point.
There are also much poorer associated health behaviours around sexual health, alcohol and drug use, and smoking (Dale, 2016).
Reasons for poor mental health
Care experienced young people are not a homogeneous group, and the link between care-experience and mental health is not deterministic, but they are more likely to have experienced early adversity.
A 2008 study found that 72% of children aged between five and fifteen had some kind of emotional or behavioural problem at entry to care (NSPCC, 2015). Research and evidence from professionals working in the care system suggest that poor mental health outcomes are likely to result from the interaction of pre-existing mental health conditions, the situation that led to them being taken into care, exposure to (and length of exposure to) maltreatment, and their experience in the care system (NSPCC, 2015; ScotSen, 2018).
Studies have demonstrated a strong long-term association between childhood trauma and adult mental and physical ill-health and behaviour (Who Cares? Scotland, 2016b). Almost two thirds of children looked after by the local authority are in care due to abuse or neglect. There are strong links between exposure to adverse childhood experiences (ACEs) and mental illness (The Mental Health Foundation, 2002; Education Policy Institute, 2019). ACEs include parental substance misuse, physical or emotional abuse, neglect, parental mental illness or a parent in prison.
Most studies highlight the lack of mental health support, particularly in terms of early intervention and preventative services, and specifically around depression, self-esteem and anxiety (Coram Voice, 2015).
Perpetuation of trauma and failure to support healing where children are already experiencing poverty and inequality is reflected in poor outcomes for many who have experience of the care system (Care Review, 2020a).
Trauma
The link between trauma (such as abuse and bereavement) and mental health is well established. With incidences of trauma more likely among care experienced children, the importance of trauma-informed practice and care - stressing the young person’s history and circumstances as well as the symptoms - is clear (NYAS, 2019; Barnardo’s Scotland, 2020).
Most children and young people are taken into care following abuse and neglect. Being unable to cope or inadequately supported, being removed from family and established connections, can traumatise further and lead to or exacerbate mental health problems (Who Cares? Scotland, 2016b).
The young adults from a CYCPS report (2020a) stated more could and should be done to raise awareness and understanding of the links between early experiences and later difficulties with emotional and mental health and wellbeing. They suggested that schools and social workers should find ways to talk to children about mental and emotional health and managing feelings.
Stigma
Young people often express concern that seeking help for mental health problems will lead to labelling or would be recorded on their case file and affect their future (The Mental Health Foundation, 2002; Coram Voice, 2015), adding to existing feelings of public misperception and stigmatisation at being care experienced. This may discourage or prevent them asking for help or wanting to use mental health support services. Individualised and specialised support is important for care experienced young people so it’s essential they receive the right support (Who Cares? Scotland, 2016a).
Instability
Stability can be vital to mental health, but figures show 5 in 6 children in care experience a change of home, school or social worker (NSPCC, 2015). Instability and multiple placements can re-trigger experiences of separation and loss, and mental health difficulties.
Placements
From foster homes to group-care settings, care experienced young people live in diverse and often transitory settings, making it difficult to standardise interventions. They often live unstable lives, being moved from one placement to the next, sometimes with little notice or explanation. Many children experience multiple moves, particularly those with significant behavioural problems (Hambrick, 2016), or spend long periods of time in one placement before being moved to permanent carers or adoptive homes. All of this can have a negative impact on the development of attachment and the experience of trauma and loss, can cause or worsen feelings of anxiety, fear and instability, and make continuity of mental health services difficult.
Moves and placements can sometimes take them away from the area they know, their school, friends and extended family.
Interventions
Instability, changes and a lack of permanence in living arrangements for many care experienced children are unsettling and can hamper support and interventions. Issues get overlooked or aren’t followed up. Appointments and regular planned treatments are more likely to be missed. The use of alcohol and drugs can further complicate the situation (Hiller, 2020).
Frequent moves mean a loss of continuity when receiving mental health care. Moving to different health boards means treatment might not continue at the same stage or with the same practitioner, and the referral process may have to begin again (Who Cares? Scotland, 2016a).
Staffing
There are huge problems in recruiting and retaining social workers, and staff turnover is high. This can lead to gaps in services, missed opportunities for interventions, as well as instability and inconsistency for children and carers (The Mental Health Foundation, 2002).
The consequences
The consequences of poor mental health for care experienced children are considerable. Children who have poor mental health when they enter care are at greater risk of placement instability. Studies show that children who have more severe emotional and behavioural problems and have experienced more types of abuse when they enter care, are more likely to go on to experience instability and placement breakdowns (NSPCC, 2015). This instability can in turn cause or worsen poor mental health.
Poor mental health is also associated with poor educational attainment and other far reaching social and financial outcomes (NSPCC, 2015). The trauma experienced by care experienced children and young people early in life means they often face complex and long term mental ill health (Who Cares? Scotland, 2016a) which significantly impacts on their health, education, social and emotional needs.
What approaches are used?
Criteria free, community-based therapies that do not stigmatise can help and support care experienced children and young people through the difficulties they may be facing. As can family therapy that covers all families - kinship, foster, adoptive, family of origin (Care Review, 2020a).
What is generally emphasised is high-quality caregiving, with targeted interventions either at the child or through the carer / carers (NSPCC, 2014).
Some approaches aim to encourage positive mental health and wellbeing and improve the social and emotional skills of the young person. Others offer treatment for those diagnosed with a mental health disorder such as depression or anxiety. Others might offer support and training to foster carers and residential carers. Some programmes look to change how medical professionals or social workers work with children and young people, such as development of a trauma-informed approach among social work teams.
What is clear from the research is that there is no one-size fits all approach, and if interventions are to work it is likely to be a mix of different support services (NSPCC, 2014).
Assessments
The uniqueness of individual responses to early trauma and adversity is one reason for the importance of ensuring an adequate assessment and understanding of care experienced young people’s mental health (NSPCC, 2014; NSPCC, 2015; Who Cares? Scotland, 2016a).
Health Assessments are vital to consistency and improving the experience and outcomes of individual care experienced children, and in understanding their needs at a national level (Barnardo’s Scotland, 2020). Without robust assessments it is difficult for professionals and carers to identify the support needed to promote the child’s wellbeing, support caregivers, and maintain placement stability (NSPCC, 2015).
Undiagnosed and unsupported mental health issues will only add to the issues already faced by care experienced children, potentially leading to increased risks of substance abuse, loneliness and isolation (Care Inspectorate Wales, 2019).
An NSPCC review (2014) found:
- Assessment instruments are helpful as part of the regular system of checks used to monitor looked after children’s progress in care, enabling services to pick up on any issues at an early stage
- They provide a good estimate of the prevalence of mental health conditions, allowing the identification of children with psychiatric diagnoses based on the Development and Well-Being Assessment
- They can increase the detection rate of socio-emotional difficulties during routine health assessments
- The Strengths and Difficulties Questionnaire (SDQ) is short and user-friendly enabling it to be completed on a regular basis by carers or healthcare staff, and is an easy way to broadly monitor well-being over time
Most agree though that improvements are required. Timely assessment of emotional, mental health and other developmental needs should be identified on entry to care by a qualified mental health professional, and monitored throughout, with a plan setting out the support that they and their carer will receive (NSPCC, 2015).
There is insufficient clarity for practitioners about how they should assess emotional and mental health. Reports (NSPCC Wales, 2019; Barnardo’s Scotland, 2020) found that health assessments are varied, limited, not adequately assessing emotional and mental health, not fully capturing the range and variety of complex issues, and are often not conducted by qualified professionals (Care Inspectorate Wales, 2019).
Their usefulness as tools depend on their ability to detect change in individuals over time, predict mental health service needs, or help select and direct the best allocation of resources and diagnostic assessments (NSPCC, 2014). Their reliability is also dependent on the time being available to complete properly, the context they are carried out in, and on who is completing and interpreting them.
Health Assessments are a difficult experience for some so it’s essential they visibly serve a purpose in improving their futures (Barnardo’s Scotland, 2020).
In Scotland, Health Assessments, including mental health and emotional wellbeing, should feed into a Child’s Plan, including information about measures to be taken to address any difficulties or support recovery. Evidence suggests though there is little attempt to monitor this at either local or national level (Barnardo’s Scotland, 2020).
Placement matching
This also means information about children’s emotional, behavioural and mental health needs is not always gathered early or properly enough to inform placement decisions, despite the huge importance of deciding who cares for them. Many professionals feel that resource constraints limit the extent to which careful matching is possible.
Mental health needs should be assessed before placement matching and care planning, support and intervention be put in place at the outset of a placement (NSPCC, 2015).
Support and interventions
But Health Assessments are just one part of a system to support mental health and wellbeing.
While limitations of the research and evidence make it difficult to say a particular intervention or factor ‘works’, there are some general principles for support that are agreed on.
It is also important to recognise that many of the mental health and well-being interventions used with the general population can be used with care experienced young people (NSPCC, 2014).
Child and adolescent mental health services
Child and Adolescent Mental Health Services (CAMHS) assess and treat young people with emotional, behavioural or mental health difficulties, such as anxiety and depression, eating disorders, self-harm, abuse, violence or anger, bipolar disorder, schizophrenia. Teams are made up of nurses, therapists, psychologists, psychiatrists, support workers and social workers, as well as other professionals.
But there is unprecedented pressure on the service and poor provision of support, with an increase in rejected referrals and few alternative services available to absorb the need (Care Inspectorate Wales, 2019; The Children’s Society, 2020a).
Barnardo’s (2019) identified two main issues with CAMHS:
- The types of therapy made available are not always suited to meet the needs of care experienced young people whose mental health problems are likely to be a result of trauma
- They create additional barriers for care experienced children and care leavers accessing support
Despite recognition that the majority of children who are in care for lengthy periods will experience mental health issues and poor wellbeing they are disproportionately affected by rejected referrals to CAMH services (Barnardo’s, 2019) because of lack of stability, lack of engagement, or symptoms not being severe enough.
This is further compounded by long waiting lists and moving between placements and local authorities (Mental Health Foundation, 2002).
A joined-up approach
A system that supports, embeds and prioritises mental wellbeing throughout health and care, with greater integration of services - both child and adult - is best placed to support care experienced young people.
Connected services should include carers, social workers, health professionals and teachers – and all should be given the knowledge and skills required. Promoting care experienced children’s emotional wellbeing should be the responsibility of everyone connected with the care system (SSIA, 2007; NSPCC, 2014; NSPCC, 2015).
Care experienced young people describe how agencies supporting them - health, social care, education - are not working effectively together to provide seamless support. This disjointed approach limits the ability to fully support them (The Mental Health Foundation, 2002; NSPCC Wales, 2019).
The NSPCC (2015) suggest social care, health and education should work together to jointly commission a spectrum of integrated services to support care experienced children’s emotional and mental health needs and build their resilience.
Therapeutic support
Access to tailored support services for mental health problems has been identified as a significant factor in improving mental health (SSIA, 2007). This support may include individual or family therapies to help with attachment difficulties, recover from bereavement, trauma and loss, and turn around problem behaviours.
The most successful treatments seem to share the following characteristics:
- early intervention
- structured and intensive
- addressing the multiple contexts for problem behaviour (i.e. home, school, and community)
- provided in a range of different ways across social care, health and education
Interviewed young people (Coram Voice, 2015) valued the opportunities therapeutic interventions gave to build trusted relationships with staff, which added value to the purpose of the intervention, and gave them a sense of feeling cared for.
An example from CYCPS (2020a) argues secure care should provide psychologically safe, containing and therapeutic care to help young people make sense of the trauma they have experienced. Every secure care centre should have a wide range of programmes such as holistic therapies, cognitive behavioural therapy, education and vocational qualifications, and community-based opportunities like college and work placements to prepare them for the future.
Hambrick (2016) identified and evaluated ten interventions with children in foster care with positive mental health outcomes:
- Attachment and Biobehavioral Catchup (ABC)
- Child Parent Psychotherapy (CPP), Fostering Healthy Futures (FHF)
- Incredible Years (IY)
- Keeping Foster Parents Trained and Supported (KEEP)
- Kids in Transition to School (KITS)
- Parent-Child Interaction Therapy (PCIT)
- Short Enhanced Cognitive-Behavioral Parent Training (CEBPT)
- Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
- Treatment Foster Care Oregon for Preschoolers (TFCO-P)
Again, it should be noted that the evidence for these interventions is mixed.
Community and in-patient care
Although the evidence around which services work best, both community-based treatment and inpatient care can be effective interventions for young people with mental health difficulties.
Community-based treatment can be administered more flexibly and reduces the disruption to the lives and relationships of young people and their families, avoiding out-of-area placements and unsuitable facilities (Mental Health Economics Collaborative, 2020). But it does present problems particularly for those who lack family support or are severely unwell.
In-patient care can provide supportive relationships and shared experience, structure and routine, and respite. But could also mean a loss of local support and disruption of relationships, a loss of autonomy, and difficulties readjusting after discharge.
Further research into the advantages and disadvantages of different models of care is needed, as is the preferred options for treatment preferences of young people and their parents.
A recent review concluded that effective community care (assertive community treatment, wraparound services and multisystemic therapy) integrated with short periods of inpatient treatment is the optimal approach. It recommends exploring how different services join up and combine (Mental Health Economics Collaborative, 2020).
There are however gaps in accessible community-based services and inpatient facilities which can lead to the use of inappropriate secure accommodation, particularly for those at high risk of self-harming and suicide (Hiller, 2020).
Relationships and communication
Strong, positive relationships are central to the wellbeing of care experienced young people and stability of placements. Specific mental health support for peer networks, parents, foster and kinship carers, teachers, healthcare and residential care workers is vital to this (NSPCC, 2014; NSPCC, 2015; Who Cares? Scotland, 2016b).
The 2015 NSPCC report highlighted that looked after children and young people, and the adults supporting them, all viewed relationships as being central to young people’s experiences of care and building resilience and wellbeing. They discussed the importance of stable relationships with foster and residential carers, consistent relationships with social workers and continuing relationships with their family members (Barnardo’s Scotland, 2020).
However, family contact can sometimes be detrimental to young people’s emotional wellbeing (NSPCC, 2015), and when children return home there is currently little support from mental health services to help children and parents to heal relationships.
One study suggests the important role of confiding in the development of trusted and safe relationships (Eldridge, 2020). The findings highlight a need for safe, secure and stable care placements that can support the development of trusted, confiding relationships and greater attachment security.
Young people told the NSPCC (2015) that one of the most important influences on their emotional wellbeing was the extent to which they felt they were listened to by the adults around them. They talked about the importance of carers’ and social workers’ communication skills, and the need for them to understand communication is not just verbal, and that some children express themselves through their behaviour. They also felt let down by professionals who had not taken the time to acknowledge their feelings.
Resilience
Resilience has been defined as normal development under difficult conditions, or the quality that enables people to find fulfilment in their lives despite their disadvantaged backgrounds, the problems or adversity they may have undergone, or the pressures they may experience.
Research shows that shifting from a focus purely on problems, towards developmental strengths enables them to better cope with adversity. Gilligan (2004) identified that children in the care system are likely to be more resilient to adverse circumstances if they have:
- Supportive relationships with adults, siblings, and friends
- A committed adult other than a parent who takes a strong interest in them as a long-term mentor and role model
- The capacity to develop and reflect on a coherent story about what has happened and is happening to them
- Positive experiences in school
- A capacity to think ahead and plan in their lives
Gaps and recommendations
While there are a range of policies and services aimed at supporting the emotional wellbeing of care experienced children, priorities and approaches aren’t always consistent, and it is unclear which interventions and programmes work or are successful in or transferable from other countries.
The clear differences between the mental health experiences of care experienced children and young people and their non-care experienced counterparts suggest there are unmet needs (Who Cares? Scotland, 2016a).
Some highlight the need for thoughtful, trauma informed assessments that recognise the totality of children’s needs. This should be followed up with support services and therapies, from low level to psychiatric, including speech and language, and mental health support (The Care Leavers’ Association, 2017; Care Review, 2020a). Waiting times must be reduced and opportunities to access increased for these services.
A lack of communication between services, poor support from services, and lack of access to child and adolescent mental health support are seen as key barriers to foster carers providing effective support to young people in their care struggling with behavioural and emotional difficulties (Hiller, 2020).
NSPCC (2015) identified five priorities for a system that promotes emotional wellbeing for looked after children:
- Embed an emphasis on emotional wellbeing throughout the system
- Take a proactive and preventative approach
- Give children and young people voice and influence
- Support and sustain children’s relationships
- Support care leavers’ emotional needs
Trauma-informed
Support services do not consistently recognise the impact of the trauma and abuse that care experienced children and young people have often experienced.
NYAS (2019) argues for improved, and more timely, access to evidence-based support and understanding for trauma-related mental health needs, with evidence-based training around the trauma exposure on children’s development and wellbeing for social care staff.
A recent CYCPS report (2020a) highlighted the prevalence of early traumas and losses in secure care, with young adults wanting to see more done to connect services and recognise the mental and emotional health needs of children who experience abuse, neglect and separation from family. All reflected that they had previously been or were now on medication for mental health issues, particularly anxiety and depression. Most believed their poor mental and emotional wellbeing had not been addressed during early childhood, which was further impacted by being taken into care and experiencing multiple carers and placements.
Barnardo’s Scotland (2020) suggest a move away from the SDQ towards a more holistic model of assessment, with regulation and guidance around child mental health roles and responsibilities aligned with the 2014 Guidance on Health Assessments, and greater support offered to Health Boards to deliver training on trauma.
The Scottish Government are currently working towards a trauma-informed workforce (Barnardo’s, 2019).
Proactive and preventative
The mental health system needs to promote early intervention, be proactive and preventative and move away from requiring people to be in crisis before meaningful help is offered, or just treating symptoms. It should be one that advocates on behalf of care experienced children and young people, supports them through critical times, and addresses trauma at the earliest opportunity (The Care Leavers’ Association, 2017).
One of the major key issues associated with care experienced young people’s mental health is the lack of a proactive and preventative approach. Their experience is of a slow moving, fractured, bureaucratic care system that mainly operates when children and families are facing crisis (Care Review, 2020a).
And while the Scottish Government (2019) have talked about targeted pathways for young people in, or at the edge of care, focused mainly on early intervention, there remain structural barriers to mental health support.
Barriers to accessing support
Care experienced young people describe how difficult it is to access specialist mental health services, particularly at the point it is needed. And at the same time social care staff often have difficulty finding appropriate placements that meet the needs of young people.
One of the main barriers to accessing mental health services are referral requirements (NSPCC, 2015). Children and young adults should not require a significant mental health diagnosis before they can access support. Mental health diagnosis is important and must be a supportive process, but diagnosis is not always a requirement to promote healing (NSPCC Wales, 2019; Care Review, 2020a).
Despite seeing significant need, foster carers also report requests for formal mental health support being unsuccessful either at the social care or mental health service level, and often over long periods of time. Many had experiences of a young person whose early mental health issues were not adequately supported going on to be homeless, experience teenage pregnancy, self-harming or being sectioned under the Mental Health Act (Hiller, 2020).
Long waiting times to access CAMHS and being placed at the bottom of waiting lists after placement moves are frequently highlighted. Young people emphasised dedicated CAMHS resources for those in the care system, including therapeutic services and counselling. Accessing other less formal services to support their mental health, such as yoga, gyms and outdoor activities, is also seen as important.
A CAMHS psychologists interviewed by the NSPCC (2015) acknowledged their service was overstretched to the point of sometimes being unable to offer any form of early intervention for lower-level problems.
Person-centred and co-produced
Care experienced children and young people often describe care as something that is done to them, not with them, feeling they have no control over their lives. Being subject to decisions outwith their control or perceived abuses of trust can make them wary of engaging with health and care professionals, which in turn can leave issues untreated until a crisis develops (Who Cares? Scotland, 2016a).
In practice they should be experts in their own experiences, with a right to contribute to their own mental health care and service developments. NSPCC Wales (2019) argue care experienced children and young people must be involved in the planning of improved mental health services that meets their needs and supports their engagement. This means:
- Enabling children to express their wishes
- Regular opportunities to feed back on the quality of care and support
- Co-design services
An example from Glasgow City Council (2017) saw provision of accommodation moved away from large residential children’s units to smaller ‘home-like’ houses, and promoting more community-based care settings, such as foster and kinship care. In developing this approach, children and young people met with designers to inform the refurbishment.
Young people also discuss the importance of ensuring access to advocacy and opportunities for participation (NSPCC, 2015) and express frustration at having little say in decisions about their care, not been kept informed, or that plans they had agreed with their social worker were not then carried out.
Some have argued that not enough thought is put into how young people want to access mental health services. The models used tend to follow traditional models of intervention, such as therapy in clinics, which can sometimes alienate young people (NSPCC, 2015).
Training
Care experienced children and young people who do access support can find the process challenging, especially when the professionals supporting them are unaware and untrained in issues specific to them (Who Cares? Scotland, 2016a).
From interviews (NSPCC Wales, 2019) young people felt foster carers, teachers, residential workers and social workers are not given enough training (or regular training) to equip them with the skills, knowledge and confidence needed to properly support them through emotional and mental health difficulties. They also called for adults working with care experienced children and young people to receive mental health training on the impact of trauma.
The Mental Health Foundation (2002) highlighted particular areas for training:
· support and training for foster carers to deal with behavioural and mental health problems
· specialist mental health training for all staff working with care experienced children
· regular, local advice and consultation sessions from mental health services
· staff at all levels are made aware of and act on policy changes
The Education Policy Institute (2019) suggest training programmes such as weekly consultations with a systemic family therapist for social workers and foster carers.
Foster carers suggested that social workers needed better knowledge of attachment and child development (NSPCC, 2015).
Communication
Communication is a common theme around gaps in learning and training.
NSPCC (2015) interviews show that young people think non-verbal or behavioural communication isn’t always well understood by the adults around them, and were clear that carers needed more training in how to communicate with them about their feelings, and emotional and psychological needs.
Children in care commonly begin to disclose the full extent of their early experiences to their carers first. The reactions of adults when children make disclosures of maltreatment can be highly important to both their willingness to continue to disclose and their mental health (Hiller, 2020).
There are missed opportunities when it comes to support, often occurring when those assessing and caring mistake indicators of poor mental health as difficult, troublesome or attention seeking behaviour. The effects of alcohol or substance use can also disguise signs of poor mental health (Who Cares? Scotland, 2016a). Therefore training, resources and full assessment are crucial.
Identity and life stories
Care planning guidance and NICE guidance highlights the importance of enabling care experienced children to develop their sense of identity and carry out life story work. It’s also something consistently highlighted by young people and their carers (NSPCC, 2015). In practice though there is often little support to make sense of their early life experiences, reasons for entering care and family relationships.
Advocacy
A lack of formal advocacy or the absence of someone constant to confide in, for example due to multiple placements, staff turnover, or problems accessing CAMHS, make consistent mental health support more difficult (Mental Health Foundation, 2002).
NYAS (2019) recommend all children and young people involved in mental health support should be offered independent advocacy services. This offer should also be available to all young people throughout their transition from CAMHS to Adult Mental Health Services or support in the community.
Care leavers
Care experienced young people often need emotional and mental health support when they leave care, but many see it as care leaving them, not them leaving care (NYAS, 2019).
Leaving care can be a difficult, chaotic, isolating experience which can lead to fluctuating mental health (Who Cares? Scotland, 2016a) and it is recognised that support for the emotional wellbeing of care leavers is inconsistent and insufficient. The NSPCC (2015) report leavers frequently experiencing a number transitions in a short period of time, including leaving their placement (and carer), changing key worker, and moving to a new area / home. With those transitions out of care, leavers can find that they are no longer eligible for support from mental health services, despite research showing many care leavers report a deterioration in their wellbeing in the year after they leave care.
Proactive and preventative mental health support is as important when leaving care as much as during, more so when CAMHS or adult mental health services are not available. Professionals noted (NSPCC, 2015) the limitations in the support they can offer and the time they have to build relationships with care leavers, which can’t adequately deal with issues such as abandonment, trauma from the care system, transitioning into independence at a premature age, and manifestations of childhood trauma in adulthood.
Next steps
There is a lack of research on and evaluation of the quality of care, assessment, support and interventions for care experienced children and young people’s mental health. Follow up is needed to measure whether benefits or improvements are sustained, with clear requirements for collecting data and outcome measures to track progress.
Aside from long-term outcomes there is generally a need for more research, particularly around gender, ethnicity and faith, the value of early intervention, and outcomes of different treatments and approaches.
While more is still needed on what maintains or escalates problems and treating symptoms some argue there should be more focus on the positive outcomes that care experienced children want (NSPCC, 2014; NSPCC, 2015).
Who Cares? Scotland (2016b) suggest more needs to be done to listen to care experienced young people on their mental health and mental health services throughout their care journey.
Covid-19
The Covid-19 virus and subsequent approaches to dealing with it have had serious consequences for well-being and mental health. This applies to young people as much as adults and is particularly concerning given the high rate of mental health difficulties among care experienced young people. This is particularly problematic for those with unresolved family trauma, whose emotional foundations and sense of safety are already fragile, for those who are living at home in difficult circumstances, adolescents seeking to manage their distress through self-harming behaviours, and care leavers whose networks of support are limited (Become, 2020; CYCPS, 2020b; Scottish Government, 2020).
The pandemic which is heightening feelings of anxiety and worry, could exacerbate low-mood and other mental health conditions (The Children’s Society, 2020b). Young Minds (2020) report increased anxiety, problems with sleep, panic attacks or more frequent urges to self-harm among those who already self-harmed. more anxious during the lockdown, respectively, According to The Children’s Society (2020b) feelings of anxiety have increased during the lockdown - children living in care by 45% and care leavers by 86%.
Positives
It is important to note that anecdotal evidence suggests that not facing the pressures of being at school has left young people more able to manage stress and anxiety. Smaller class sizes and fewer school days, with a greater focus on well-being and creative activities, may have also resulted in more positive experiences of education. Some have found the opportunity to build stronger relationships with their carers and enjoyed more flexibility around care and support (The Children’s Society, 2020a).
Access to support
The COVID-19 pandemic is creating additional anxiety and uncertainty as well as making it more difficult for those with existing mental health needs to access support. Care experienced children would normally have regular interactions with a range of support services, critical to maintaining their mental health and wellbeing.
Lack of access to mental health services or support is a long-standing issue which has been exacerbated by the outbreak (The Children’s Society, 2020a). There are further impacts from delays and withdrawal of services, cancellation of face-to-face support, the challenges of remote and online support, and ongoing lack of clarity (Young Minds, 2020).
Local mental health teams have seen an increase in self-harming and hospital admissions (Scottish Government, 2020).
The Children’s Society (2020a) highlights placements being made without ensuring access to mental health support, where services are available new referrals are sometimes not being taken, and thresholds for support have been raised.
It’s important that access to support continues where possible, and those with limited access to internet or digital technology are supported in other ways (CYCPS, 2020c).
Loneliness and mental health
Social distancing and isolation exacerbate the loneliness and isolation already felt by many of those who do not have the usual family support networks (CYCPS, 2020b; Voices From Care Cymru, 2020). Disrupted contact with families will have an impact on their emotional wellbeing and create significant challenges for carers in terms of managing behaviour and mental health. Staying in touch with parents, siblings and other important people helps children develop a sense of identity and belonging and promotes healthy and stable relationships, but it’s not always possible to do this digitally (Become, 2020). These problems are made worse by out of area care placements.
The views from care experienced young people (Voices From Care Cymru, 2020) highlight increasing anxiety around the lack of interactions with support networks, personal advisor / social worker or trusted individuals, and peers.
Recommendations (Become, 2020) to reduce loneliness and experiences of poor mental health include:
- increasing contact between care leavers and Personal Advisers, including offering support around how to manage loneliness and isolation
- ensuring timely provision of internet access and equipment to all places where children may live
- guaranteeing the continuation of contact / family time in accordance with care plans and contact orders in other ways face-to-face is not possible
The Children’s Society (2020b) highlight the importance of:
- safeguarding and having identified professionals to support on safety and wellbeing
- good, age appropriate communication about changes and any delays with provision of support
- continuing access to advocacy services to help them raise concerns if they are not happy with the care received
Approaches and recommendations
Each care experienced young person will have their own experience of this crisis and the disruption it has caused. A person-centred and trauma informed approach will help to address mental and emotional needs, both in collective and individual approaches (British Psychological Society, 2020).
The Children and Young People's Commissioner Scotland (2020a) made several recommendations for during and after lockdown, including:
- ensuring sustainable equity of access to high quality family group decision making and family support services
- careful monitoring of the use of child assessment, child protection secure accommodation authorisations, and interim compulsory supervision orders to assess proportional usage
- ensuring quality of assessment, support to and care by kinship carers, foster carers, and residential carers
- enhanced emotional and practical support to kinship carers, foster carers, and residential carers, and social workers supporting them, to ensure that children and young people have positive experiences of entry to care, changes in carers or care placements, and of ongoing direct and indirect contact with their birth families and relatives
- enhanced access to early intervention strategies to promote emotional wellbeing and support trauma recovery
- enhanced access to targeted intervention strategies to promote sustained support for trauma recovery and acute and chronic mental health conditions
Key papers
Alliance For Children In Care And Care Leavers (2017) Promoting looked after children’s emotional wellbeing and recovery from trauma through a child-centred outcomes framework (pdf)
This paper examines options for assessing and measuring looked after children’s wellbeing and mental health outcomes across their care experience as mechanisms for assessing ‘good quality care’. It sets out proposals on developing new measures and ways of using existing data more effectively to drive improvements across the system.
Barnardo’s Scotland (2020) Care In Mind Paper 2 Health Assessments for Looked-after Children (pdf)
This paper investigates the provision of Health Assessments for looked-after children, specifically, the way in which local Health Boards are carrying them out and the data that is collected nationally.
The Care Leavers’ Association (2017) Caring For Better Health: An investigation into the health needs of care leavers (pdf)
This report summarises the findings of research into the views of care leavers and health professionals on how health services can be improved to better meet the needs of care leavers of all ages, including adult care leavers over the age of 25 years. The report makes recommendations designed to improve the commissioning process and improve health outcomes for care leavers.
Care Inspectorate Wales (2019) National Overview Report in relation to care experienced children and young people (pdf)
This report summarises findings from Care Inspectorate Wales’ programme of work, undertaken throughout 2018, focussing on looked after children and care leavers.
Care Review (2020a) The Promise (pdf)
Part of Scotland’s Independent Care Review findings and recommendations for children and young people, which cover the changes the Care Review recommends, plans for implementing changes and the investment in services that is required.
Coram Voice (2015) Children and Young People’s Views on Being in Care: A Literature Review (pdf)
Literature review highlighting the voices of looked after children from existing research, on their journey through the care system. The review establishes both the positive and adverse experiences of being in care and provides them with a platform to be heard without distortion.
Education Policy Institute (2019) Access to child and adolescent mental health services in 2019 (pdf)
Report on the proportion of referrals to child and adolescent mental health services that are rejected, and waiting times to assessment and treatment for accepted referrals. It also looks at mental health provision for certain groups of vulnerable young people: those with conduct disorder or difficulties, in contact with the social care system, and those transitioning from CAMHS to adult mental health services.
Hambrick, E (2016) Mental Health Interventions for Children in Foster Care: A Systematic Review Children and Youth Services Review. 70 (open access)
The goal of this article was to systematically review the mental health intervention research that has been conducted with children in foster care, and to identify future research directions.
Hiller, RM (2020) Supporting the emotional needs of young people in care: a qualitative study of foster carer perspectives BMJ Open 2020;10:e033317 (open access)
The aim of this study was to understand how carers support the emotional needs of the young people in their care and their views on barriers and opportunities for support.
Mental Health Economics Collaborative (2020) Bringing care back home: Evaluating the New Care Models for children and young people’s mental health (pdf)
Report on the six NHS England New Care Models Programme pilot sites focused on children and young people who are being treated for their mental health out-of-area, often long distances from home.
NSPCC (2014) What Works In Preventing And Treating Poor Mental Health In Looked After Children? (pdf)
This review provides an overview of the evidence available to address what works in preventing and treating poor mental health in looked after children in England.
NSPCC (2015) Achieving emotional wellbeing for looked after children (pdf)
This report explores the causes of poor mental health among looked after children and considers how services in local areas can work together to promote good emotional wellbeing for looked after children.
NYAS (2019) Looked After Minds: Prioritising the Mental Health of Care-Experienced Children and Young People (pdf)
The recommendations in this report form the basis of NYAS’ campaigning efforts to encourage all relevant politicians and decision-makers to improve public policy and legislation relating to the mental health and well-being of care-experienced children and young people.
Social Market Foundation (2018) Looked-after Children: The Silent Crisis (pdf)
This report analysed inspection data from Ofsted, which assesses local councils’ services for children in need of help and protection, looked-after children and care leavers.
SSIA (2007) What Works in Promoting Good Outcomes for Looked After Children and Young People? (pdf)
This paper focuses on helping commissioners to gain an understanding of the needs of looked-after children and young people, and provides a number of key messages from research and best practice which relate to the different types of placements and to other factors that are needed to ensure good outcomes.
Who Cares? Scotland (2016b) Mental Health in Scotland: A 10 year vision (pdf)
Response to the Scottish Governments Mental Health Strategy engagement paper, which makes recommendations for future mental health services in Scotland.
References
Alliance For Children In Care And Care Leavers (2017) Promoting looked after children’s emotional wellbeing and recovery from trauma through a child-centred outcomes framework (pdf)
Baginsky, M (2020) Managing through COVID-19: the experiences of children’s social care in15 English local authorities NIHR Policy Research Unit in Health and Social Care Workforce, The Policy Institute, King's College London (pdf)
Barnardo’s (2019) Care In Mind Paper 1 Rejected Referrals: Looked After Children and Care Leavers’ Access to Child and Adolescent Mental Health Services (pdf)
Barnardo’s Scotland (2020) Care In Mind Paper 2 Health Assessments for Looked-after Children (pdf)
Become (2020) Coronavirus and its impact on care-experienced young people (pdf)
British Psychological Society (2020) Supporting care-experienced children and young people during the Covid-19 crisis and its aftermath (pdf)
Care Inspectorate (2020) A report on the deaths of looked after children in Scotland 2012-2018 (pdf)
Care Inspectorate Wales (2019) National Overview Report in relation to care experienced children and young people (pdf)
The Care Leavers’ Association (2017) Caring For Better Health: An investigation into the health needs of care leavers (pdf)
Care Review (2020a) The Promise (pdf)
Care Review (2020b) The Pinky Promise (pdf)
Cassidy, C (2020) Breaking into secure: Introducing philosophical discussions to young people in secure accommodation Journal of Social Work, 20(3), 287–306 (open access)
The Children’s Society (2020a) Recovery Plan –Children in care and care leavers (pdf)
The Children’s Society (2020b) The impact of COVID-19 on children and young people (pdf)
Coram Voice (2015) Children and Young People’s Views on Being in Care: A Literature Review (pdf)
CYCPS (2020a) Secure Care in Scotland: Young People’s Voices (pdf)
CYCPS (2020b) Independent Children’s Rights Impact Assessment on the Response to Covid-19 in Scotland (pdf)
CYCPS (2020c) Independent Children’s Rights Impact Assessment on the Response to Covid-19 in Scotland: Appendix 2 (pdf)
Dale, H (2016) Looked after young people: Reducing health inequalities through an evidence- and theory-informed intervention Health Education Journal. 2016;75(7):811-822 (paywall)
Education Policy Institute (2019) Access to child and adolescent mental health services in 2019 (pdf)
Eldridge, J (2020) Confiding in others: exploring the experiences of young people who have been in care Adoption & Fostering, 44(2), 156–172 (open access)
Gilligan, R (2004) Promoting Resilience in Child and Family Social Work: Issues for Social Work Practice, Education and Policy Social Work Education (open access)
Glasgow City Council (2017) Glasgow Integrated Children and Young People’s Service Plan 2017-2020 (pdf)
Hambrick, E (2016) Mental Health Interventions for Children in Foster Care: A Systematic Review Children and Youth Services Review. 70 (open access)
Hiller, RM (2020) Supporting the emotional needs of young people in care: a qualitative study of foster carer perspectives BMJ Open 2020;10:e033317 (open access)
Mental Health Economics Collaborative (2020) Bringing care back home: Evaluating the New Care Models for children and young people’s mental health (pdf)
The Mental Health Foundation (2002) The Mental Health of Looked-After Children (pdf)
National Assembly for Wales Public Accounts Committee (2018) Care experienced children and young people (pdf)
NSPCC (2014) What Works In Preventing And Treating Poor Mental Health In Looked After Children? (pdf)
NSPCC (2015) Achieving emotional wellbeing for looked after children (pdf)
NSPCC Wales (2019) Listen Act Thrive: The Emotional and Mental Health of Care Experienced Children and Young People (pdf)
NYAS (2019) Looked After Minds: Prioritising the Mental Health of Care-Experienced Children and Young People (pdf)
Public Health England (2020) Guidance for parents and carers on supporting children and young people’s mental health and wellbeing during the coronavirus (COVID-19) pandemic (website)
Scottish Government (2014) Guidance on Health Assessments for Looked After Children in Scotland (pdf)
Scottish Government Getting it right for every child (GIRFEC) (website)
Scottish Government Children and Young People (Scotland) Act 2014 (website)
Scottish Government (2019) Mental health strategy 2017-2027: second progress report (pdf)
Scottish Government (2020) Children, Young People and Families COVID-19 Evidence and Intelligence Report (pdf)
Scottish Parliament (2019) Secure care and prison places for children and young people in Scotland (pdf)
ScotSen (2018) Public attitudes to care experienced young people (pdf)
Social Market Foundation (2018) Looked-after Children: The Silent Crisis (pdf)
SSIA (2007) What Works in Promoting Good Outcomes for Looked After Children and Young People? (pdf)
Triumph (2020) Priority Areas for Research to Improve Youth Public Mental Health (pdf)
Turney, K (2016) Mental and Physical Health of Children in Foster Care Pediatrics. 2016;138(5):e20161118 (open access)
Voices From Care Cymru (2020) Inquiry into the impact of the Covid-19 outbreak on children and young people in Wales (pdf)
Who Cares? Scotland (2016a) Outcomes for care experienced children and young people (pdf)
Who Cares? Scotland (2016b) Mental Health in Scotland –a 10 year vision (pdf)
Who Cares? Scotland (2020) The Impact Of Covid-19 On Scotland’s Care Experienced Community (pdf)
Young Minds (2020) Coronavirus: Impact on young people with mental health needs (pdf)
Suggested reference: Sanders, R (2020) ESSS Outline: Care experienced children and young people’s mental health. Iriss. https://doi.org/10.31583/esss.20201012
