Are we failing children in care?

The number of children placed in care has been steadily increasing since 2008. Often Looked After Children (LAC) have experienced multifaceted abuse and multiple placement breakdowns in childhood and adolescence. Prompt therapeutic intervention then becomes a necessity before their mental-health-related issues worsen.

With government spending under scrutiny, the effectiveness of services such as Child and Adolescent Mental Health Services (CAMHS) inevitably comes under the microscope. Currently, supply does not seem to meet demand for therapeutic interventions for young people presenting with mental health related issues; research suggests that the barriers for LAC accessing CAMHS are not at initial referral stage, but are later within the system with long waits for specialist provision (York & Jones, 2017) when these services can potentially be commissioned more quickly outside of the service. Overall, improvements are necessary in service provision and prevention of children/adolescents' mental health deteriorating to the point where inpatient services are necessary. This highlights the critical state of affairs our 'LAC' are facing to get support.

Clearly there are issues with funding and the availability of NHS provision to address the growing psychological needs of young people (e.g. trauma symptoms: Morina et al., 2016). An increase in private therapeutic provision, which can help CAMHS and other services meet the demand should be looked upon as beneficial (e.g. psychological interventions delivered in children's home setting). This is because publicly delivered CAMHS are not always accessible consistently to those who need it, for reasons often beyond their control. Those who have trauma-related needs and no other diagnosable mental health problem can 'slip through the net', or are de-prioritised, especially where the young person will not engage with offsite provision. However, in our experience, the stigma attached to commissioning privately provided psychological intervention seems ever present, even where this can be provided more quickly to at least the same quality. We put forward the following suggestions we've experienced as barriers to the stakeholders commissioning this work, when it is in the best interests of the child to receive such provision:

• The value and the belief systems of the service managers who commission the intervention.

• The pro-activeness of the child's social worker or other responsible professional.

• Working in a 'blame culture' society focused on the lack of provision, rather than pro-actively seeking alternatives.

• Decision-makers operating in ways driven by short-term costs and targets. This shifts the emphasis from service quality to targets such as, how many clients can we see in a week.

When such commissioning decisions are made are we not forgetting the thoughts and feelings of the young person, the importance of the therapeutic alliance for positive outcomes, the detrimental effects of treatment non-completion, and the long-term costs (recommissioned at a later time or inpatient services should the treatment need escalate)? We leave you to consider whether the whole system works in the best interests of the child. Does this differ elsewhere? What are your experiences of commissioning privately provided services for other client groups?

Richard T. Jones
Forensic Psychologist in Training, Nottingham
Dr Ruth J. Tully
Consultant Forensic Psychologist, Nottingham

References
Morina, N., Koerssen, R. & Pollet, T.V. (2016). Interventions for children and adolescents with posttraumatic stress disorder: A meta-analysis of comparative outcome studies. Clinical Psychology Review, 47, 41–54.
York, W. & Jones, J. (2017). Addressing the mental health needs of looked after children in foster care. Journal of Psychiatric and Mental Health Nursing [Advance online publication]. doi:10.1111/jpm.12362