The forgotten vulnerable

Government measures through the Covid-19 pandemic have attempted to balance physical health with risk to the economy and to young people's education. Since March, journals have been filled with discussions about chronic effects on physical health and acute and longer-term effects on mental health. However, there has been a notable lack of consideration of the risk of violence to and from families of young people stuck and frustrated at home, the lack of supervision/ support/ opportunities for young people with risk behaviours in the community, the effects of fewer activities and time out of cells in custody and the difficulty in planning transitions between secure and community settings.  

Discussion about the marked effects of Covid-19 on young people with high-risk behaviours and/ or in contact with the Youth Justice System (YJS) has been limited to a letter in The Lancet (Bell et al., 2020) and a 2020 report by the National Youth Agency. Professionals working in these settings have found it hard to defend the need for their work, which includes working tirelessly to build up engagement and therapeutic rapport with historically labelled 'hard-to-engage' young people, against the need for professionals in acute inpatient settings. The risk of staff being moved at any time, has led to less contact time and longitudinal input for young people, reducing the chances of engagement with vital support services. Practitioners have found themselves with less time to process and reflect upon young people's needs in preparation of holistic formulations to guide intervention, instead relying on brief initial assessments and limited resources.  

It is our opinion that this short-term thinking will have long term consequences, leading to increased social and personal costs. Not meeting the needs of these young people now may well lead to increases in risk both to themselves and the public.

There is also an inherent hypocrisy in the message that society has given to these young people. Whilst they see measures to protect other people's lives, they have often been subject to a greater individual risk from abuse, neglect and trauma, with no such protection. In fact, they often feel punished for behaviours which are in fact responses to their experiences. Many members of the public who are considered to be mature and responsible can be seen flouting Covid restrictions with no consequence. The more vulnerable of society continue to be criminalised and punished whilst those in power are given mitigating circumstances and forgiven.  

Many young people in custody also reported feeling anger at society's reported 'challenges' with the national lockdown, as these restrictions are something they experience every day. Some, though, express hope for more compassion towards their experience in future.   

Transitions

Transition between placements in the community and on release from secure settings or hospital discharge, were much more difficult to manage safely during the first wave of the pandemic. 

There were significantly less opportunities for appropriate planning and transition. For those being discharged from secure hospitals who would typically have had access to custodial day release, it was not possible to have leave to new placements. Thus, young people leaving secure settings went 'blind'. Restrictions on face-to-face contact and travel meant that many young people leaving custody were not picked up by professionals who knew them but, instead, placed in a taxi to arrive at an unfamiliar placement. Many also returned to overcrowded housing with a lack of outdoor space, lack of community protective factors and an enforced evening curfew such that they had less freedom, with less time outside and private space than they had in custody.  

All of this, coupled with limited support available from professionals in the community, inevitably led to a higher risk of young people breaking lockdown restrictions and curfews. This in turn placed them at higher risk of criminal exploitation, further offending behaviour, and contact with the police, reducing the chances of desistance from future risk behaviours. 

For many of those moving between community placements, new placements demanded that young people isolate before or on moving. As this was not feasible for many, moves were jeopardised, and some young people went missing for long periods of time.

For those going into secure placements, the 14-day quarantine resulted in the isolation of young people in their cells, bedrooms or seclusion rooms putting their physical and emotional health at risk. Family visits were also restricted, which caused distress and isolation and increased the risk of young people breaking their curfews or restrictions. 

All of this jeopardised placement and community success.

Youth Custody Settings

A significant issue highlighted in our discussion was that of young people spending longer durations on remand due to extensive delays in trials. Extensions beyond the regulated acceptable remand times for young people were requested pre-covid for trials of serious charges when adults are co-defendants. However, during the pandemic, it is our experience that extensions were agreed for more minor offences, such that some young people with lesser charges were held for longer than their potential sentence. The Howard League stated that "A third of all children in prison are on remand", two thirds of which will not be given a custodial sentence" (Frances Cook, Custody Time Limits, 2020). This is a challenge for all young people on remand but is particularly problematic with those where there are concerns around criminal exploitation; thus, young victims of modern slavery may be further penalised by being remanded for longer periods of time.  

The second issue of concern is that those in prison during the pandemic have had to spend significantly more time in their cells, which may have deleterious effects on their psychological and emotional well-being. Concerns have already been raised about some young people spending over 22 hours in their cells and plans were being developed to ensure that this did not occur, when the pandemic struck. Young people were isolated on arrival to prevent spread of the virus; the time of greatest risk for suicide-related behaviour, especially for first time entrants, putting young people detained during the pandemic at higher risk. Many agencies withdrew their staff during the first lockdown – whilst this reduced the risk to staff and young people of contracting Covid, it also meant a reduction in the support available for children in custody and an increased pressure on the remaining staff groups (i.e., prison officers and health services). Access to education and other activities reduced as education departments initially closed and then reopened with smaller class sizes in July, mirroring the community education system. There were also reduced staffing levels due to sickness. This reduced level of contact impacted on the mental and physical health support available and increased time spent in cells (HMIP, 2020b). 

As a result, young people were also more isolated in custody. Social visits were initially stopped, then replaced with video calling. However, not all families were able to engage due to limited resources. Difficulties with technology and concerns around privacy caused young people frustration and led to the termination or cancellation of visits.     

Staff training was suspended at the start of the lockdown, which meant that reform projects implemented prior to the pandemic risked being stalled. Whilst in the community there was a strong message of support for keyworkers, staff working in custodial settings reported feeling that their work was forgotten and undervalued mirroring the young people's experience of marginalisation.  

Secure Adolescent Mental Health Wards

Visits and leave were cancelled at the height of the pandemic. Disruptions in a young person accessing their social support systems may not only cause adjustment difficulties to an environment but can also be a significant risk factor for increased mental health difficulties, and other risk concerns (e.g. suicide and self-harm). Visits allow for the maintenance of links to life in the community and are a valuable source of hope and progression towards discharge. Efforts were made to reinstate visits as countrywide lockdown restrictions were lifted but guidance stipulated no physical contact, which has been especially difficult for young people with their parents / carers.

Almost all education departments in secure wards closed, which had a twofold impact: (1) on education and learning, which is important for this group of young people who often have a fractured education history; and (2) there were less activities and distractions for the young people and fewer staff to support them.

Young people showing risk behaviours in the community

In the community, with schools closed, young people at risk had less structure to their days and less access to professionals monitoring and supporting their emotional wellbeing. For all working from community bases, it was harder to arrange face to face meetings due to lack of Covid-safe premises and, for some, difficulty obtaining the correct PPE. With community offices shutting, most face-to-face contacts were completed through walks in the park or standing on doorsteps, making confidential conversations difficult. Some voluntary sector services tried to maintain face to face contact, but this was dependent upon home visits where possible. 

Though CAMHS services remained open during the first wave of the pandemic, most appointments were virtual, creating potential engagement barriers. Social care and Youth Offending Teams (YOT) offered a mixture of virtual and face to face appointments but were not able to monitor as closely as prior to the pandemic, resulting in a loss of wraparound care and a pause to ongoing intervention. 

Some families experienced difficulty in attending virtual meetings about their children due to struggling with technology or not having access to appropriate resources. Some young people responded well and felt safer having conversations over the telephone or video calls, but others disengaged. 

Therefore, some therapy was effectively put-on hold and opportunities missed as once space was available for face-to-face meetings, young people may have come to an end of their court orders. Often at this stage it is more difficult to engage and begin therapy. Furthermore, the reduction in consistent contact with services impacted on engagement with care plans, such that some of those who had engaged after much work from services, disengaged once regular appointments were not available. Overall, as a consequence of young person's having less meaningful contact with professionals due to school closures and limited monitoring through children's agencies, there was a noted escalation in mental health difficulties. This included acute crises such as self-harm and possible risk to others. 

One group of young people in the community who suffered greatly during the first wave were those with Neurodevelopmental Disorders or Special Educational Needs and challenging behaviour. Though the government restrictions specifically stated that 'specialist schools' did not need to close, many did. Furthermore, many parents were concerned about transmission and therefore did not send children to school though places were open for them. There were also occasions where these young people refused to attend school after noting the disparity between themselves and others in mainstream education.

We observed two different sets of reactions in young people with Autistic Spectrum Condition (ASC) and / or Learning Difficulties. One group, who show challenging and risk behaviours due to anxiety about attending school, settled once they could remain home. The concern for them has been around settling back into school in Autumn. This required careful planning and we have, unfortunately, seen exclusions as a result of re-adjustment difficulties. The second group experienced increased stress at home due to difficulties in self-regulating emotions and co-regulating with their family. In this group, violence increased in the home, placing the young people and their families at greater risk. Clinicians working in courts noted that they had seen an over representation of this group of young people when the courts reopened.

Many young people coming to the attention of our services have either diagnoses or traits of Neurodevelopmental Disorders, often only identified when their difficulties made them vulnerable to child criminal exploitation. Wait lists for assessments are well documented (The Guardian, February 2020). During the pandemic restrictions, assessments for ASC and learning disability were not possible, delaying waiting lists and extending time to assessment. A consequence of this is that some young people will turn 18 before they are assessed. It is our concern that this will prevent multi-agency care planning as they transition into adulthood, and a cohort of vulnerable young people will be left without support and criminalised.

Another group of concern were those who had previously gone missing prior to the pandemic as they were at increased risk of extended and more frequent missing episodes during the first wave. Much work was done during this time within multi-agency services to manage this.  However, the reduced structure available, limited face-to-face contact and monitoring from services, made this a significant challenge. Our concerns were that county lines and local gangs preyed on vulnerable young people during this time in order to groom them into further child criminal or sexual exploitation (National Youth Agency, 2020).

In view of these increased risks in the community, some of us found ourselves recommending secure placement, as the safest longer-term option at this time, though more restrictive.

A concerning outcome of all of this might be a reduction in opportunity for young people to desist from offending and/or risk behaviours. Clinicians have noted a reduction in available educational and vocational provisions for these young people, also many have moved online creating further engagement barriers. As a consequence, we may see an increase in the number of socially excluded young people over the coming years. This cohort may then be labelled as antisocial and experience prolonged social exclusion when sadly things could have been different for them.

Benefits

It would be wrong to suggest that it has been all negative. There have been some surprising benefits to the changes that have been made to manage the pandemic. 

With withdrawal of many agencies from secure settings, health professionals have had greater access to young people to offer support and assessments whereas previously, there have been many professionals wanting access, with limited space. As well as video calling for social and legal visits in custodial settings, telephone consultations for hospital appointments have meant that young people do not have to experience the difficult journey to a hospital, a trip which usually includes being handcuffed and searched before departure and upon return. 

There have also been some successful interviews and risk assessments carried out via video calls across all settings. Perhaps the proliferation of online assessment methods resulting from the pandemic has been helpful in providing access to assessment and therapy for some of our disenfranchised young people, allowing them to speak to us directly whilst holding a degree of distance and possibly a sense of control.  

We have experienced improved multi agency working around young people at risk in the community and secure settings and strengthened relationships between health and other agencies. We have also noticed an increase in appropriate information sharing and collaboration to safeguard young people. Moving meetings online has also enabled staff to attend promptly when previously travel might have prevented involvement. Clinicians were also responding to the increased welfare needs of young people and their families including supporting access to food banks, vouchers and other local authority provisions. The involvement in meeting their practical needs changed the dynamic of the relationship on occasion and helped with building a therapeutic caring relationship.

The pandemic has also brought the conversation about staff support in custody to the forefront, something which is integral to the trauma-informed principles of the SECURE STAIRS reform project – 'you cannot look after others if you are not being looked after yourself'. Within the YOI's this has included establishing local teams, effectively coordinating staff support, and enabled reflective practice to be better embedded within the estate. This work aims to reduce burn-out and compassion fatigue resulting in improved care and a more adaptive, less reactive system. 

Additionally, we would like to note that young people managed their frustrations about the increased restrictions in custody well. They understood that this was not the fault of staff and they felt part of wider society managing the pandemic, rather than being excluded and separate. Smaller 'bubble' groups in place in custody which were designed to reduce contact in order to prevent any Covid outbreaks were also of benefit to both the staff and young people as all reported feeling safer, with significant reduction in violent incidents reported and benefitting from the opportunity to build better relationships. 

Finally, the experience of a shared crisis provided the opportunity for conversations with young people about our own responses and coping during the pandemic. This supported the normalisation of experiences of anxiety, sadness, isolation, and frustration due to the restrictions imposed on us.

Contributors

1. Lovedeep Rai, Clinical Psychologist, Lewisham ARTs CAMHS, South London & Maudsley Trust NHS. Email: [email protected]
2. Ali Shnyien, Specialist Clinical Psychologist YOT CAMHS Wandsworth, South West London and St-George's NHS Trust. Email: [email protected]
3. Delores McPherson, Senior CAMHS specialist for ARTs & Team leader, Lewisham ARTs CAMHS. Email: [email protected] 
4. Duncan Harding, Consultant Child & Adolescent Forensic Psychiatrist, South London & Maudsley Trust NHS Forensic CAMHS. Email: [email protected]
5. Emily Curtis, Youth Justice Liaison and Diversion, Hammersmith and Fulham Youth Offending Service, West London NHS Trust. Email: [email protected]
6. Gabrielle Pendlebury, Clinical Lead, Forensic CAMHS at The Port Forensic CAMHS team. Email: [email protected]
7. Heidi Hales, Consultant Adolescent Forensic Psychiatrist, West London FCAMHS. Email: [email protected]
8. Kate Chalker-Wye, Child and Adolescent Clinical Nurse Specialist CAMHS, West London NHS Trust. Email: [email protected]
9. Layla Clayton, Assistant Psychologist, HMYOI Feltham, Central and North West London NHS Trust. Email: [email protected]
10. Melissa Beaumont, Team leader & Clinical Nurse Specialist, Health & Wellbeing Team - HM YOI Feltham, Central and North West London NHS Trust. Chair of the London Youth Justice CAMHS Forum. Email: [email protected]
11. Rhiannon Lewis, Consultant Clinical Psychologist, Clinical Lead - Enhanced Support Unit (ESU) & SECURE STAIRS HMYOI Feltham, Central and North West London NHS Trust. Email: [email protected]

The London Youth Justice CAMHS forum meets quarterly and is open to mental health clinicians of all disciplines working in Greater London with young people in contact with the Youth Justice System, across all secure and community settings, including staff working in YJLD (Youth Justice Liaison and Diversion), YOT (Youth Offending Team), CAMHS (Child and Adolescent Mental Health Service), community FCAMHS (Forensic CAMHS), SECURE STAIRS and YOI (Young Offender Institutions).