3.6.10 Child and Family Service, Children in Care Service, Operational Policy

1. Reason for the Policy

Lincolnshire Partnership NHS Foundation Trust provides a dedicated service for Looked After Children (LAC) via the Child and Family Service. LAC are 5 times more likely to develop emotional and mental health difficulties when compared to children in the general population. This awareness is reflected in the policy perspectives and guidance in the National Service Framework for Children (NSF, 2004), Care Matters and Every Child Matters (DHSC, 2003). Looked after Children have less success in the education system than their peers and are far less likely to go on to university. Between a quarter and half of rough sleepers have been in care and around half of adults in prison spent some time in care as children. The reasons for this are complex, relating to children's experiences before they enter the care system as well as to the trauma of separation from their families and sometimes communities, whilst in care. We know that improving the mental health of children also has a positive impact on their ability to form positive relationships with peers and adults, their success at school and a whole range of outcomes as adults.

2. Background and Context of the Policy Including Legislation

The Child and Family Services' LAC Service was developed in 2006 in response to improving access and equitability to Children and Young People’s Mental Health Services (CYPMHS), now known as Child and Family Services (CYPMHS and Child Psychological Therapies) for LAC.

3. Purpose of the Policy

To prioritise timely and efficient response to requests for consultation and advice in respect of the mental health needs of children and young people who are cared for within statutory fostering or residential care home arrangements, or children placed with their parents under Section 31 referred to in this specification as Children in Care (LAC).

To ensure priority of access to mental health services as assessed, providing a single point of contact with provision for consultation, assessment and intervention via dedicated LAC Primary Mental Health Workers.

To provide specialist mental health advice and assessment to LAC and their carers, working with other agency child professionals and carers to develop awareness of mental health needs and support placement stability.

4. Summary of Responsibilities

• Most requests are for consultation with a maximum of 2 consultations to be offered regarding a young person, prior to seeing them individually where appropriate or discharge. The process is shown in the LAC Pathway for Operational Policy Flowchart;
• The team can be contacted for advice before or after referral. Urgent needs should be identified to the nominated lead for the LAC team and on discussion an appointment will be offered within two weeks unless otherwise agreed;
• Training, advice and support to foster carers/children's homes;
• Short term intervention in respect of a young person;
• To liaise with C&FS colleagues to provide a seamless transfer for complex cases or where the need for long term work is identified at assessment.

5. Detailed Areas of Responsibility

The LAC service comprises the provision of Tier 2 services e.g. access, consultation, assessment and intervention and access to Tier 3 services where assessment indicates longer term or more complex needs. The LAC team comprises a Lead member and CYPMHS Primary Mental Health Workers for Children in Care, who are either a Registered Mental Health Nurse or a Specialist Social Worker. The role of the Primary Mental Health Worker is to provide consultation, assessment and intervention in respect of a young person's mental health. The team work closely with CYPMHS staff in the Tier 3 community teams who also will have LAC on their caseload.

Types of mental health concerns which can be addressed:

• Anxiety, sadness, obsessional behaviour, emotional dysregulation, disordered attachment, post-traumatic stress, eating disorders, self-harming behaviour, depression (this is not an exhaustive list);
• It is the severity of the symptoms, reasons behind them and the impact on the Service User which will determine whether CYPMHS involvement at Tier 2/3 is required or if another service is required to meet the needs.

Range of Services provided

To Professionals

• Advice, guidance and consultation to support members of the wider children's workforce (any professional working with a child or young person in public care where there is a mental health concern) in meeting children's mental health needs, aiming to prevent them requiring more intensive help at Tier 3. This includes foster carers and other agencies; CYPMHS workers may also suggest reference books for foster carers and therapeutic work they can undertake within the home, to explore feelings and improve self esteem. Through improved understanding of the child's presentation and suggesting management techniques to foster carers the service aims to improve relationships, reduce stress for foster carers and assist the foster carers in meeting the child's health needs in relation to emotional and mental well-being;
• Link working to the county's residential children's homes to liaison support and training to residential staff to support stability of placements. This service is provided by dedicated foster care support workers (Primary Mental Health Workers). Primary Mental Health Workers also provide general mental health awareness training as part of Local Authority induction programme for foster carers;
• Provision of training, on request, on mental health awareness and attachment, including parenting groups as part of the countywide LA foster care induction and support process.
  
  This is provided on request and includes information on attachment theory, how early attachment issues and deprivation can create presentations that can be identified as similar to Autism/ Asperger i.e. Autistic Spectrum Disorder (ASD), and/or Attention Deficit Hyperactivity Disorder (ADHD);
• Attendance at review meetings, or provision of a report if enough notice is given;
• Behaviour management advice and support in the absence of a clearly identifiable mental health or psychological difficulty will be provided;
• If deemed necessary the CYPMHS LAC professional will liaise with the medical and psychological team to further assess to confirm possible diagnosis. ADHD assessment may include completion of the CONNERS assessment tool, a mental health assessment, a developmental assessment and is likely to require further psychological assessment that identifies how the young person's cognitive abilities are functioning and possibly their IQ. ASD assessment may also require mental health assessment, developmental assessment, and other psychological assessments around cognitive functioning, but the DISCO assessment would be used to formally diagnose ASD. This will not be for every case but dependent on need.

To Children in Care

• Direct assessment and clinical interventions, often co-working with other agencies to enhance universal support to children and young people and to enhance the stability of placements. The approach used is Cognitive Behavioural Therapy (CBT) based including solution focused therapy helping the young person to develop coping skills and make sense of their situation, exploring how it affects them;
• Ensure provision of Choice appointments for LAC screened as appropriate for direct referral to Tier 3 specialist services;
• Direct face to face assessment in line with Tier 2 service provision, with availability to provide short term intervention where assessed as appropriate. Such intervention would normally be in the region of 6 sessions and then a review, further interventions may be offered if need identified.

The CYPMHS LAC Team may transfer a case to the Tier 3 services within C&FS when it is considered that the child requires further assessment, indicating that longer term work would be beneficial to the child. The number of sessions will vary depending on the type of work undertake; i.e. cognitive work, which is structured and includes tasks, both in the session and for homework, tends to be shorter in length than psychotherapeutic exploration, which is child led in terms of pace and content. Regardless of the number of sessions undertaken it is expected that all work is reviewed every 4-6 sessions (maximum 8, unless specifically agreed by the young person, carers and clinician). The length of stay in service is dependent on the needs of the young person. 

6. Nominated Leads

Nominated Lead: Team Coordinator LAC

7. Policy Content

Lincolnshire Partnership NHS Foundation Trust Child & Family Services incorporates Children and Young People’s Mental Health Services (CYPMHS) and the Child Psychological Therapies Service, working together to offer a range of professional clinical interventions including needs assessment, diagnostic services (where appropriate), behaviour management programs and child centered therapies to support recovery and wellbeing. The service is jointly commissioned by NHS Lincolnshire and Lincoln County Council and is an integrated service, except for Tier 4 provision which is commissioned solely by NHS Lincolnshire.

Services are provided by a range of professionals and are available for children and young people who are resident in the county of Lincolnshire and registered with a Lincolnshire GP, (Exceptions will be addressed on a case by case basis when it is deemed beneficial for the service user to access Lincolnshire CYPMHS) up to their 18th birthday under a 4 tier framework (as set out in the Department of Health and Social Care (DHSC) publication Together We Stand, Health Advisory Service, 1995) and known as Tiers 1 to 4 and described as follows:

Tier 1

This service is provided by Primary Care and universal services such as school nurses, health visitors and GPs, professionals not trained in mental health.

Tier 2

This is a service for moderately severe problems requiring attention from professionals trained in child mental health. Tier 2 services have input from the following professionals:

• Primary Mental Health Workers;
• Social workers;
• Clinical psychologists;
• Community psychiatric nurses;
• Child and adolescent psychiatrists.

The key tasks at Tier 2 are:

• Mental health promotion activity, including training to members of the wider children's workforce to improve the identification of, and response to, emerging mental health and psychological needs;
• Advice, guidance and consultation to support members of the wider children's workforce in meeting children's needs, aiming to prevent them requiring more intensive help; and
• Short-term clinical intervention, often co-working to enhance others' support to children and young people.

It is acknowledged by the Council that:

• Within current levels of resourcing, Child and Family services do not provide the full range of Tier 2 services equally across the County;
• Behaviour management advice and support in the absence of a clearly identifiable mental health or psychological difficulty will be provided;
• Services designed specifically to treat neurological disorders such as Attention Deficit Hyperactivity Disorder and Autism will not be provided, although given the nature of these disorders, many children and young people have co-morbid mental health and psychological difficulties;
• There are county wide designated teams for LAC, Learning Disabilities (LD) and Youth Offending Services (YOS).

Tier 3

This is a specialist service for the more severe, complex and persistent disorders. Because of the complexity of the work that they undertake, the staff identified above work in multidisciplinary teams in a community child mental health clinic or child psychiatry outpatient service

In addition to those of Tier 2, the tasks of Tier 3 services are:

• The assessment, treatment and management of children, adolescents and their families whose mental health problems and disorders cannot be managed in Tier 2 because of the complexity, risk, persistence and interference with social functioning and normal development, and the consequent need for specialist skills;
• To act as gatekeepers, with clearly agreed criteria, for the assessment for referrals to Tier 4;
• To have relationships which ease the passage of children and young people into such care;
• To contribute to the services, consultation and training at Tiers 1 and 2;
• To ensure smooth transition of individual cases or families to Tiers 2 and 1 before completion of the involvement of Tier 3 service;
• To participate in research and development projects.

Tier 4

Tier 4 Services should be seen as part of a continuum of care for clients and families. They are essentially tertiary services such as day units, highly specialised outpatient teams, and inpatient units for older children and adolescents who are severely mentally ill or at of risk suicide.

Tasks undertaken in Tier 4 involve:

• The assessment, treatment and management of children, adolescents and their families whose mental health problems and disorders cannot be managed in Tier 3 because of their complexity, risk, persistence and interference with social functioning and normal development, consequently requiring very specialised skills;
• Provisions of interventions that require such a level of skill;
• Provision of services that would not be cost effective in every locality because of sporadic demands for them in smaller populations;
• Provide support to staff working in Tiers 1, 2 and 3, where they are engaged in complex cases that might otherwise require management in Tier 4.

LPFT Child & Family Services provide in-patient care for 12-17 year olds at Ash Villa, Greylees, Sleaford. A total of 10 beds, including one for emergency admissions, are provided.

It is acknowledged by the Council that:

• Inpatient assessment and treatment for children aged under 12 will not be provided;
• Children and young people with complex needs may need to be placed out of County. In these circumstances, their need for such placements results from the complexity of need (including education and social care such as for children with disabilities), rather than the severity of mental health presentation;
• In rare circumstances, 16 and 17 year olds may be placed on adult wards, particularly if they choose this in preference to admission to a young person's unit.

8. Definitions

CAPA - Choice and Partnership Approach

This is the process through which referrals are allocated and assessed and care/treatment provided if appropriate. CAPA was devised by 2 child & adolescent psychiatrists working in the NHS. CAPA embraces the concepts of Choice (Our Choices in Mental Health, 2005). Initial contact with the service is in a fully booked Choice appointment with a clinician with extended clinical skills. Choice describes this contact as it includes choice of appointment time and clinician and informed choice about what help from CYPMHS would involve. If the family want to engage further in the service then a Partnership appointment is booked with the most appropriate clinician in the Choice session. Partnership work may be further assessment or treatment.

CORC - CYPMHS Outcomes Research Consortium

Child & Family Services are a member of the National collaboration, 'CORC' (CYPMHS Outcomes Research Consortium). This is a consortium of 52 other member services; however the data relating to the rest of CORC in the annual report relates to only 30 other member services, this is because not all member services are at the stage of being able to submit data to the consortium as yet.

The CORC annual report includes data from the following core outcome measures that are routinely administered in all community teams across Lincolnshire:

• CGAS - Children's Global Assessment Scale - A clinical rating outcome scale administered at first contact and 6 months later or discharge, whichever occurs first;
• SDQ - Strength & Difficulties Questionnaire - A self reporting tool, age 11 - 18 and parent carer tool for young people aged 4 - 18, administered at first contact and 6 months later or discharge, whichever occurs first;
• CHI-ESQ - Commission for Health Improvement - Experience of Service Questionnaire - a self reporting tool for young people aged 9-11 and 11 - 18 and a parent/carer version, administered at 6 months or discharge, whichever occurs first.

Aims and objectives of the service

To prioritise timely and efficient response to requests for consultation and advice in respect of the mental health needs of children and young people who are cared for within statutory fostering or residential care home arrangements, or children placed with their parents under section 31 referred to in this specification as LAC.

To ensure priority of access to mental health services as assessed, providing a single point of contact with provision for consultation, assessment and intervention via dedicated LAC Primary Mental Health Workers.

To provide specialist mental health advice and assessment to LAC and their carers, working with other agency child professionals and carers to develop awareness of mental health needs and support placement stability.

Service Scope

Children and young people up to their 18th birthday who are in statutory fostering or residential care home arrangements.

Exclusion criteria

Inpatient assessment and treatment (Tier 4 Services) for children aged under 12 years will not be provided.

Geographical population served

Service Users shall be registered for NHS Services in Lincolnshire. The Service shall be a Lincolnshire county wide service. Exceptions will be addressed on a case by case basis when it is deemed beneficial for the service user to access Lincolnshire CYPMHS.

Service description/ care package- overview i.e. what is provided

• Assessment;
• Care planning;
• Interventions etc.

The Service comprises the provision of Tier 2 services e.g. access, consultation, assessment and intervention and access to Tier 3 services where assessment indicates longer term or more complex needs. The service is provided by a team of [3] CYPMHS Primary Mental Health Workers for Children in Care, who are either:

• A Registered Mental Health Nurse; or
• A Specialist Social Worker.

The role of the Primary Mental Health Worker is to provide consultation, assessment and intervention in respect of a young person's mental health,

The team work closely with CYPMHS staff in the Tier 3 community teams who also will have LAC on their caseload.

Types of mental health concerns which can be addressed:

• Anxiety, sadness, obsessional behaviour, emotional dysregulation, disordered attachment, post-traumatic stress, eating disorders, self-harming behaviour, depression (this is not an exhaustive list);
• It is the severity of the symptoms, reasons behind them and the impact on the Service User which will determine whether CYPMHS involvement at Tier 2/3 is required or if another service is required to meet the needs.

Range of Services provided

To Professionals:

• Advice, guidance and consultation to support members of the wider children's workforce (any professional working with a child or young person in public care where there is a mental health concern) in meeting children's mental health needs, aiming to prevent them requiring more intensive help at Tier 3. This includes foster carers and other agencies; CYPMHS workers may also suggest reference books for foster carers and therapeutic work they can undertake within the home, to explore feelings and improve self esteem. Through improved understanding of the child's presentation and suggesting management techniques to foster carers the service aims to improve relationships, reduce stress for foster carers and assist the foster carers in meeting the child's health needs in relation to emotional and mental well-being;
• Link working to the county's residential children's homes to liaison support and training to residential staff to support stability of placements. This service is provided by dedicated foster care support workers (Primary Mental Health Workers). Primary Mental Health Workers also provide general mental health awareness training as part of Local Authority induction programme for foster carers;
• Provision of training, on request, on mental health awareness and attachment, including parenting groups as part of the countywide LA foster care induction and support process.
  
  This is provided on request and includes information on attachment theory, how early attachment issues and deprivation can create presentations that can be identified as similar to Autism/ Asperger i.e. Autistic Spectrum Disorder (ASD), and/or Attention Deficit Hyperactivity Disorder (ADHD);
• Attendance at review meetings, or provision of a report if enough notice is given;
• If deemed necessary the CYPMHS LAC Professional will liaise with the medical and psychological team for them to further assess to confirm possible diagnosis. ADHD assessment includes completion of the CONNERS assessment tool, a mental health assessment, a developmental assessment and is likely to require further psychological assessment that identifies how the young person's cognitive abilities are functioning and possibly their IQ. ASD assessment may also require mental health assessment, developmental assessment, and other psychological assessments around cognitive functioning, but the DISCO assessment would be used to formally diagnose ASD.

To Children in Care:

• Direct assessment and clinical interventions, often co-working with other agencies to enhance universal support to children and young people and to enhance the stability of placements. The approach used is Cognitive Behavioural Therapy (CBT) based including solution focused therapy helping the young person to develop coping skills and make sense of their situation, exploring how it affects them;
• Ensure provision of Choice appointments to support prioritisation of need for LAC screened as appropriate for direct referral to Tier 3 specialist services;
• Direct face to face assessment in line with Tier 2 service provision, with availability to provide short term intervention where assessed as appropriate. Such intervention would normally be in the region of 6 sessions and then a review, further interventions may be offered if need identified.

The CYPMHS LAC Team may transfer a case to the Tier 3 services within C&FS when it is considered that the child requires further assessment, indicating that longer term work would be beneficial to the child. The number of sessions will vary depending on the type of work undertake; i.e. cognitive work, which is structured and includes tasks, both in the session and for homework, tends to be shorter in length than psychotherapeutic exploration, which is child led in terms of pace and content. Regardless of the number of sessions undertaken it is expected that all work is reviewed every 4-6 sessions (maximum 8, unless specifically agreed by the young person, carers and clinician). The length of stay in service is dependent on the needs of the young person.

Service Delivery

9. Glossary