What do we know about children with complex needs?

1. What do we know about children with complex needs? Rosemary Chesson Health Services Research Group

2. Fast lane assessment schemein NE Aberdeenshire • Set up 1998 • Scheme included representatives of NHS & Aberdeenshire Council (Education & Social Work Departments) • For children with complex problems at a critical time for whom standard packages not working • To enable the prioritisation of children with high needs who required multi-disciplinary assessment

3. Purpose of scheme To reduce the waiting time for the mental health assessment for children with serious and complex needs Issues to be addressed: • delays causing problems in entrenched cases (children might not be seen as urgent cases) • psychiatry seen as a last resort • unrealistic expectations of psychiatry

4. National and local context • Increasing emphasis on inter-agency working in delivering children’s services • Multi-disciplinary and multi-partner approach critical for local integrated mental health services • Key national and local policy documents on children and young people’s mental health

5. National and local documents 1995 Together We Stand (NHS Health Advisory Service) 1999 Bright Futures: Promoting children and young people’s mental health 2000 Strategic development of CAMHS in Grampian (Dempster) 2001 Grampian CAMHS: Optional Appraisal (Laxton)

6. Referrals to scheme Education referrals NHS referrals SW referral North Aberdeenshire Assessment Team Child referred to fast lane scheme

7. NE Aberdeenshire • Rural as well as urban deprivation • High levels of disadvantage in Fraserburgh and Peterhead - Fraserburgh – health deprivation among worst 10% in Scotland - 76% of crime for N. Aberdeenshire in Peterhead and Fraserburgh

8. Evaluation • Five year duration (1998 to 2003) • Qualitative approach • including observation, questionnaires and interviews • review of children’s records • Comparative study attempted but abandoned • included 10 children fast lane 11 children pre fast lane 21 children in total

9. Findings Profile of children referred to fast lane • two girls and eight boys • mean age 9.5 years • 7 primary school (3 SEN units) + 1 special school • 7 from Fraserburgh Similar age and gender distribution for pre-fast lane cohort

10. Home circumstances (pre-fast lane and fast lane cohorts) • Few children lived with both biological parents 4/21 • Majority lived within single parent households (11 with lone mothers) • Of four within marital relationships – one parent worked away from home, the other had lengthy separations.

11. Parental Health • Majority of parents had physical illness or psychological problems (leading to referral to adult mental health) • Some children had experience of serious illness in both parents e.g. child’s mother had life threatening illness and mental health problems and father died recently.

12. Separation Experience of separation through: • breakdown of relationships • illness • death • imprisonment

13. Complex relationships residential care fostered adopted relationship breakdown second foster home

14. Foster / residential care (parents) • 7 of children’s parents had experience of foster/ residential care • Parental siblings may have had care/ residential placements

15. Previous contact social work services • 16 (8 pre-fast lane, 8 post fast lane) of children’s families had previous contact with social work department Relating to: - child protection issues - concerns re adequacy of parenting - long standing contact through older siblings - provision of respite/ home care/ support

16. Children and service input • 8 of the 10 children referred to fast lane in receipt of specific additional service input in early years • Of children attending mainstream schools in 14 cases auxiliary support or additional learning support provided (in some cases up to 20 hours per week) • Other input - attendance at family centre - play therapist - family support worker at weekends - attendance at after school group

17. Input following fast lane • Ritalin considered • Respite care • Family support group run by clinical psychology • Befriender

18. Outcomes • More appropriate referrals to child mental health services • Referrals to scheme were appropriate • Benefits from review meetings • Closer working been achieved across agencies • Senior staff group provided a forum for more strategic approach to children

19. Complex needs • Research indicates confusion around term complex needs; no commonly agreed definition • Research focus on physical illness e.g. Stalker et al (2003) included children with - acute and chronic medical conditions - multiple and profound impairments - learning disabilities

20. Definitions Child Review report on Carla Bone (2003) Need for ‘more understanding, consensus and agreement about thresholds when using terms - vulnerable - significant harm - neglect - protecting children - in need

21. Risk factors in the child Poor concentration Specific learning disabilities e.g. dyslexia Communication difficulty, language delay as per autism Moody, oppositional, aggressive Physical illness Academic failure/underachievement Low self-esteem Poor social skills Low expectations Risk factors in the family Overt parental conflict Family breakdown Inconsistent or unclear discipline Hostile and rejecting relationships Poor parenting (care) Physical, sexual and/or emotional abuse Parental mental ill health Parental criminality, alcoholism Poor parental adjustment to community Poor social adjustment Death and loss – including loss of friendship Poor relationship with agencies Low parental confidence Trauma in the family: - death - abuse - house fire - drug involvement (hard) Risk factors in the child and family (1) Modified from Bright Futures, Mental Health Foundation (1999)

22. Finally Need to be able to make sense of complexity ‘We need to see public services as complex adaptive systems in which different individuals and organisations have different histories, cultures and goals... Policy makers need to work across boundaries.’ Chapman, 2002

23. Chesson R., Bruce C., Chisholm D., Fotheringham J., Theodoreson K. & Wilson G. (2005) No Magic Wand: Evaluation of the Fast lane assessment scheme in North East Aberdeenshire. Aberdeen: The Robert Gordon University. pp 1-77. A full copy of the report can be found on our website: http://www.rgu.ac.uk/hsrg