Inquiry into the emotional and mental health of children and young people in Wales
1. The extent to which new (and/or reconfigured) services are helping to reduce waiting times in specialist CAMHS. Whether the improvements in waiting times Welsh Government expected from CAMHS have been met.
It has been suggested that 72% of children who are adopted from the care system in the UK will have experienced abuse and neglect (Selwyn, Meakings & Wijedasa, 2015). There is a body of evidence (e.g. Jaffee & Christian, 2014) demonstrating the long term consequences of early adversity (such as maltreatment or drug/alcohol misuse during pregnancy). Numerous studies demonstrate that early exposure to trauma, neglect, abuse and the absence of a secure attachment figure from birth has a profound impact on the later development of mental and physical health (Feeney, 2000). Advances in neuroimaging and neurobiology is also beginning to demonstrate that early trauma through exposure to abuse and neglect has a significant impact at the structural and functional level of the child’s brain (e.g. McCory, De Brito, & Viding, 2010; CDCHU, 2012; Jaffe and Christian, 2014). Wales Adoption Cohort Study by Cardiff University, examined the presence of Adverse Childhood Experiences (ACES) in the cohort. This showed that 47% of children had experienced at least 4 Adverse Childhood Experiences (ACES) before they were placed for adoption. This places them in the highest risk group for later life difficulties.
A large number of adopted children present with complex needs throughout childhood and into adolescence which can be extremely distressing for the whole family system (Selwyn & Meakings, 2015). There remains significant concern that this population often has complex needs with few services available to provide timely and skilled interventions, based in a good understanding of the unique issues facing both adoptive parents and their children (Ottaway, Holland & Maxwell, 2014). It is has been suggested that Specialist Child and Adolescent Mental Health Service (S-CAMHS) have been increasingly focused on diagnosable mental health disorders as a way to manage increasing demand and reducing budgets and those children living with the consequences of trauma are frequently excluded from these services (Silver, et al, 2015). As a result many children and families who are living with the consequences of early trauma are simply not receiving the support they require.
In order to respond to this unmet need the Aneurin Bevan Child and Family Psychology and Therapies Team has developed a small team of Clinical Psychologists (approximately 1 WTE) who work alongside the South East Wales Adoption Service, providing training, consultation and advice to both staff and families and also direct therapy to children and their families where this is indicated. Feedback from professionals and families has been positive, in both supporting other professionals to adopt these psychological ideas within their work with families, but also in reducing the number of children they may previously have referred to CAMHS services.
Examples of qualitative feedback:
a. “The psychologists we have met have been the only professionals in the adoptive support system who truly understand Developmental Trauma and have the training and expertise to offer genuine assistance to us” (Adoptive parent)
b. “They answered all our questions, gave really good advice. Came out feeling positive, with a clear idea of what we need to do and continue to do” (adoptive parent)
c. “A psychological perspective on the issues presented by the child and useful strategies to present to the family in relation to helping them understand the presenting behaviours and endeavour to address them” (professional)
We believe that if access to psychological services and therapies are offered as standard, and right from the beginning of the adoption journey, it will serve to avert the narrative of failure for families when they need some additional support, and over the longer term result in a reduction in the number of adopted children being referred to CAMHS services.
2. ▪ What the data tells us about the variations in practice (equity of access) across Wales.
Review of adoption support services indicate that there is significant variation in the accessibility of mental health services for adoptive children across Wales. It has been suggested that the mental health needs of adoptive children could be better supported if they received the same priority access in education and health as Looked after Children, as the lifelong impact of developmental trauma does not end once a permanent family home has been established.
3. ▪ The extent to which changes have addressed the over-referral of children and young people to CAMHS.
We have anecdotal feedback from many of our social work colleagues working with adoptive families that they are now less likely to refer to CAMHS for support with mental health issues as a result of being able to access psychological consultation and intervention within the SEWAS service. It is proposed that through joint investment from both social care and local health boards, that provision of appropriate support, based upon a good understanding of the impact of developmental trauma, could be provided for adoptive families. It is suggested that if this support was made routinely available to families this would have the impact of addressing the over-referral of children and young people to CAMHS.
4. ▪ Referrals and access to CAMHS by individual Health Board, including the restrictions and thresholds imposed by CAMHS
In response to restrictions and thresholds imposed, the Heads of Child and Family Psychology Service, alongside our partners in specialist CAMHS, dedicated a proportion of Clinical Psychology time into adoption services to ensure that this population has improved access to Clinical Psychologists, who have a good understanding of the impact of developmental trauma on a child’s mental health.
5. ▪ The extent to which access to psychological therapies for young people has improved. Whether there has been a subsequent reduction in the use of medication for young people.
It is suggested that the increased emphasis on diagnosable mental health disorders to reduce the demand of CAMHS services, has meant that the emotional, psychological and developmental consequences of early developmental trauma are being routinely excluded. Given that that traditional CAMHS services are designed to offer focused time-limited interventions around a discrete ‘problem’, it is suggested that psychological services to address the emotional/mental health needs of adoptive children and their families are best placed within local authority settings where they would be more able to offer timely, light touch interventions across the whole adoption journey rather than interventions being based upon a referred ‘problem’
6. The extent to which the funding has been used to meet the needs of vulnerable children and young people, for example, children who are in care, children and young people with ADHD and autistic spectrum disorders, and those who are already in or at risk of entering the youth justice system, including those who are detained under section 136 of the Mental Health Act 1983.
It is suggested that greater consideration and understanding of the impact of developmental trauma is required when assessing young people for neurodevelopmental disorders. Research suggests that those children with a higher ACE score are also more likely to be diagnosed with ADHD (Brown et al, 2017). It is suggested that there is too much emphasis on the assessment of whether a certain constellation of behaviours are present, which might fulfil the criteria for a diagnostic label, with far less importance being placed upon how we might understand these difficulties within the child’s context and most importantly how we can best support these families to address these challenges.
7. Links with Education (emotional intelligence and healthy coping mechanisms)
There has been a lot of positive work undertaken by adoption UK in terms of producing a booklet for schools and also delivering training to schools, which for some adoptive families has made a significant difference to their child’s experience whilst in school. There does however continue to exist a huge variation in the knowledge and skills within education regarding adoption issues and the impact of early trauma on a child’s developing emotional well being and their ability to form healthy relationships with others. In some schools the belief that a child who is adopted has somehow been ‘fixed’ by virtue of their adoption status continues to pervade. It is suggested that education authorities need to consider the emotional needs of an adoptive child to be the same as a child within the looked after system, and that the same level of support be provided for these children.
Educational staff will continue to need ongoing training and support to understand and implement the types of educational interventions needed in order that these children are able to feel safe enough to settle and to learn within the classroom. Greater understanding is needed of the impact of developmental trauma on the child’s developmental stage, and why many adopted children will demonstrate delays in their ability to attend, apply focused concentration and build collaborative relationships with their peers.