Children in care are much more likely to experience mental health problems than young people in the general population. Early life experiences, such as abuse, neglect, parental drug-use or violence likely play a major part in this. So too could the instability that is often inherent in the care system. Supporting their mental health is essential to help them learn to cope with some of these difficult experiences and build resilience. Unaddressed mental health needs are seen as a key driver for the poorer outcomes we see in care-experienced adults, such as unemployment, homelessness and contact with the criminal justice system (Murray et al., 2020). For this reason, it is really important that young people in care get timely access to mental health treatments, before these difficulties and related complexities worsen.
My PhD is focused on understanding access to mental health services for young people in care and care-leavers. In one study, recently published in JCPP-Advances, we used anonymised local authority data to explore referral rates of young people in care (see Phillips et al., 2023). The sample was taken from a larger study using this data (see Hiller 2022). We identified around 100 young people in care who had mental health problems according to a carer-reported questionnaires (Strengths and Difficulties Questionnaire; SDQ). In this group we looked for evidence that they had been referred to or accessed mental health services according to local authority records. What was striking, was that 79% were referred to mental health services within their first year of being in care. This means that the adults caring for care-experienced people (e.g., foster carers, social workers), were usually aware when a young people needed support, and followed up with a referral to mental health services. However, there were three common issues: rejected referrals, instability and apprehension.
Around 13% of referrals were rejected despite a validated questionnaire (SDQ) indicating that the young person was struggling with their mental health. It is not clear from records why referrals were rejected. However, recent research by McGuire et al., (2020) indicated that the mental health needs of care-experienced people aren’t always recognised by mental health professionals. Identifying what the mental health problem is, is a critical step towards effective mental health support. It is also important that our mental health professionals are equipped with an understanding and have confidence in their ability to treat the mental health difficulties experienced by care-experienced people. It may also be that this finding at least partially reflects the chronic under-funding of mental health services, meaning they are having to make difficult decisions on who moves forward for treatment. Of course, high thresholds for speciality support is not just an issue just felt by children in care, with a 2020 report by the Education Policy Institute indicating that 25% of all referrals to CAMHS are rejected in the UK. As a next step, it would be important to map the availability of alternative local services which are available to support children in care who cannot access CAMHS.
We also found that almost one-third of those who accessed mental health services, saw their treatment end prematurely. Qualitative notes we found within social care records indicated that this was usually due to two reasons: placement instability or disengagement.
Many young people in care have unstable lives. In 2021/22, 31% of young people in care in the UK moved homes at least two times (Department of Education, 2022). Our research points to something we hear anecdotally, that treatment is sometimes not offered if a young person is not in a stable placement. However, we also know that those with the greatest mental health needs often have the greatest placement instability (Hiller et al., 2022). Sometimes children in care are going through court proceedings, or other disruptive experiences which might make it difficult for them to engage with mental health support. This means it is very important that all services seek to find ways to provide support, even in the face of instability. At the same time, turnover of social care staff is a growing problem in the UK. There are several practical things mental health workers and other professionals can do to ensure continuity of care despite instability. For example, mental health workers should try to have multiple contact numbers/emails for people in care, such as the foster carer, the social worker, or even the social work team leader. Accurate record keeping is also really important, so if there is a change in staff, the next person can pick up where they left off, without the young person having to repeat details.
Working with apprehensions
As we already mentioned, the other main reason for treatment stopping early was because the young person disengaged. Previous qualitative research indicates that care-experienced people prefer seeking support from informal sources (Powell et al., 2021). We wanted to understand why care-experienced people might avoid formal mental health support, so we conducted interviews with care-experienced young people aged 18-25 about their experiences of accessing support (Phillips et al., under review). This work highlighted some common worries and apprehensions. Many of the young people we spoke to wanted support but didn’t know how to explain what their mental health problem was. They feared that professionals would not understand their pre-care and in-care experiences. Though they recognised that talking about the past would be important for their recovery, they were still apprehensive about “opening that door”.
In our qualitative research, the main thing that helped care-experienced young people engage with an access support was a consistent adult (e.g., social worker, leaving care coach, mentor). Our research indicated that trusted adults recognised when they were struggling, attended appointments and advocated for their needs. This finding echoes a recent survey with around 10,000 care-experienced young people, which indicated the central importance of trusted adults for wellbeing (Selwyn et al., 2022). In this way, it is important that people who work with care-experienced children and adults have capacity and the know-how to support mental health related decisions.
Our research, and research by others, show that changes need to happen across almost all systems that support this vulnerable group of young people. We need to listen to what care-experienced young people tell us and ensure services are set-up to provide best-evidenced assessments and support.
Department of Education. (2021). Children looked after in England including adoption: 2020 to 2021. Retrieved 10th November 2023 from https://www.gov.uk/government/statistics/children-looked-after-in-england-including-adoption-2020-to-2021
Education Policy Institute (2020). Access to child and adolescent mental health services in 2019. Retrieved 10th November 2023 from: https://epi.org.uk/wp-content/uploads/2020/01/Access-to-CAMHS-in-2019_EPI.pdf
Hiller, R. M., Fraser, A., Denne, M., Bauer, A., & Halligan, S. L. (2022). The Development of Young Peoples’ Internalising and Externalising Difficulties Over the First Three-Years in the Public Care System. Child Maltreatment, 10775595211070765. https://doi.org/10.1177/10775595211070765
McGuire, R., Halligan, S., Meiser-Stedman, R., Durbin, L., & Hiller, R. (2022, 06/14). Differences in the diagnosis and treatment decisions for children in care compared to their peers: An experimental study on post-traumatic stress disorder. The British journal of clinical psychology, 61. https://doi.org/10.1111/bjc.12379
Murray, E. T., Lacey, R., Maughan, B., & Sacker, A. (2020). Association of childhood out-of-home care status with all-cause mortality up to 42-years later: Office of National Statistics Longitudinal Study. BMC Public Health, 20(1), 735. https://doi.org/10.1186/s12889-020-08867-3
Phillips A. R., Halligan, S. L., Denne, M., Hamilton-Giachritsis, C., MacLeod, J. A. A., Wilkins, D., & Hiller, R. M. (2023). Secondary data analysis of social care records to examine the provision of mental health support for young people in care. JCPP Advances, e12161. https://doi.org/https://doi.org/10.1002/jcv2.12161
Phillips, A. R., Hiller, R. M., Halligan, S. L., Lavi, I., Macleod, J. A. A., Wilkins, D. (under review). A qualitative investigation into care-leavers’ experiences of accessing mental health support.
Powell, K., Huxley, E., & Townsend, M. L. (2021). Mental health help seeking in young people and carers in out of home care: A systematic review. Children and Youth Services Review, 127, 106088. https://doi.org/https://doi.org/10.1016/j.childyouth.2021.106088
Selwyn, J. & Briheim-Crookall, L. (2022) 10,000 Voices: The views of children in care on their well-being, Coram Voice and the Rees Centre, University of Oxford
Take a listen to this Papers Podcast, with Alice Phillips discusses her JCPP Advances paper ‘Secondary data analysis of social care records to examine the provision of mental health support for young people in care’. The Provision of Mental Health Support for Young People in Care