In this Papers Podcast, 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’ (https://doi.org/10.1002/jcv2.12161). Alice is the first author of the paper.
There is an overview of the paper, methodology, key findings, and implications for practice.
Discussion points include
- The relationship between being in care and the likelihood of experiencing mental health difficulties.
- Gender difference in terms of accessing services.
- The barriers and challenges making it more difficult for youth in care to get mental health support.
- Implications for CAMH professionals and recommendations to make CAMHS more accommodating for young people in care.
- The message that policymakers should take from this research.
Also have a read of this blog from Alice – Mental health and care-experienced young people: are our mental health support services appealing and accessible?
In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.
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Alice Phillips is a PhD researcher based at the University of Bath, Psychology Department. Their research focusses upon the mental health needs of children under care of social services (e.g., foster care), and how to meet these needs with mental health services. Alice also researches childhood maltreatment and trauma, and its impact upon mental health during adolescence and emerging adulthood, as well as the relationship between trauma, social support and interpersonal functioning.
[00:00:07.470] Jo Carlowe: Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a Freelance Journalist with a specialism in psychology. In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are the Journal of Child Psychology and Psychiatry, commonly known as JCPP, the Child and Adolescent Mental Health, known as CAMH, and JCPP Advances.
Today, I’m interviewing postgraduate research student, Alice Phillips, of the Department of Psychology at the University of Bath. Alice is the first author of the paper, “Secondary Data Analysis of Social Care Records to Examine the Provision of Mental Health Support for Young People in Care,” recently published in JCPP Advances. This paper will be the focus of today’s podcast. If you’re a fan of our Papers Podcast series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and do share with friends and colleagues.
Alice, thanks for joining me, welcome. Can you start with an introduction about who you are and what you do?
[00:01:10.240] Alice Phillips: Thank you for having me. So, I am a postgraduate research student at the University of Bath, and I’m studying for a PhD investigating the mental health of children in care, and also adults who are care-experienced.
[00:01:23.270] Jo Carlowe: Great, thank you. Before we go into the details of your paper, can you set the scene for us, by telling us something about the relationship between being in care and the likelihood of experiencing mental health difficulties?
[00:01:36.899] Alice Phillips: Sure. So it’s pretty well established in the literature now that if you are in care or if you have experiences growing up in care, you are more likely to have mental health difficulties. So, a recent meta-analysis found that one in two children in care meet the criteria for a mental health problem. And those mental health problems are more likely to be complex, so, for example, more likely to be comorbid. They’re also much more likely to be neurodivergent, so have things like ADHD or dyslexia.
And we also know that those mental health difficulties often prolong into adulthood, and they’re considered a key driver for the poorer mental health outcomes that we see for care-experienced adults. So, for example, care-experienced adults are disproportionately represented in the homelessness population, and also in the prison population.
[00:02:25.690] Jo Carlowe: Thank you. Let’s turn to the paper itself, so this is, “Secondary Data Analysis of Social Care Records to Examine the Provision of Mental Health Support for Young People in Care,” recently published in JCPP Advances. Can you give us an overview of the paper? What did you look at and why?
[00:02:42.159] Alice Phillips: So, this paper is part of a series of projects, which examines the mental health of young people, once they enter care, and then across the first three years of being in care. And this paper focuses more on the access to mental health support for care-experienced young people.
So far, a lot of the research that’s been done in this area has been done in the US, and that has a very different context to healthcare access in the UK. And on top of that, a lot of the research that’s been done so far looks at access to mental health support, which ignores the complexities of help seeking. So, for example, in the UK, you might first speak to a GP, you might get a referral, have an assessment, and so we really wanted to pick apart some of those key stages of accessing mental health support.
But we had three main research questions. So, the first was to describe the provision of mental health support during the first year of being in care, for a cohort of young people with elevated mental health difficulties. We also wanted to see whether there were any predictors of accessing mental health support, both in terms of referrals, but also receipt of mental health support. And finally, we wanted to have a look at whether accessing mental health support was associated with improvements in mental health difficulties during the subsequent years of being in care.
[00:03:58.409] Jo Carlowe: We’ll look at the findings in a moment, but can you tell us a little about the methodology used for the study?
[00:04:04.209] Alice Phillips: This is a secondary data analysis project, which means that we’ve extracted anonymised information from social care records. And one of the main benefits of doing this is that this is a lot less burdensome for social care teams, by comparison to primary research data collection. However, it does raise some issues related to the reliability of the information that can be found within the records, because the records aren’t collected for research purposes.
And something that’s written into policy in the UK is that care-experienced people have an annual health review, and included in that health review is a mental health questionnaire called the Strengths and Difficulties Questionnaire, and that’s completed by the carers. So, we used that questionnaire, within social care records, to identify young people who had elevated mental health needs in their first year of being in care. And then we had a look at provision of mental health support during that time.
[00:04:55.980] Jo Carlowe: Alice, what key findings from the paper would you like to highlight?
[00:05:00.280] Alice Phillips: I think some of the most interesting and revealing findings from the paper are actually related to the descriptive findings that we have. The first thing that we were interested in looking at was, “What is the provision of mental health support for young people who enter care with elevated mental health difficulties?” And what we did find was that in the majority of cases, so we had a sample of around 100 young people, and in the majority of cases, young people with elevated needs were being referred to mental health support, in their first year of being in care. So only one in five were not receiving a referral.
And then after the referral, most of the time, this did lead to a young person accessing mental health support. So, something like 68% of the sample did reach a mental health professional. But what was interesting was that actually once they access support, there seem to be issues with retention, whereby around 30% of the total sample, so of that around 100 young people, around 30% of them had their support end prematurely, for various different reasons. And one other thing that we looked at was, sort of, predictors for being referred to mental health support, and predictors for accessing mental health support, so getting to see a mental health professional.
And we looked at things like gender, whether within the social care records there were reports of neglect, the different types of abuse that were reported within social care records, the age at which the young person was entering care, and their level of externalising and internalising difficulties, as measured with the SDQ, which is the Strengths and Difficulty Questionnaire. And what we found was that those who had higher externalising symptoms, they were more likely to be referred to mental health services, which I think is – it makes sense. Interestingly, what we did find was that being female was related to being more likely to access mental health support. But this is quite a small sample, so it’s difficult to draw any real conclusions on that.
[00:06:52.800] Jo Carlowe: So, I’m interested in the gender difference then, because my understanding is that boys tend to have more externalising symptoms than girls, but you’re saying that girls better accessed…
[00:07:01.099] Alice Phillips: Yeah.
[00:07:02.099] Jo Carlowe: …or tended to access services more often? So…
[00:07:04.470] Alice Phillips: Yeah, I guess, it seems as if you’re more likely to be referred if you have externalising symptoms, but then there might be something happening whereby those who have externalising symptoms aren’t necessarily accessing services, perhaps ‘cause of the behavioural difficulties. So, being female was related to accessing services, but I don’t really have an explanation for that, because externalising symptoms wasn’t a predictor of access or wasn’t a predictor of being less likely to access, if that makes sense? It just didn’t seem to be related.
[00:07:33.539] Jo Carlowe: I was interested in what you mentioned before, that often though people were accessing support, the support often ended prematurely. What barriers and challenges are making it more difficult for youth in care to get the support they need, or to retain the support that they access?
[00:07:49.840] Alice Phillips: Something that’s really common for young people in care in the UK is to have placement instability. Which essentially means that they are often times moving between foster carers or across residential facilities quite often, so that their address is changing, but also the adults are – in their life and their carers are changing as well. So, when you’ve got changing adults and changing addresses, and perhaps changes in Social Workers, that means that it’s really difficult for that young person to have one individual who’s advocating for their needs. And I think that this can be seen in our research as well. So, one of the main reasons for disengagement from support was placement instability. So, perhaps moving out of the area for that mental health support team, or moving to a different local authority.
But on top of that, we do know from other research that care-experienced young people sometimes can be a little bit ambivalent towards engaging with professionals, and that extends to mental health professionals as well. Or they have a lot of apprehensions around what they’re going to be asked to discuss in mental health support, so that might lead to them disengaging from mental health support. And, again, that seems to be reflected in our sample, whereby the second most common reason for disengagement from services was because the young person wasn’t ready to access that support themselves, or they chose not to turn up.
[00:09:06.440] Jo Carlowe: Of the young people in care who did receive mental health support, what was the impact? Did their mental health improve?
[00:09:14.110] Alice Phillips: What we were looking for in our research was reliable and clinical improvement. So, we were essentially taking their mental health scores in their first year of being in care, and looking at how that changed by comparison to their second year and third year of being in care. And what we did find was that there no evidence that accessing professional mental health support was associated with any particular changes. So, was just completely unrelated to mental health outcomes in the second year and third year.
And there are a few caveats to give with this finding. As I said earlier, in our sample, a large proportion weren’t actually completing their treatment. So, it’s highly unlikely that your mental health is going to be improved in your second and third year of being in care, if you haven’t received the entire course of mental health support.
We also don’t necessarily know what’s happening in those years as well. So, other research shows that if you have really unstable placements, if you are separated from your siblings, for example, those related to worse mental health outcomes. And so we don’t really know, those things weren’t accounted for in our analyses.
And then the other problem is around the reliability of the data as well, so, like I said, it’s social care records. Although the social care record indicated that they didn’t access mental health support, for example, we don’t know if that’s really the case, because we don’t know whether or not they did, it just wasn’t written down. So, this definitely would need to be replicated again to see if the finding holds.
[00:10:37.300] Jo Carlowe: What are the implications of your findings for CAMH professionals?
[00:10:41.040] Alice Phillips: Yeah, so I think something that mental health professionals aim for is continuity of care, and we all understand that’s really important. But the difficulty for these young people is they often have really instable lives, which means that as a mental health professional, what might be really helpful is to make sure that you have multiple points of contact for that young person. So, whereas for a child in the general population you might have their parent, and that’s your main point of contact, for a young person in care, that parent might change, so it’s important that you have backup contacts. So, for example, that would usually mean the Social Worker, or other adults that you know that look after that young person.
I also think it’s important to understand some of the reservations that care-experienced young people might have with accessing mental health support, and making sure that these are addressed early on in therapy, so that young people understand the importance of accessing mental health support.
And finally, I would say that something that would be quite important would be to make sure that you’re keeping really accurate records, if you’ve got the time to do it, make sure that’s being done. Because it might be that you’re seeing the young person for three weeks, and then they’ll come back to the services in six months, or in a year, and someone else will be picking up that case. So, making sure that there’s a really good description of what went on, so that it’s easier for that person to – the child to pick up therapy where they left off, more or less.
[00:12:01.209] Jo Carlowe: Thanks, that’s really important. And what recommendations do you have to make mental health services more accommodating for young people in care?
[00:12:08.690] Alice Phillips: Yeah, I think it mirrors a lot of the things that I’ve just said. But one additional thing that I would add would be to make sure that there are systems in place that allow the young person to re-engage with the service, even after a period of disengagement or non-attendance. As I said, lots of instability in these young people’s lives, but things like court cases might be happening, that might mean that the young person really isn’t feeling like engaging with therapy for a month or six weeks. And being aware of those things that are happening, and having the systems in place, so that that young person can come back when they’re ready, would be something that I think would be really game-changing for young people in care.
[00:12:44.990] Jo Carlowe: Alice, what message should policymakers take from your research?
[00:12:49.149] Alice Phillips: So, something that’s discussed a lot is priority access for care-experienced people, so that they are at the top of the list when they’re referred to mental health services, that they access support more quickly, due to their care-experience status. And one thing that we’ve found is that sometimes the status of being care-experienced isn’t necessarily something that’s even recorded in healthcare records, so I think that would be a really good place to start.
There are some teams across the UK that are implementing priority access really well and have the capacity to do that, but lots of our mental health services are incredibly overburdened, which makes it difficult to give priority access to care-experienced young people. So, supporting our teams would be really, really important.
And then I also think it’s important to look at care-experienced people within their wider systems, so we’re focusing really heavily on mental health teams at the moment, but they also exist within social care teams. And making sure that the language that’s used by Social Workers and Mental Health Workers and policymakers, and by young people themselves, is similar, so that there can be better communication between these services, so that we can better support those young people. And really taking a bird’s eye view of all of the different systems that are interacting around that young person is important.
[00:14:00.519] Jo Carlowe: And Alice, are you planning any follow-up research? Or is there anything else in the pipeline that you would like to share with us?
[00:14:07.220] Alice Phillips: So, a piece of work that I’ve conducted since this, and is part of my PhD, and it’s being prepared for publication, is some qualitative work that we’ve done, that really gives insight into how care-experienced young people themselves experience accessing mental health support. So, I’ve conducted some interviews with care-experienced people. So, I think taking the voices of the young people and their perspectives is really important too, so I would recommend for people to go on and read that, once it’s published, as well.
And also the work of my supervisor, Dr. Rachel Hiller, who’s based at University College, London. And she’s doing a lot of work around barriers and facilitators for implementing evidence-based mental health support for children in care. So, if you’re interested in this topic, I’d recommend you go off and read her research, as well.
[00:14:51.980] Jo Carlowe: And finally, what is your take home message to our listeners?
[00:14:55.720] Alice Phillips: I think this work highlights a need provision gap, there’s a disparity between how much support is required for this group and how much support they’re accessing, and it’s impacting a really highly vulnerable group of young people. So, I think it’s really important that further work is done, both in terms of changes in practice, in policy, but also further research is done to adequately support these young people, mainly just to avoid some of the poorer outcomes that we see in this group in adulthood, and try and address that as early as possible.
[00:15:28.340] Jo Carlowe: Alice, thank you ever so much. For more details on Alice Phillips, please visit the ACAMH website, www.acamh.org, and Twitter @acamh. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoyed the podcast, with a rating or review, and do share with friends and colleagues.