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Accessing CAMHS for children in care proceedings - a guide for family law professionals

Dr Matt Woolgar, a clinical psychologist at the South London and Maudsley NHS Foundation Trust's National CAMHS Adoption and Fostering Service, reviews requests by family law practitioners for therapeutic assessments, and advises on the way the legal and clinical professions can work harmoniously for the benefit of children and adolescent clients.

Matt Woolgar, clinical psychologist, South London and Maudsley NHS Foundation Trust's National CAMHS Adoption and Fostering Service

How often have you made a request to Child and Adolescent Mental Health Services (CAMHS) for a therapeutic assessment or for help to be provided for a child currently subject to care proceedings, only for the request to be declined? From reading the Family Law Week blog, I gather that this happens all too often, with the blogger's experience that CAMHS typically refuse to offer services to children in care proceedings. Sometimes a refusal occurs when CAMHS want placement stability to be evident before embarking upon assessment or intervention and that is certainly the ideal situation. However, I would argue that the failure of the various systems around children to provide them with stability should not bar them from accessing appropriate assessment and treatment, not least because these children are often the most needy of an already very vulnerable group.

I work in a national CAMHS service for adopted and fostered children. This type of service is not quite the same as a local Looked After Children's service (sometimes called CLAMHS) with which many of you will have had contact. We routinely see children at any stage of the care process, including those who sometimes fall through the gaps between services, e.g., those whose established placement is breaking down or who are currently subject to care proceedings where their future placements are unknown. These gaps arise due to a number of reasons. Sometimes the service model adopted by a local team prioritises long-term therapeutic work over other care options;  if this is the case then it can be impractical to work with children whose future is unknown. In contrast, I would argue that it is quite possible to provide a helpful service for children whose future placements are unknown, following appropriate best-practice models (for example, see guidelines by Chaffin et al, 2006), which deal with the current situation, while simultaneously planning for the future longer term care needs. However, the problems that arise accessing services for children in care proceedings are not just to do with some CAMHS service models. Another common reason concerns the way in which legal and social care professionals communicate with CAMHS.

My aim with this article is to consider some reasons why this unacceptable impasse arises, to facilitate a dialogue between the different understandings and to offer some practical examples of how to get around it.

While the nature and range of mental health problems relating specifically to children involved in care proceedings are not well established, we do know a lot about the related and overlapping group of children who are looked after (i.e., in foster care). For example, we know from excellent UK research that children who are looked after suffer elevated rates of mental health problems, and that these problems cannot be solely attributed to being from families with higher than average levels of social risk and disadvantage (Ford et al, 2007). This evidence tells us the sorts of disorders we can expect to see and which are much more common than in children raised in birth families. They include behavioural disorders (39% vs. 4%), ADHD (9% vs. 1%), anxiety disorders (11% vs. 4%, especially PTSD 2% vs. 0.1%), as well as elevated rates of neurodevelopmental problems (13% vs. 3%) and autism (3% vs. 0.3%). There is a very similar picture with regard to educational problems, with increases in significant intellectual delay (11% vs. 1%), literacy/numeracy problems (34% vs. 10%) and statements of educational needs (23% vs. 3%). The raised incidence of such problems is not simply derived from living in conditions of social disadvantage, because these problems are also between 2 and 10 fold higher than in children raised within birth families facing significant social adversity.  There are unique risks in being a looked after child, over and above the well-known risks of social disadvantage.

Children in care proceedings are likely to share many of the problems of looked after children but will frequently have the additional risk of on-going uncertainty regarding whether they are to be removed from their primary caregivers and attachment figures, and where their future might lie. Given this, their presentation is likely to be especially complex and requires a comprehensive assessment. This involves a high degree of clinical skill and considerable experience of working with the mental health and well-being needs of this very vulnerable population… so why is it that CAMHS services, which ought to be well placed to carry out the requisite multidisciplinary assessments, seem so often to refuse to assess them? I will use a recent example from our service, which is well equipped to offer assessment and intervention to children in care proceedings, to illustrate some of the communication and expectation problems which CAMHS may experience with family law professionals.

Our service provides intensive multidisciplinary assessment, within the NHS, usually in one session with a care plan provided at the end of the day, usually in a professionals meeting. Where indicated some interventions can start immediately. These interventions are evidence based and therefore do differ from the requests frequently seen in LOIs and court reports (and for which I know of no convincing evidence) typically of the form 'long-term intensive psychotherapy to deal with their difficulties'. For local cases we can ourselves offer evidence-based interventions within our clinic or as appropriate, and for national cases provide recommendations for similar treatments to be undertaken locally with CLAMHS or CAMHS. Where there are direct implications for the child's mental health and well-being we may also make specific recommendations about placements.

A recent case came to our service in which a child had been in long-drawn out care proceedings. The guardian had recognised that the child needed a clinical assessment independent of the other issues about placement. We agreed to see the child and current carers, perform a clinical assessment and provide recommendations for his mental health and well-being. Of course, we were happy for our report to inform his care planning and to help the other professionals in the relevant networks consider how his clinical needs could inform their thinking, and to meet with them to discuss this in a formal setting. Having been clear that we were not providing expert opinion for court, we received just days before the assessment, as so often happens, an unsolicited half metre high bundle of unsorted paperwork and a long LOI which bore no relation to the previously agreed aims of our clinical assessment.

From the CAMHS perspective this feels like a 'back door' request for a court report. A more charitable interpretation is that it reflects the habitual response of solicitors in their dealings with clinicians to operate via LOIs. I can understand the mistake – we are professionals skilled in the relevant area and some of our clinicians have also worked in the dedicated NHS Child Care Assessment Team within our hospital. But the piece of clinical work we proposed is of a different kind. It provides different information under different frameworks and with different cost implications for the NHS. Our standard fixed-price assessments can cost referrers (e.g. NHS PCTs or social services etc.) less than a tenth of a high quality, multidisciplinary court report, and there are very good reasons for that. This is not the place to explain the financial factors in detail, but at the very least, there is no way a team such as ours, geared up to offer quick responses to children's immediate needs, could read through bundles of court papers or make sense of an LOI and still provide comprehensive clinical assessments for the high number of children in urgent need of them. Indeed, while our report in this instance made recommendations about contact and placement, this was because these factors had direct impact upon our assessment of managing this child's immediate clinical needs and were therefore part of a normal care plan.

It can take a lot of time for clinicians to deal with solicitors, who of course can be under great pressure from the court to deliver quick outcomes. The mismatch in expectations between solicitors and clinicians may lead to strained communication, in which clinicians can feel under pressure to go beyond their usual service and solicitors let down, expecting something quite different from what can be realistically offered in a purely clinical assessment. As a national service, which must negotiate funding and treatment options with referrers, we are familiar with the need to reach a common understanding and a plan with which all parties are satisfied. If attempts are made to change the agreed program at the last minute we may need to cancel the case, which wastes time and resources all round, but more importantly fails the child. In the light of these complexities, it can be a lot easier for CAMHS to refuse cases in the midst of proceedings and to wait until things are more stable, so that a decent clinical assessment and treatment can proceed relatively unhindered. This is especially true if the preferred service model is primarily focussed upon a long-term therapeutic orientation rather than upon comprehensive assessment.

Good practice guidelines for the assessment and treatment of children who have experienced maltreatment and disruption in their attachment relationships are fairly simple (e.g., Chaffin et al, 2006): secure a decent placement; ensure that a thorough mental health assessment is conducted that considers common disorders; take an evidence-based treatment approach to the problems identified; and engage with and support education as much as possible. This permits a stage-like approach, in which acute problems are addressed straightaway, with a view to stabilise placements. Indeed, much can be done even in a single session or with a brief and time-limited piece of work, without precluding the need for some longer-term work, if indicated, down the line when placement stability allows. For example, in so far as attachment issues may need to be addressed, the evidence tells us that the best way to do this is not through individual psychotherapy but by ensuring long term stability with decent carers, who can show sensitive responding.

Ideally teams should be prepared to do both the comprehensive assessments necessary to address acute problems as well as thinking about the longer term issues which can be addressed once placement stability permits. Having said that, it would be unwise to start some evidence-based treatments for frank mental health problems when a child is in an unstable placement. For example, addressing PTSD symptoms might be contraindicated if there is not a safe and secure placement around a child. Starting a potentially distressing intervention before maximising its chance of success within the buffer of a safe and stable placement would be unwise and could be unethical. However, I would argue it is still possible to assess the full range of current problems and to begin to think what the child's immediate clinical needs might be as well as identify those likely to be helpful in the longer term.

Finally, I offer an example to highlight what can be done, regardless of the stage of the proceedings, to meet a child's current clinical needs. The case relates to two primary school-aged brothers in care proceedings following allegations of neglect in the home and evidence of sexual abuse by a third party. I contrast our reports with the expert report commissioned for the same case that sought to respond to a different set of needs, i.e., a LOI that had little emphasis on current clinical phenomena and a reliance upon psychotherapy style themes rather than the evidence base.  We frequently see cases in which there have already been conducted expert reports of extremely variable quality; in this instance the report was, in my opinion, certainly one of the poorest I have seen. I believe the variable quality of expert reports is a significant problem, encompassing ethics, effective safeguarding, competence and even value for money, but this is a different issue so I will skip over it in the current article.

The expert report in question, stretching to over 100 pages, was based on several consultations over a period of weeks and hence likely to have been costly. The findings relevant to the clinical issues indicated no diagnosable mental health disorders, but recommended that both boys would need long term psychotherapy for trauma (even though this is not an indicated treatment for trauma). The report also noted that during a play therapy assessment one brother picked up a police car, but the other did not. This was interpreted as the first brother having a well-developed superego, while the second may not. According to the report, the second brother would therefore be at risk of becoming a sexual offender, based on the fact that he had been a victim of sexual abuse himself. Following the recommendations made in the report, school had felt compelled to provide a 1:1 worker, not to support the child's learning, but to permit continuous surveillance of him in order to reduce his risk to other children.

Whilst these proceedings were underway, our NHS service accepted a referral from social services about the boys' well-being. One session of multidisciplinary team assessment (including psychiatry, clinical psychology and specialist social work) was conducted for both boys and their carers. This produced two reports of less than ten pages each for each boy. The findings were presented at the end of the single session, provided in the context of a pre-arranged professionals meeting and indicated multiple mental health problems. Both boys had intellectual delay and difficulties with adaptive functioning, indicating significant learning disability, so a referral to Children with Learning Disabilities Services was made. Both boys also had a specific learning disability (i.e., dyslexia) over and above their intellectual delay, with their literacy skills behind both their chronological age and IQ. Thus, the plan was to liaise with school with recommendations to address the difficulties and to support the immediate start of the Statementing process. Both boys had conduct disorder, so the plan was to meet with the carers to begin an evidence-based parenting program as indicated by NICE guidelines. Even if an alternative placement were to be directed by court, it would still be beneficial to get a dose of an effective treatment into the caregiving system for the boys. One boy had ADHD, based on clinic observations plus school and carer reports, hence his diagnosis was hyperkinetic conduct disorder, which in the context of literacy problems, has a particularly poor prognosis. Therefore the assessment suggested that he would need particularly effective parenting to avoid a poor outcome. The plan was to begin a medication trial and an evidence-based parenting program, as per NICE guidelines. There was no evidence of current trauma symptoms, so no treatment for this was indicated, but if trauma were present the treatment would have been trauma-focussed CBT as per NICE guidelines (and not long term psychotherapy). Instead, the recommendations were for 'watchful waiting' and to educate the system about the possibility of sleeper effects, e.g., the possibility of trauma symptoms reappearing in later development. There was no evidence of sexually harmful or inappropriate behaviours reported in home or school and so the plan included the strong recommendation to remove the 1:1 monitoring of the child in school and instead to consider him as a victim of abuse and not, on current evidence, a likely perpetrator. The 1:1 surveillance would probably inhibit his opportunities for normal social development and integration, and needed to be removed. This was discussed in the professionals meeting and backed up by a report within 2 weeks, to help school justify the revised risk-management arrangements.

Most of these plans can be begun very quickly, some on the same day, and can be carried forward to any further placement. They do not require proven placement stability and can be applied whatever else is going on during care proceedings. This service approach works because it is quick and flexible, focussing on what the evidence and best practice are telling us we need to do for children who have been maltreated and who may have attachment difficulties. Namely, facilitate a decent stable placement; promote educational engagement; identify frequently occurring distressing disorders with a thorough assessment, and then treat them with evidence-based approaches. For example, ensuring that the current educational placement suits their needs as soon as possible is entirely consistent with maximising their engagement with education. Even if, following the court's decision about their future, the boys were to move school, this would not have been a wasted effort. In order to encourage educational engagement we want to minimise the negative experience of school as soon as possible and to ensure it quickly becomes as rewarding. Such an approach, designed to give quick outputs, does not preclude the possibility of longer-term work, nor the need for extensive involvement with services in the future, nor should it be seen as in competition with other longer term approaches, but complimentary to them.

I would argue there is a joint responsibility for CAMHS to be prepared to adopt a variety of service models to address children's needs throughout their journey into and out of the care system, but also for legal professionals, guardians and social workers to be aware of the difference between a clinical assessment and an expert report. So if you have a client in the midst of care proceedings, and you think they need a mental health assessment, talk to a specialist NHS service with capacity for multidisciplinary team assessments and a commitment to working with the evidence base. All parties will need to be prepared to negotiate a common ground and this has the potential to be mutually enlightening, even if it does take up more time than a routine clinical case. But please do not ask an NHS service, which is primarily about assessing clinical needs to do a court report on the cheap. They will not appreciate the invitation, not least because it stops them seeing other vulnerable children who also need a service!
Dr Matt Woolgar is a clinical psychologist at the South London and Maudsley NHS Foundation Trust's National CAMHS Adoption and Fostering Service, and is a senior researcher at the National Academy for Parenting Research at the Institute of Psychiatry, King's College, London. For more information please visit: Adoption and Fostering Service: 

Chaffin, M., Hanson, R., Saunders, B. E., Nichols, T., Barnett, D., Zeanah, C., et al. (2006). Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems. Child Maltreatment, Vol.11(1), 76-89.

Ford, T., Vostanis, P., Meltzer, H., & Goodman, R. (2007). Psychiatric disorder among British children looked after by local authorities: Comparison with children living in private households. British Journal of Psychiatry, 190(4), 319-325.