Children’s Mental Health - Joint Targeted Area Inspections (JTAI)
Summary
Six audits were carried out on the Children’s Mental Health theme during 2019/20 as part of a preparation for a possible JTAI in Leeds. A multi-agency working group met monthly to discuss the theme, and carry out multi-agency audits of relevant cases.
Joint Targeted Area Inspections are carried out by Ofsted, the Care Quality Commission (CQC), Her Majesty’s Inspectorate of Constabulary, Fire & Rescue Services (HMICFRS), and Her Majesty’s Inspectorate of Probation. The inspections look at multi-agency arrangements and take a ‘deep dive’ approach to look at responses to mental health for children and young people.
Key learning and practice improvements
Mental health diagnoses and medication
Conflict, difficulties and non-alignment can arise where parents / carers are focused on a particular diagnosis, but practitioners and clinicians’ assessments do not support it; particularly where the professional opinion is that the presenting issues or behaviour is related to trauma, family functioning and / or early life experiences. This can be a significant barrier to progress.
Diagnoses can be difficult to ascertain and in some cases young people did not have a formal diagnosis, but medication (e.g. ADHD, anti-psychotic) appeared to help. This can result in difficulties for young people in settings where medication protocols are tightly aligned to diagnoses.
The effectiveness of medication can be affected by physical changes within young people such as growth spurts, which can result in an escalation of challenging behaviour.
Placements
Practitioners and services can struggle to respond to children looked after when it is not safe for them to return home, but placements can be hard to secure due to the level of risk and presenting behaviours. This can result in longer stays in hospital than are medically necessary and make discharge planning difficult.
Crisis response versus stability
Young people entering care in crisis can often experience a range of short-term or emergency placements which can impact on their ability to stabilise and have an effect on placement stability.
A&E is not an appropriate place for young people in crisis if there are no other medical needs. However, young people may feel safe there, and if they don’t feel they have anywhere else to go, their behaviour can escalate when attempts are made to discharge them.
It can be difficult for practitioners and services to work therapeutically or follow a plan of work with young people who are frequently in crisis and where there are safeguarding and risk issues to deal with (e.g. criminal activity, arrests, missing episodes).
Multi-agency working
For complex cases where there are many practitioners involved the following difficulties can arise: co-ordination, agencies taking the lead, young people having different advocates / champions in different services who may not be known to each other, who may be pushing for different things, and who may not understand each other’s roles or statutory responsibilities.
Different and competing statutory processes
Different agencies may have a different understanding of what the risks are and whose duty of care the young person falls under. There are parallel, and sometimes conflicting, statutory processes for children looked after, and for those sectioned under the Mental Health Act.
For young people in in-patient care, there are different and competing responsibilities for all of those in parenting roles, i.e. corporate parents and in loco parentis. This is further complicated by geographical aspects if young people are living outside of their home local authority.
Competing statutory processes can prevent a holistic approach to need, for example, work in accordance with an Education, Health and Care Plan cannot be progressed while a young person is in a secure facility on a Detention and Treatment Order.
Relationships with practitioners
Organisational pressures and / or the way that work and intervention is structured can result in relationships between young people and practitioners ending. Where relationships are positive, services should work flexibly and creatively wherever possible to encourage relationships to continue and use them to improve outcomes for the young person.
The resilience and personal qualities of young people are often the strengths and protective factors within a situation, for example, forming positive relationships with practitioners, or being assertive enough to request a different worker when it is felt that the relationship isn’t working.
Parent / carer relationships
Parental views and engagement can present barriers, for example, consenting to recommended medical or therapeutic input for their child.
There can be challenges in balancing foster carers’ desire to advocate on behalf of the children in their care, against their not having parental responsibility. Practitioners should consider whether to override this as there is the potential of threatening the relationship with the carers and viability of a long-term placement.
Education
The Virtual School needs to be involved in conversations about the education of any looked after child or young person who has mental health needs, at the earliest possible opportunity, and changes to education plans should be considered in discussion with the Virtual School.
School changes are highly significant for children and young people, and as such the desire for a ‘fresh start’ needs to be weighed against the difficulties of a transition. There needs to be a balance when capturing the young person’s voice and views where their desired outcomes / actions may not be in their best interests.
The transition to secondary school is difficult for all young people, but particularly for those with additional vulnerabilities, for example, children experiencing mental health problems. It is important for practitioners to consider that a stable primary school education, a stable placement and an absence of ‘acting out’ or challenging behaviour does not mean that additional support around this transition is not necessary.
Behaviour policies in schools can disadvantage young people further if they are rigid and not adapted to take account of developmental trauma or neurodiversity.
Personal Education Plans need to be in place and up to date for all children looked after, especially for those with additional difficulties in relation to mental health which can impact upon their engagement with school.
Engagement and support offer
Although a wide range of approaches, support and services can be offered, and significant efforts can be made to support young people to access these, young people do not always wish to engage.
Services should demonstrate a flexibility of support, for example where young people do not want to engage in therapeutic work themselves, support should be offered to their parents and carers.
Stability
The resilience and determination of services and carers in maintaining placements and providing stability for young people, despite challenging behaviour, is positive. In contrast, where children have experienced a range of short term or emergency placements as behaviour has escalated, stability can be very difficult to find, which can be a perpetuating factor.
Despite difficulties experienced by young people and the presentation of challenging behaviour, significant levels of stability and consistency in their support has a positive impact on young people.
Voice and influence
When young people don’t feel they are being heard behaviours can sometimes rapidly escalate.
The involvement of parents and carers in planning and decision making, and robust and persistent efforts to involve young people, even when they do not want to engage with practitioners or processes, has a positive impact on outcomes for children and young people.
Your next steps
Share and discuss the identified good practice and learning points with colleagues, and ensure the following is embedded in your practice:
- Work with partners to know and understand their roles, responsibilities and statutory frameworks. Where possible work together to achieve outcomes collectively rather than in silos.
- Recognition and consideration of the impact of transition between schools for children and young people.
- Stability and consistency has a significantly positive impact on the outcomes of children and young people.
- The importance of listening to the wishes and feelings of children and young people, as well as the engagement of both children and young people and their parents / carers.
- The involvement of parents and carers in planning and decision making.