By Anna Rebowska, 2nd September 2021
An earlier blog post reports on a COP case in which a 17-year-old girl (anonymised as “N”) endured numerous placement breakdowns and found herself repeatedly detained in Emergency Department and in police stations for her own protection and for the protection of others.
N has been diagnosed with autism, mild learning disability and ‘emotional dysregulation’. She has been subject to detention under Mental Health Act but this has been quickly rescinded before transfer from acute hospital to a psychiatric unit took place.
Due to the complex nature of N’s presentation, the Local Authority struggled to find a suitable long-term placement that can meet her needs despite a nationwide search.
At the time of the last report, N was in a temporary accommodation in an annex of a care home while the search continued for a provider that can offer her a home and the long-term support she requires.
The scale of the problem
This is not an unusual case. The Children’s Commissioner recently explored this problem in detail producing a report, which highlighted that over the last three years close to 1,500 children have experienced sustained placement breakdown defined as 2 or more placement moves. It has been identified that some groups of children are at particularly high risk of placement breakdown:
- Older children who have recently entered care – 6.6% of children aged 12-15 who also entered care age 12-15 experienced 2+ placement moves in both 2018 and 2019, more than double the average rate.
- Children with social emotional, mental health (SEMH) and special educational needs (SEN) with 2.8% of this group experienced 2+ placement moves in both 2017/18 and 2018/19 compared to 1.4% of those with no identified SEN.
- Children whose first placement during 2018/19 was in a secure/specialist residential placement or children’s home – 7.5% of this group experienced 2+ placement moves in both 2017/18 and 2018/19 (349 children).
As a Named Doctor for Child Protection in a large mental health Trust, which puts me in frequent contact with Local Authorities, I frequently face dilemmas relating to placement search or devising additional supportive resources to try to prevent placement breakdown for children and young people with complex social, emotional and mental health needs.
I also work in forensic Child and Adolescent Mental Health Services (CAMHS)where we support young people who are particularly challenging to place because of their convictions and the risks they pose to others. Those young people might have spent a period in secure care but on discharge can often find themselves in unregulated post-16 placements with minimal support – such as B&Bs or in a flat of their own visited by ever-changing care agency staff who have good intentions but little specialist training. The scale of the problem has been examined by the Children’s commissioner in a 2020 report, bringing into the spotlight both the poor quality and spiralling costs of unregulated placements provided by a wide range of private companies.
The focus of discussion surrounding those complex cases often relates to the question of whether the young person can be legally detained under one of the sections of the Mental Health Act. There is less attention paid to exploring if they should be so detained and if it is truly in their best interest.
There is an assumption that inpatient psychiatric units (where a young person would go if detained under the MHA) will provide access to therapeutic interventions and create a safe environment that will help the young person to heal from their underlying trauma and to develop coping strategies that will allow them to manage in less restrictive environments in the future. It less commonly recognised that whilst an admission to a psychiatric hospital offers an immediate solution to management of short-term risks but it does often come with unintended long-term consequences.
Admission is an appealing solution and those working with young persons in the community hope that the hospital will be able to ensure their safety and help the person to cope better in future. Unfortunately, while the environmental restrictions of the hospital environment can reduce risk short term, in the long run we tend to see an escalation in self-harm, which creates a barrier to discharge. A knee jerk reaction to admit can have profound consequences for the young person, particularly if they find themselves admitted to an out-of-area psychiatric unit, 100s of miles away from home and familiar support networks formed by family, friends, school community, their social worker and many other potentially supportive peers and adults.
Admission to a restrictive hospital environment does not resolve the underlying reasons as to why young people self-harm and may paradoxically increase risk by encouraging young people to move to new and often more lethal ways of harming themselves once access to their usual means is removed.
Hospital environments place together many young people with severe difficulties. Although this can facilitate the ,creation of new supportive peer networks it also generates possibilities for young people to become aware of self-harm methods that they were not previously exposed to.
Caretakers within hospital environments often respond to episodes of self-harm by placing more and more restrictions on the young person and further diminishing their access to ways of coping. Everyday items and creature comforts, which we all enjoy and take for granted start to be scrutinized through the prism of risk and one by one make their way to a list of things that young person can no longer access. The situation continues to escalate exponentially, sometimes to the point when young people are nursed in a completely bare environment of long-term seclusion, where they continue to self-harm out of boredom, desperation and hopelessness. This creates a life that is hardly worth living and powerfully reinforces suicidal ideations. Any prospects of discharge back to the community move further and further away.
This bleak scenario is particularly relevant to young people with autism and learning disabilities. Frequently admitted in crisis, for what is supposed to be short-term care, they find themselves without a clear pathway back to the community and languish in hospital for months and in some cases years. There is no treatment for their core conditions and restrictive regimens of inpatient units combined with overwhelming sensory environments often make their presentation worse. Those issues have been highlighted in multitude of reports, most recently by the Care Quality Commission (CQC) report with a very fitting title: Out of sight, who cares?
The way forward
All children and young people need a home to call their own and psychiatric hospitals do not create environments that are helpful to long term recovery. The key element of an effective strategy to address the current issue of looked-after young people facing prolonged admissions to adolescent psychiatric units and delayed discharges is to look upstream and to try to prevent those admissions from happening in the first place. In order to achieve that, there needs to be a substantial investment in specialist community mental health services for this group of young people based around the principles of trauma-informed care and offering specialised evidence-based intervention to address complex post-traumatic stress disorder that often arises from the developmental trauma and the difficult, abusive, and neglectful experiences faced by looked-after children early in life.
Those include provision of trauma-informed care and evidence-based interventions such as Dialectical Behavioural Therapy (DBT) proven to effectively reduce one of the key reasons why admission is seen as required, which is immediate threat to safety of the young person resulting from deliberate self-harm. The other key area is centred around improving understanding of self-harm among care staff working directly with the young people on day-to-day basis, who do not normally have mental health training. Finally, the need to create lives that are worth living through focus on things that are important to the young people, empowering and handing back control in an age- and developmentally appropriate way.
The problem that we face is complex and there may well be competing goals between different stakeholders. From the child psychiatry perspective, as well as NHS England and CCG perspective reduction of the length of stay in inpatient psychiatric beds for both adults and young people has always been seen as a positive and has been a long-term strategic goal. Adopting alternative perspectives brought to the forefront of my mind the possible unintended consequences and impact that this approach may have on other systems such as paediatric wards in acute hospitals and social care networks run by local authorities. It explains why attempts at early discharge or strategies designed to reduce the number of admissions can be met with so much resistance from other agencies involved.
Unfortunately, at the present moment many healthcare and social care leaders seem to be taking steps backward. The specialist Looked After Child CAMHS teams are increasingly decommissioned with an expectation that the complex needs of this group of children will be met within existing pathways of mainstream CAMHS services. Local Authorities have closed many children’s homes, which resulted in increasing number of young people being placed out of area in placements run by private for-profit providers, severing existing ties with their communities. The waits faced by young people requiring a diagnostic assessment for possible underlying neurodevelopmental difficulties extend, in many areas, to months or years creating barriers to effective support in education and beyond.
Although the challenges are substantial there is some hope that efforts are being made to tackle them in a systemic way. A once in a lifetime review of children’s social care is currently ongoing and I would like to encourage anyone with experience and interest in this area to contribute to it so that the lens of the review can be as broad as possible and the most thorny and pressing issues brought to the forefront. There is definitely a case for change to be made. The challenge is ensuring that change moves us in the right direction.
Anna Rebowska graduated from Manchester University Medical School in 2010. She works as consultant child and adolescent psychiatrist with both inpatient and outpatient experience. She tweets @Belis8686