Situation: Kenny Adamson is 15 and has periodically stayed with foster carers; but he has always absconded. He mainly lives with his mother who has had a series of eating disorders which have required in-patient care. Kenny’s father is serving a life sentence for stabbing his wife’s sister to death five years ago. Kenny wants to visit his father (indeed he has turned up at the prison each time he abandoned his foster carers) but his father won’t see him or any other family member. Kenny also occasionally stays with his uncle (father’s brother) but he works away from home a lot, and his maternal grandparents, whose relationship with him is at times hostile because he strongly resembles his father (who killed their daughter).
Problem: Kenny has recently begun experiencing disturbing thoughts and hallucinations (including being visited by his father telling him he is bad – just like his father) that are leaving him confused and distressed. His mother is becoming seriously ill and Kenny too is binge eating and throwing up. His physical health is now deteriorating. Kenny has said if he is placed in care again he will stop eating altogether or will kill himself with a knife. Seven-day support for Kenny at home would potentially help keep him in the community but it is not available. His attendance at school, which had been good, is now lax and he hasn’t managed a full day for three weeks.
The name of the service user mentioned has been changed.
With a history of broken relationships, it can be of no great surprise that Kenny is experiencing such a turbulent adolescence. Because of the disturbing thoughts and hallucinations that he is experiencing, Kenny’s situation may worsen if he is labelled mad.
He needs a comprehensive and rapid assessment of his mental health needs and behaviours, taking account of Kenny’s cognitive condition as well as his moral and sexual development.
It will need to identify or discount an attention deficit hyperactivity disorder, conduct disorder, autism, eating disorder, mood disorder (including depression), or psychotic illness. Risks (including self-harm) will need to be assessed and a management plan considered.
This is the only way we can possibly be sure and know whether he should be steered away from – or into – mental health services.
Many areas are building on existing child and adolescent teams and developing child and adolescent mental health services. The introduction and continued development of a National Service Framework would help to standardise such specialised service provision across all geographical areas.
Kenny is too young for adult psychiatric services which could well include an adult psychiatric in-patient unit – although I believe there is precedent for ignoring the lower age limit of 16 years in Milton Keynes and elsewhere. Though an adolescent psychiatric bed will be difficult to find, this may be exactly what Kenny needs.
The Mental Health Act 1983 Code of Practice relates specifically to children and young people under the age of 18, and in particular it raises practice issues of information-sharing between agencies and consideration of whether the Mental Health Act or Children Act 1989 might be more appropriately used if “necessary to require a child’s residence”.
Only after a comprehensive, multi-agency assessment can a reasoned decision be made about how to help Kenny in, as the Code of Practice defines it, “the least restrictive possible [manner] and result in the least possible segregation from family, friends, community and school”.
One of the difficulties of situations such as Kenny’s is the strong pressure to “do something”. Those involved, including professionals, will feel that removal from his home to another type of placement will solve or improve Kenny’s problems. However, experience would suggest caution is in order.
Two possible solutions likely to be suggested at some point for Kenny will be accommodation under section 20 of the Children Act 1989 or admission to a psychiatric unit.
The possibility that Kenny is a danger to himself might justify one of these courses of action, but this risk should be balanced against the known negatives of being placed in institutional care.
Few foster placements or residential establishments will have the expertise to deal with Kenny’s mental health issues. There is nothing in the research on outcomes for looked-after children that would encourage any optimism about an improvement in his circumstances as a result of going into care. Kenny shares this view. Other than secure accommodation, it is unlikely that any voluntary or compulsory care could control Kenny’s behaviour, ensure the take-up of treatment or afford him protection.
Similarly, there are few psychiatric resources equipped for teenagers. Most are adult-orientated and unlikely to be helpful to Kenny.
A type of resource that may be recommended for Kenny would be a “therapeutic community”. The central philosophy of these communities, which can be found in NHS, prison, education and independent sectors, is that service users are active participants in their own and each other’s mental health treatment and that responsibility for the daily running of the community is shared among themselves and staff. However, such places are not easy to find.
Although the case study states that seven-day care is not available, it would be interesting to know why. Presumably, there are financial constraints. Lastly, I would look to increase what professionals could offer with family and extended family input. A family group conference could be really helpful in this way. The fact that some family members have experienced acute mental health problems should not be used as an excuse for not looking at what others in Kenny’s network may have to offer.
This young boy needs someone to tell him he’s loved and wanted, writes Kay Sheldon. He must be feeling very frightened and lonely, and probably confused and angry as well. He’s desperate for a supportive family. He needs the opportunity to develop a secure and trusting relationship with a parent figure or substitute. This could be with a therapist or with a carefully selected and supervised volunteer. Kenny needs to be helped to build up his confidence and self-worth.
His relationship with his father is obviously very important to him. Strenuous efforts should be made to set up and maintain regular meetings between Kenny and his father, who should be made aware of the impact his refusal to see his son is having on Kenny. It may well be that Kenny’s father feels too ashamed to see his son but with careful counselling he could be made aware of the importance of developing a good father-son relationship with Kenny. Equally Kenny’s relationship with his mother, and his wider family, should be strengthened and reinforced. This is likely to need tact and perseverance but would be worthwhile to build up family ties for Kenny.
The present situation could lead to Kenny being admitted to hospital. This could either be disastrous or very positive depending on what services for adolescents are available in Kenny’s area. Being placed on an adult acute admission would be unlikely to meet his needs. It may deal with the immediate crisis but would probably not make any significant difference to the quality of Kenny’s life in the long term. Ideally, access to a good adolescent unit which is child-centred and skilled in working with families could be very beneficial.
It seems that Kenny is now in need of specialist mental health input. The nature of the help will depend on what’s on offer in his area. It may well include appropriate medication but needs to go beyond that. An approach which might be appropriate to Kenny’s needs and his age could include art therapy, drama-therapy, supportive counselling, family therapy, sport and exercise, and diet and nutritional advice. School work is something which Kenny has been conscientious about until recently and should be re-introduced as soon as Kenny is up to it, possibly gradually. Strong emphasis should be placed on establishing a good rapport with Kenny which values and takes account of his views and feelings.
Kay Sheldon is a mental health service user.