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Obtaining residential placements outside a looked-after child’s locality is a common cause of friction among agencies, commissioning managers and practitioners. Some of the reasons are obvious, particularly the complexity of needs that cannot be met by local foster, residential, school or psychiatric placements.

Children’s needs and resulting responsibility often fall across the three sectors of social care, education and health, but their respective remits may be unclear. Such placements are costly, need justification and agreement by several parties, they have to fit certain definitions and criteria, are difficult to find and monitor, their future success cannot be guaranteed and they are away from the child’s community.

The aims, funding and reviewing process can become blurred. For example, are the aims to contain high-risk behaviour and make a local (for example, foster) placement later, or is this unrealistic and a medium- or long-term option better? The latter depends on the funding streams.

Children and young people with a range of relationships, emotional and behavioural issues fall in the category of those with severe attachment difficulties. Therefore, a “block” definition for such groups of children is unlikely to be adopted, as it would not be pragmatic to meet their needs. Consequently, each case will have to be considered individually.

One concept that has caused misunderstanding and misperceptions is the use of the term “therapeutic” in defining such a placement, which can mean any of the following: providing “more than usual”, specialist and skilled staff, structured programme, high staff ratio, a multimodal approach or individual therapeutic work.

It should encompass all these components, as none on their own would address the child’s long-standing and often entrenched difficulties that may have been accentuated by recent placement instability. Making such a decision often affects the child’s future and can only be made on the balance of potential gains weighed against risks of further disruption and rejection.

What can we do for those children and young people who are placed in such settings? If all other options have been exhausted, it is essential to plan without either deferring decisions or responding to crisis. Standards for these costly and difficult-to-obtain placements should be set jointly by providers of such services, commissioning authorities and regulators.

We all have a responsibility to ensure that these standards are met before and after the placement. They include solid and regular review mechanisms that look at all aspects of the child’s life and the therapeutic help they receive and training for staff of such units. In the case of child and adolescent mental health services, the active development, commissioning and sustainability of links and service protocols should be the responsibility of therapeutic residential units and not of the commissioning local authority.

Panos Vostanis is a consultant child and adolescent psychiatrist, and professor of child psychiatry at the University of Leicester


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