Mission impossible?

A teenager with learning difficulties and attention deficit
hyperactivity disorder presented social worker Joan Clarke with a
huge challenge when she tried to help him and his family. Mike
George reports.

Children and young people with complex and multiple needs are
still inadequately served by social care, health and educational
organisations, even though many acknowledge that there are major
problems in most if not all parts of the country. So until matters
such as institutional barriers and financing are addressed
effectively, social workers will often be facing near-impossible
challenges as they try to uphold these children and young people’s
interests.

Joan Clarke, who is in a children with learning difficulties
team, has certainly experienced her version of Mission
Impossible in the work she has undertaken with John Townsend
(not his real name). Townsend, who is now in his early teens, has
learning difficulties, attention deficit hyperactivity disorder
(ADHD) and has exhibited challenging, and increasingly violent,
behaviour throughout most of his life.

Because of his behavioural problems he has not been in
mainstream schooling since the age of six. Until recently he was in
a term time residential school for children with learning
difficulties, where, despite these problems he was gaining
educational benefits. However, whenever he returned home to his
mother from the out-of-county school, she found it very difficult
to cope with him.

His mother was his main carer, even though she had a new partner
after an earlier divorce. Clarke cites a long list of interventions
made by her colleagues before she took on the case, including
short-term respite help for the mother during holidays, and
attendance for them both at a child and family clinic where
behaviour modification and boundary-setting help was provided. Also
about three years ago, the child protection team became involved
after it was discovered that Townsend had been exhibiting
inappropriate sexual behaviour and using explicit language towards
his very young sister; consequently both were placed on the child
protection register.

Townsend’s behaviour became more violent and unpredictable, and
when Joan Clarke took over two years ago she says that the school,
and John’s mother, were really struggling to maintain and contain
him. Consequently, her first task was to arrange an assessment from
a community nursing team which specialised in challenging
behaviour.

The assessment was inconclusive. “I then started searching for
an appropriate agency, or set of agencies, who could carry out a
very full assessment, because I felt we were missing something,
some reason why his behaviour had worsened so much. I had in mind
matters such as hormonal changes, attachment issues arising from
the separation of his school from his home, or possibly a mental
health problem,” she adds.

Meanwhile, the respite foster carers who helped John’s mother
during school holiday, which among other things allowed her to
spend time alone with her daughter, had, reluctantly, refused to
continue, saying his behaviour was unmanageable. This put extra
pressure on Clarke, who was by now looking for a 52-week
residential placement in an appropriate educational
establishment.

She explains that although she had arranged a childminding
service to help protect the daughter, and sessional workers during
the holidays to engage John in a variety of activities, the
situation was not tenable in the longer term: “I was acutely aware
that his mother was becoming increasingly anxious, tired and
depressed,” she says.

She faced another crisis last July when his school stated that
he could no longer be accommodated because his behaviour presented
an unacceptable level of risk to staff and other students.
Meanwhile, despite Clarke’s efforts to provide the mother with
additional support, it was clear to her, she says, that the risks
he presented when he was at home had also become unacceptable.

Eventually, with the help of colleagues from other agencies, she
obtained a psychiatric assessment. The psychiatrist’s intervention
helped Clarke to clarify what was happening, and she continued to
search for a suitable residential placement, and an assessment
which could encompass all of the issues (Townsend also had
epilepsy, which was managed by medication). Clarke estimates that
she contacted at least 40 agencies or establishments in all.

Clarke’s negotiation with other agencies failed to provide a
solution and ultimately the commissioning manager obtained a
one-bedroom flat locally. She accepted this arrangement and 24-hour
cover was provided by care agency staff with input from health
colleagues, including a psychologist, and “long-arm” support from a
residential home.

John began to take medication for his ADHD, the staff ensured
that he was presented with a full daily activity programme and,
because he was now living locally, his mother started to visit at
least once a week. Since he moved there his behaviour has improved
significantly.

This unexpected placement arrangement has been beneficial, but
Clarke is continuing to try to find a long-term placement. “I am
concerned about John’s lack of interaction with his peers; that
after a fairly long period without education we’re only able to
offer him very limited home tuition and what I feel he desperately
needs is some long-term security in an educationally-based
establishment.

“John questions his future and where he is going to live. The
whole situation is very difficult, not least because he’s said to
me: ‘I don’t want to be like this.’ Such insight makes me wonder if
we’ve really been able to meet his needs,” she concludes.

Case notes

• Social worker: Joan Clarke.
• Field: Children with learning difficulties team.
• Location: Bedfordshire social services.
• Client: John Townsend (not his real name) is in his early
  teens; he has mild to moderate learning difficulties and Attention
  Deficit Hyperactivity Disorder (ADHD). Because of challenging
  behaviour he was placed in special early years education, then had
  a very short spell in mainstream education, before being placed in
  an out-of-county term-time residential school for children with
  learning difficulties.
• Case history: When he was 10 he was referred to the team
  because his mother was finding it very difficult to cope with his
  behaviour during school holidays. She and John attended a child and
  family clinic, and she received short-term respite help. Eighteen
  months later he was found to be acting in a sexually inappropriate
  way towards his young sister, and both were placed on the child
  protection register.
• Shortly afterwards Clarke started working with him, by which
  time his behaviour was becoming more violent. Both his mother and
  the school were finding this even more difficult to deal with than
  before. She began to try to find health services which could carry
  out a comprehensive assessment, and an appropriate long-term
  educational placement, but was unsuccessful. In the meantime she
  arranged additional help for his mother.
• Dilemma: John’s emotional and educational needs are great, but
  his behaviour presents a significant risk to himself and
  others.
• Risk factor: Apart from the immediate risks, his long-term
  future is in jeopardy.
• Outcome: After the school would no longer accommodate him, a
  flat was found and 24-hour care and support services were provided.
  He was placed on a medication regime for ADHD and his behaviour has
  started to improve.

Arguments for risk

• Despite all the upheavals Townsend appears to be gaining some
  insight into his behaviour, and as the supported living arrangement
  appears to be bolstering his ability to exert some control, it
  should be continued.
• Similarly, this close one-to-one interaction with his carers
  and other professionals meets his considerable, challenging needs,
  and is ensuring that he continues with a medication regime which
  appears to be assisting him.
• His regular, time-limited, contact with his mother has improved
  their relationship. This is important given his history of
  fractured attachments, and could be put in jeopardy if he re-enters
  a residential placement.
• Clarke has made exhaustive and fruitless efforts to find a
  suitable residential placement, inside or beyond the county. As
  there is no guarantee that she will be able to do so, it might be
  more realistic to build on his current placement arrangements, but
  he needs to attend a local school which at present the county is
  unable to provide.

Arguments against risk

• Townsend has spent all of his formative years in residential
  settings, and is used to living and working alongside other
  children and supportive teaching staff.
• He has been able to benefit substantially from full time
  education, and it is crucial for his future development that he
  continues to receive appropriate education.
• Although Townsend finds working in groups difficult, his future
  social and personal development will be aided by peer
  relationships, which are much more likely to occur in residential
  settings.
• A residential setting also offers him the opportunity of
  finding and accepting boundaries for his behaviour in more “normal”
  social situations.
• He has previously demonstrated an ability to form attachments
  in residential settings.

Independent comment

Most poignant in this story is John Townsend’s simple statement
“I don’t want to be like this”, writes Peter Wilson.
However outrageous his behaviour may be, this is a telling
expression of how desperate and out of control he has felt within
himself.

Clearly he has had difficulties from early on, but it is in his
early adolescence – a turbulent enough time at the best of times,
combined with the frustrations of mild to moderate disabilities and
the agitations of ADHD, that his problems have intensified. Joan
Clarke entered into the fray at a most critical stage, in the wake
of many failures and disappointments.

Her experience of searching for a comprehensive assessment and
particularly appropriate residential placements is, unfortunately,
not at all uncommon.

As highlighted in a recent report, Whose Crisis? published by
YoungMinds, there are major gaps in provision in different parts of
the country for young people with serious multi-faceted problems
and major difficulties in achieving multi-agency collaboration.
Recent initiatives, not least the government’s recently announced
National Service Framework for Children, may well improve this
situation over time.

In the meantime, Joan Clarke has found a solution that, given
the probable unavailability of a suitable residential placement, is
in many ways as satisfactory as can be. She has in effect “wrapped
around” Townsend a number of facilities and supports that appear to
be having the effect of containing his anxiety as well as that of
his mother’s.

This has thereby reduced his compulsion to act out. There is
undoubtedly a worry about his education and his isolation from
peers. The current arrangements however should not be changed
prematurely – better at this point that Townsend consolidates his
gains in his own time, retaining links with his family and
receiving help through psychotherapy or counselling and additional
educational activities to gain insight into his difficulties and to
build on his strengths.

Peter Wilson is director, YoungMinds.