Mental healthcare for looked-after children ‘inadequate and unevidenced’, warn experts

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Despite having significantly higher needs than their peers, children in care are often shut out of mental health services, including on the grounds of “pseudoscientific” views about trauma, according to a report by specialist clinicians and academics.

To tackle the issue, councils and the NHS should commission evidence-based services, delivered by teams with co-located social care and mental health staff, said the study. Social workers and personal advisers should receive high-quality training in mental health, while mental health practitioners working with looked-after children should be skilled up to better understand their needs, it added.

The report on improving children in care’s access to evidence-based mental health care was produced by academics from University College London, King’s College London, and Cambridge, Bristol, Sussex and Kingston universities, in partnership with the UK Trauma Council and CoramBAAF. It was commissioned by the government funded National Institute of Health and Care Research.

Mental health needs far higher than general population

While the rate of mental health disorders in the general population aged 5 to 15 was 10%, it was 45% for looked-after children, according to 2021 guidelines on supporting the group produced by the National Institute for Health and Care Excellence (NICE).

This reflected their greater exposure to known risk factors for poor mental health, including abuse, neglect, poverty, parental substance misuse and mental illness, the impact of separation from their families and experiences within the care system, including frequent placement moves, said the new study.

Despite this, their access to evidence-based mental health support was “poor”, it added.

CAMHS ‘rejecting referrals for children in care’

While acknowledging the general pressures on child and adolescent mental health services (CAMHS), the report said many did not accept referrals for children in care or only did so in relation to very specific needs.

CAMHS rejected referrals on the grounds of the child’s needs being “a social care issue” or operated unofficial thresholds under which children were not seen if their placement was seen as stable, despite this group being likely to have the highest mental health needs, the report said.

Children in care commonly accessed help through bespoke teams for the group, commissioned by councils, the NHS or both. However, the services provided by these teams were often indirect – for example, helping foster carers meet children’s needs or providing consultations for social workers – leaving young people without direct support for their needs.

And joint working between children’s social care and CAMHS was often inadequate, “with service leaders rarely meeting, and a lack of shared understanding of need from the commissioning level to the front line”.

From evidence-based care to ‘pseudoscience’

The inadequate access to care was exacerbated by a “growing trend” in social care and CAMHS to “move away from evidence-based mental health practice and towards pseudoscience”, particularly in relation to trauma.

Practitioners tended to overemphasise attachment issues among children in care, describing mental health needs using “non-specific trauma labels, such as using ‘developmental trauma’, instead of established conditions, such as post-traumatic stress disorder (PTSD)”.

The report said this was “largely driven by the pervasive myth that children in care do not meet criteria for existing mental health difficulties”.

Use of costly services lacking an evidence base

It also criticised a growing use, by some children’s social care services, of costly, large-scale services that lacked any evidence base, often with no effort made to transparently assess their potential benefits and harms.

Inadequate funding also led to inappropriate provision, for example, offering few or low-intensity sessions to children with multiple and complex mental health needs, which the report likened to “putting a Band-Aid on a broken leg”.

Even in services that did provide evidence-based mental healthcare to looked-after children, there was “rarely the staffing or general resource capacity to adequately address the scale of need”.

Call for co-located teams and mental health checks 

The study made five key recommendations to enable children in care to access the evidence-based mental health services they needed:

1. All local authority areas should develop a joint service delivery plan between CAMHS and children’s social care, with clear accountability for assessment and treatment and key performance indicators (KPIs), including to measure access to care and young people’s perceptions of its impact.
2. Looked-after children should receive a health and wellbeing assessment, including a comprehensive mental health check covering standard and trauma-specific symptoms, four to six months after entering care
3. Councils and the NHS should commission a service, delivered by co-located teams of children’s social care and CAMHS staff, offering evidence-based direct support to children in care – and potentially, care leavers – as well as indirect support to professionals and carers supporting them. It said co-location should build “a culture of shared understanding and shared learning”, but added that these teams should also work closely with CAMHS services more generally, so they could refer young people on where required.
4. A training programme should be set up to upskill the children’s social care-based mental health workforce on the needs of children in care and to enable them to provide low-intensity, evidence-based therapies to them.
5. NICE should update its guidelines on looked-after children, which, according to the report, were “commonly interpreted or misused by services in such a way as to ultimately not provide best-evidenced care”. The update should stress the importance of relevant services following NICE’s separate guidelines on mental health, and that children in care have high rates of both common and trauma-related mental health needs that should be assessed using existing standardised measures.

Improved training for social workers urged

The report also made four further recommendations specific to children’s social care, including for social workers and personal advisers to receive high-quality, evidence-based mental health training, to increase their mental health literacy.

This should include understanding of the overlap and differences between trauma, mental health and neurodevelopment, confusion around which can impede practitioners’ ability to support children in care and create barriers to inter-agency working.

The other social care-specific recommendations were for:

• Children’s social care staff and foster and kinship carers to receive high-quality and mandatory training on talking to children about mental health, discussing getting mental health support, and supporting a child or young person through therapy.
• All children in care accessing mental health support to be provided with an advocate who is completely independent of the local authority, to help young people understand their rights and access services.
• Social care and CAMHS should co-develop forms for referring children in care to mental health services, with all social care staff trained in filling these in. The report said referrals should focus on observable behavioural or emotional concerns, and the young person’s self-reports of their needs, and not assume all problems are attachment-based or trauma-related.

Children in care not getting support they deserve – government

In response to the report, a government spokesperson said children with mental health issues, including those in care, were “not getting the support or care they deserve” and were a “top priority” for ministers in relation to reforming mental health.

The spokesperson pointed to the Children’s Wellbeing and Schools Bill, which, among other measures, would place NHS organisations and other public bodies under a duty to consider the wellbeing of looked-after children and care leavers and promote access to services for them.

They also referenced the government’s plan to recruit an additional 8,500 mental health workers by the end of its first term in power (which is likely to be 2029) and boost mental health provision in schools.

‘Urgent need for stable care placements’

For the Association of Directors of Children’s Services, president Rachael Wardell said the study showed “the urgent need for stable placements, trusting relationships with carers and social workers, and timely access to mental health support that truly understands trauma” for looked after children.

However, “too many children in care [were] facing long waits or inconsistent support” due to a “postcode lottery” in CAMHS services, she added. Wardell also stressed that transforming mental health outcomes for children in care also required “a nationally led, well-funded effort is needed to build and sustain a strong workforce across all children’s services and partner agencies” and reform of the placements market to provide young people with stability.

Recommendations ‘should be considered in NHS reorganisation’

Rebecca Gray, mental health director at the NHS Confederation, said: “Mental health trusts understand that many young people don’t always have their needs met. This is particularly stark for young people with complex needs who are in or who have been through the care system.

“Some of this relates to mental health services facing significant pressures but as this report highlights, collaborative working could be improved to address the needs across a child’s life and to join up support across systems.

“Many NHS mental health trusts are working effectively with local authorities to meet the needs of the most vulnerable young people…The recommendations outlined in the report should be considered when looking at how the NHS and local authorities work together at a time of significant reorganisation, including a requirement for integrated care boards to reduce their costs by 50% by the end of this year.”