Loading ...Mental healthcare for looked-after children is ‘inadequate’ and often ‘unevidenced’, experts have warned.
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:
- 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.
- 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
- 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.
- 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.
- 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.”
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Very disappointing to see the true impact of developmental trauma being downplayed. The reality is that poor mental health follows when a child’s need for therapeutic connection with care giving adults is not met. They are intrinsically linked and in my experience most social work practitioners are clear about the difference. PTSD is not an adequate diagnosis to give to children who experienced relational trauma and neglect as infants. It’s extremely offensive to all the different families, parents and carers out there trying to support their children to recover to label the mounting evidence and knowledge in trauma informed practice as ‘pseudo-science’.
and somatic practice is far from a pseudoscience, right?
I thought take on board the totality of this report. As social workers we need to move away from the mindset that we are the sole experts. Ask 20 social workers what developmental trauma is and the it is likely you will get 20 different answers. PTSD on the other hand has a clear diagnostic set of criteria.most social workers fancy themselves as therapists on the side without any therapist training. I call that pseudo- scientific practice. Pays your money make your choice should never be acceptable in our work.
there’s noghing clear about the diagnostic protocol for ptsd what’s so ever ~ the recent coverage of physician associate training is seated entirely in the medical model where the lumping and splitting of treatment protocols are shaped more by contracting premiums between primary and tertiary care ….
… it’s a fair point about the clinical boundaries that designate competency as a therapist although it’s a requirement of social work to see the rathermore detailed ans nuanced systemic issues, and especially systemic invalidation, are today seated in an institutionised organisational separation anxiety starting in the noughties with the Modernisation Agenda ….
… Q: would the US license approach to practice accreditation help ie the LCSW? ….
…. Q: does the becoming a social worker today require a reflexive unbecoming from the current Frommesk sadomasochism; sweet dreams are made of, What?…
I know social workers rarely read anything let alone scientific tracts, after all once qualified with apparently the best education and the most credible skills why bother with research or texts, but last time I looked at diagnostic scales it was very clear that to get a PTSD diagnosis the presentation had to meet universally defined criteria. Shocking I know.
but theres nothing universally defined, is there? disassociation ratings scales would be a better option, no? and not least because of the scope for further queries in respect of adhd/autism …
… which is what Duncan asked about, right? …
… btw the Royal College of Forensic Psychiatry and their division on Continuing Professional Development are genuinely interested in taking up these matters; the UK/ICD is lagging behind the US/DSM classification ~ the former still biased towards lumping and the latter splitting…
… it’s very much about how ‘the lacking’ is formulated and the economic signifiers show up in trade agreements; the Profession Standards Authority takes it’s lead from Australian practice where Deleuzian (and not Freudian) notions shape the categories of disorder; similarly trauma informed approaches are seated in behavioural medicine …
… thoughts….
….thanks, genuinely, for the provocative reply Abigail, enactivism, eh! ha ha ha….
Q: How many s75 agreements are currently in place, where are they and what are they doing ?
Q: Why does NICE guidance differentiate between ptsd and cptsd when, in practice, CPTSD is considered and treated as a lumping together of ptsd+anxiety+depression; currently cptsd falls outside the scope of UK disability discrimination protection.
Q: What model of ‘Completely Independent Advocacy’ will be commissioned? The Socio-Legal Model is suited to regional and national procurement but will such an approach potentially bankrupt individual Council’s who created the conditions of harm?
Q: Where’s the cash coming from and how much?
This editorial lacks evidence – conjecture used as foundation for reason why referrals are rejected by CAMHS instead of focusing on helping social workers formulate the underlining issues of the young people’s behavioural health needs which do not always equate mental health needs.
formulate … say more
There is a lot of red meat here in terms of ‘pseudoscience’ and over emphasis on contested attachment theories.
In my experience there is a case of the blind leading the blind in terms of the interface between social workers and mental health professionals.
In one session a young care experienced person I worked with was re-diagnosed by an adult services Psychiatrist as having a personality disorder after spending her whole education in provision based on an Autism diagnosis from CAMHS.
The culture of grand theories such as Trauma Informed practice have arisen in order to fill a professional vacuum.
The poisonous culture that exists within the NHS to silence any dissent or divergent ideas needs to be tackled before any meaningful change is possible. And that goes for the gander of Social work employers to.
have you referred the case to the GMC ….
… I can assure you that they are actually listening; the number of patient deaths arising from the same is staggeringly high and the co-occurrance of say, bpd (eupd) and autism is considered a matter of patient disposal ratherthan proper care and treatment …
… it’s tough terrain for sure but there’s sufficient all party parliamentary attention on this matter to merit taking action …
… take care Duncan ….
Example of the poisonous culture within the NHS that silences dissent please. I am a social worker in an NHS setting and personally crushing of dissent or indeed disagreement is endemic in LA social work teams. Uncontested half baked ideologies presented as evidence with vigorous head nodding conformist agreement last time I attended a meeting in an LA. I’ll start us off shall I by asking what the evidence base is for formulating social work practice on “lived experience”. Here’s to a respectful engagement hopefully.
https://www.bma.org.uk/bma-media-centre/bullied-and-blacklisted-new-research-reveals-shocking-experiences-of-doctor-whistleblowers-in-scotland
There’s nothing here that doesn’t happen in a social services environment every day. Racism, bullying, belittling are the toxic drivers of managerial behaviours in large organisations. Worker experiences we can agree on but what dissent and divergent ideas are being suppressed. That was my question. The link highlights experiences of whistleblowers raising concerns about patient safety and personal experiences of doctirs.Those are two different things.
You think the experience of whistle-blower doctors and consultants is not relevant to the experience of social workers who challenge NHS decision making. Try challenging a psychiatrist on a failure to carry out a Mental Health Act assessment and see how quickly you get removed from the case. The same culture drives both mechanisms.
Experience of workers isn’t my question. NHS and LA’s are organisations which prioritise protocols over staff experiences. I do not dispute that. My question was about some specifics on which dissent and divergent ideas are being silenced? It’s that simple really. As for challenging psychiatrists I have those difficult and at times extremely heated conversations on a range of issues daily given I work in a hospital mental health unit. Again there is nothing unique here, it’s behaviours based on hierarchy and status. My friends who work in LA’s report identical conversations too. Challenging decision making is our job as social workers and advocates.That’s not dissent, it’s doing our jobs. Challenging decisions over treatment plans isn’t expressing divergent ideas, it’s offering alternatives backed up by a different professional perspective. Again that’s doing our job. It’s not radical, it’s just our bread and butter skills performed almost instinctively.
and advocates, Abigail ~ to act on the basis of your conviction towards another human being as though their concerns were you’re own (Abrahams 1976) …
… it’s refreshing to hear you voice, and clearly an ordinary expectation when the system dynamics, like See It My Way or See How Bad They Are, and other group think has set-in ….
… the fact remains that patient deaths amongst young people with autism/adhd detained for mental disorder is way too high …
… whether this represents a Tragedy of the Commons requires attention and articulation; you should, perhaps, say more ~ it’s genuinely heartening to read …
Abigail I make no exception between NHS or Social Work employers the poisonous culture exists across the board in my experience. However NHS bodies have the whip hand when it comes to implementation of new guidance such as the one launched in the article. Therefore in my humble opinion there is zero to no chance of this making tangible difference on the ground. And if you feel that you can be in professional dispute with a medical decision maker within the NHS and not feel any professional repercussions then I am concerned you are the happy exception and not the rule, as the article I shared with you evidences.
but that’s how the evidence base is created Duncan ie exceptions to the rule ~ it’s an accepted norm that most changes are happy accidents and personality driven …
… knowing when as Abigail says just doing your job costs you your job is about, what?….
…. why are whistle-blowers treated so harshly…
… disrupting behaviour is, as Abigail says, the bread and butter of social work, right? ….
… but to what end and how far can one go? ….
… what’s the difference between taking the bait and biting the hand that feeds; the noncontradiction of contradiction, eh! …
… in the meantime children do >>> ….
… What??? ….
… do we have an intrinsically shame based system? ….
.
I have colleagues who are far more direct and challenging then me. That are resilient and prepared to argue on clinical grounds. It’s not easy but they promote their clinical arguments. This is our experience in our corner of England, maybe Scotland is more punitive I have no idea. As for professional repercussions that’s on LA employers. If LA managers are spineless enough to allow their own staff to be pilloried that has nothing to do with the NHS. If LA managers have zero integrity and settle for junior partner status that’s their decision. Again nothing to do with the NHS. By the way there’s nothing exceptional about me. I’m not more resilient, I’m not more skilled and I’m certainly not more confident than a good many of my colleagues.
My employer is the NHS. My point is the culture is the same only more riven by hierarchical privileges in the NHS. And I have worked in Local Authority to.
Behind every whistleblower is a legion of health and care professionals who balk at the prospect of using the whistleblowing policy or lodging an official grievance regarding a breach of their employment contract such as having to work unpaid overtime on a routine basis.
Is that creating a safe system of work, in which the guidance issued above can be implemented effectively?
Implementation theory is relevant here.
Why are flagship policies such as Every Child Matters or the Early Intervention in Psychosis Standards foundering in the swampy lowlands of practice?
Professional policy consultants and Quango’s grow fat on the back of it but little changes on the front line.
This is a healthy and informative discussion and my little contribution. Abigail talked about hierarchy and status differences. Understanding these is crucial when challenging poor practice. As social workers we have more status, more professional safeguards and certainly more power than some health and care professionals. This gives us power and also affords us protections. If we choose not to exercise this I think as Abigail suggests we are not doing the basics of our job. No one argues that any of this is easy but being a social worker is never easy is it? Of course how we respond to these issues are shaped by our own experiences and the kinds of managers we have but when I trained many many years ago we were told that we should never forget that social workers are never just workers. We were taught that we had professional ethics, which at points might diverge from what our managers expected of us, which should always drive our interventions and advocacy. I have tried to live up to that. I’m not some naive Pollyanna world social worker and understand and at times experience the challenges you highlight Duncan. Certainly a great many social work leaders and managers are fad driven practitioners with little to no understanding of individual social worker experiences. But it is our job to anchor them to our and service used realities is it not? Otherwise we really are just bureaucrats following “orders”. I have had my fair share of bruising and have seen colleagues go through the grinder too but what we know is that not allowing colleagues to be isolated if picked on, having union support, understanding employment law, not being intimidated to mention willingness to go to employment tribunal is a form of protection. Whether we like it or not our privileges as social workers and our professional ethics compels us to be advocates and agents for change. Anyway that’s what I think.
What about the paradox of a duty of candour for NHS professionals including social workers juxtaposed with the persecution of whistle-blowers?
Are you really telling me that every instance of avoidable harm as a result of professional malpractice is being referred by social workers to the relevant regulator?
Social work as a profession is rudderless in allowing itself to be skewered in this way.
See Mculloch Brothers serious case review as evidence of this paradox.
it’s proving the omissions being claimed that’s difficult Duncan; since the Wolfe Review in 1997 and, then, the standardised protocol for all complaints handling act as filters designed to mitigate liability …
…. the significance of the PHSO to act against NHS Trusts in respect of services failure for autism/adhd still isn’t strong enough a measure of trigger an organisation to refer itself, and staff, to the respective regulatory authorities….
… the suggestion of having ‘completely independent advocates’ will only add to dilutions (and casualisation) of the formal advocacy function embedded in sw with children; once upon a time when the HSJ was the Health and Social Services Journal professional advocacy as embedded within nursing and social work was almost a permanent feature article …
… this isn’t about who is right and who is wrong (and proofs of) but rather the longrun drift towards the reduction in State Liabilities over time; the removal of formal advocacy functions, based on the same in adult services, will be the first to go …
… the diagnostic protocols beit ICD/DSM are also a splitting mechanism (and for sure there’s merit in some of this) and the contracting turf wars between primary and
tertiary care are more about market share than patient need …
… it’s truely tough terrain and just maybe the November 2025 Social Work Symposium ‘Social Work as a Resisting Force’ to be held at the Faculty of Social Work, Ljubljana University will be worth the effort to go or at the very least compare notes ….
… when, for example I asked Laura (above) to say more about ‘the formulation’ it’s because there’s practice evidence, (from within the NHS) of the use of Lacanian theory (see Todd McGowan, Leon Brenner, Ian Parker, Daniel Tutt, Julie Rhese) as the structural acknowledgement of ‘lacking and loss’ created by neoliberalism and advanced capitalism …
… there’s power in strange places, no? …
I agree with every single word Marcella has written. For far too long we have allowed ourselves to be manipulated into almost irrelevance. I’m glad that there are still colleagues who challenge the orthodoxy strangling our profession.
but … when Eileen shaped the Working Together guidelines it was from within a highly defined and bounded epistemologies of both complexity and systems thinking approaches; it’s what she meant by the term Complex Adaptive System ie organism in environment and which is today better served by Analytical Philosophy ratherthan Continental Philosophy …
… conversely, the use of, say, attachment theory, separation anxiety alongside the physical understanding of the term relational ie caseloads/volume of work/pressure of time ie machine or newtonian world views ….
… the two aren’t mutually exclusive but, and as is said in the ‘what works’ coverage of children’s care (see cc earlier this week) the synthesis of such in evaluation methodology is pretty damn hard …
… check out the UK Evaluation Methodology Society…..
… in the meantime children do >>>> ….
… what? ….
I think the original question from Abigail was about “silencing dissent and divergent ideas”. I took would like at least one example of that. I’m not sure how the dialogue has ended with referencing reporting if every instance of negligence and malpractice to the relevant regulator. That social work leadership is at best devoid of backbone or worse disinterested in minimising harm isn’t contested by most social workers and Abigail has made the same point as you have in each of their comments. The point I think is what we as practicioners can or actually do in situations where we witness bullying and harmful behaviour. Again I interpret what Abigail has written as actual and tangible responses incumbent on us to take by dint of being social workers. We may choose our battles but we should never hide behind perceived potential or actual persecution. We all try for the best outcomes as social workers don’t we?Being frightened is never a good place to be. I was disciplined for speaking out but I won. My vindication was seeing the incandescent reaction of the instigator at that outcome. Social work is hard, upholding truth and decency is hard. Integrity in closed institutional minds can be exhausting too. We choose to be social workers for many reasons. I hope none of made the choice simply to turn into policy following, instructions obeying bureaucrats. There is another thread in CC about clients recording workers. I say not before time. Uncomfortable it might be for us practitioners but it scares the sweat out of managers.