What do we know about children with complex needs?

Rosemary Chesson

Health Services Research Group

Fast lane assessment schemein NE Aberdeenshire

• Set up 1998

• Scheme included representatives of NHS & Aberdeenshire Council (Education & Social Work Departments)

• For children with complex problems at a critical time for whom standard packages not working

• To enable the prioritisation of children with high needs who required multi-disciplinary assessment

Purpose of scheme

To reduce the waiting time for the mental health assessment for

children with serious and complex needs

Issues to be addressed:• delays causing problems in entrenched cases (children might

not be seen as urgent cases)• psychiatry seen as a last resort • unrealistic expectations of psychiatry

National and local context

• Increasing emphasis on inter-agency working in delivering children’s services

• Multi-disciplinary and multi-partner approach critical for local integrated mental health services

• Key national and local policy documents on children and young people’s mental health

National and local documents

1995 Together We Stand (NHS Health Advisory Service)

1999 Bright Futures: Promoting children and young people’s

mental health

2000 Strategic development of CAMHS in Grampian (Dempster)

2001 Grampian CAMHS: Optional Appraisal (Laxton)

Referrals to scheme

North AberdeenshireAssessment Team

SW referral NHS referrals Education referrals

Child referred to fast lane scheme

NE Aberdeenshire

• Rural as well as urban deprivation

• High levels of disadvantage in Fraserburgh and Peterhead

- Fraserburgh – health deprivation among worst 10% in

Scotland

- 76% of crime for N. Aberdeenshire in Peterhead and

Fraserburgh

Evaluation

• Five year duration (1998 to 2003)

• Qualitative approach– including observation, questionnaires and interviews– review of children’s records

• Comparative study attempted but abandoned– included 10 children fast lane 11 children pre fast lane

21 children in total

Findings

Profile of children referred to fast lane

• two girls and eight boys• mean age 9.5 years• 7 primary school (3 SEN units) + 1 special school• 7 from Fraserburgh

Similar age and gender distribution for pre-fast lane cohort

Home circumstances (pre-fast lane and fast lane cohorts)

• Few children lived with both biological parents 4/21

• Majority lived within single parent households (11 with lone mothers)

• Of four within marital relationships – one parent worked away from home, the other had lengthy separations.

Parental Health

• Majority of parents had physical illness or psychological problems (leading to referral to adult mental health)

• Some children had experience of serious illness in both parents

e.g. child’s mother had life threatening illness and mental health problems and father died recently.

Separation

Experience of separation through:

• breakdown of relationships

• illness

• death

• imprisonment

Complex relationships

residential care

fostered

adopted

relationship breakdown

second foster home

Foster / residential care (parents)

• 7 of children’s parents had experience of foster/ residential care

• Parental siblings may have had care/ residential placements

Previous contact social work services

• 16 (8 pre-fast lane, 8 post fast lane) of children’s families had previous contact with social work department

Relating to:

- child protection issues

- concerns re adequacy of parenting

- long standing contact through older siblings

- provision of respite/ home care/ support

Children and service input

• 8 of the 10 children referred to fast lane in receipt of specific additional service input in early years

• Of children attending mainstream schools in 14 cases auxiliary support or additional learning support provided (in some cases up to 20 hours per week)

• Other input- attendance at family centre- play therapist- family support worker at weekends- attendance at after school group

Input following fast lane

• Ritalin considered

• Respite care

• Family support group run by clinical psychology

• Befriender

Outcomes

• More appropriate referrals to child mental health services

• Referrals to scheme were appropriate

• Benefits from review meetings

• Closer working been achieved across agencies

• Senior staff group provided a forum for more strategic approach to children

Complex needs

• Research indicates confusion around term complex needs; no commonly agreed definition

• Research focus on physical illness

e.g. Stalker et al (2003) included children with

- acute and chronic medical conditions

- multiple and profound impairments

- learning disabilities

Definitions

Child Review report on Carla Bone (2003)

Need for ‘more understanding, consensus and agreement about

thresholds when using terms

- vulnerable - significant harm

- neglect - protecting children

- in need

Risk factors in the child and family (1)

Risk factors in the child

• Poor concentration• Specific learning disabilities e.g. dyslexia• Communication difficulty, language delay

as per autism• Moody, oppositional, aggressive• Physical illness• Academic failure/underachievement• Low self-esteem• Poor social skills• Low expectations

Risk factors in the family

• Overt parental conflict• Family breakdown• Inconsistent or unclear discipline• Hostile and rejecting relationships• Poor parenting (care)• Physical, sexual and/or emotional abuse• Parental mental ill health• Parental criminality, alcoholism• Poor parental adjustment to community• Poor social adjustment• Death and loss – including loss of

friendship• Poor relationship with agencies• Low parental confidence• Trauma in the family:

- death- abuse- house fire- drug involvement (hard)

Modified from Bright Futures, Mental Health Foundation (1999)

Finally

Need to be able to make sense of complexity

‘We need to see public services as complex adaptive systems in

which different individuals and organisations have different

histories, cultures and goals... Policy makers need to work across

boundaries.’

Chapman, 2002

Chesson R., Bruce C., Chisholm D., Fotheringham J., Theodoreson

K. & Wilson G. (2005) No Magic Wand: Evaluation of the Fast lane

assessment scheme in North East Aberdeenshire. Aberdeen: The

Robert Gordon University. pp 1-77.

A full copy of the report can be found on our website:

http://www.rgu.ac.uk/hsrg