1. Stability & positive long term outcomes for Looked after Children
Efun Johnson
Designated Doctor for Looked after Children, Lambeth
Dr Efun Johnson November 2013

2. Dr Efun Johnson November 2013
Introduction
“The need for good quality health
assessments to enhance services that give stability and positive long term outcomes for Looked After Children.”
- Dr. Efun Johnson
Dr Efun Johnson November 2013

3. Dr Efun Johnson November 2013
Overview of workshop
Children’s Rights -UNRC articles
Looked after children – the background and context
Placement stability -importance
Guidance for health of Looked after Children
Action points for practitioners
Dr Efun Johnson November 2013

4. Dr Efun Johnson November 2013
UNCRC
Ratified in UK in 1991
42 articles
What the convention says about keeping looked after children safe
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5. Dr Efun Johnson November 2013
UNCRC
Article 19 – Governments should ensure that children are properly cared for, and protected from violence, abuse and neglect by their parents, or anyone else who looks after them.
Article 25 – Children who are looked after by their local authority, rather than their parents, should have their situation reviewed regularly.
Dr Efun Johnson November 2013

6. Definition of “stability”
The state or quality of being stable, or firm.
The strength to stand or endure.
Merriam Webster Dictionary
Definition of “resilience”
Process of, capacity for, or outcome of successful adaptation despite challenging or threatening circumstances.
Masten, Best Garmezy (1990)
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7. Dr Efun Johnson November 2013
Placement Stability
The short term stability indicator measures the number of placements a young person has in a year.
The long term stability measure identifies those young people who have lived in the same placement for two years, if they have been looked after for two and a half years. National Indicator 63.
Dr Efun Johnson November 2013

8. National and Local Themes
It is generally agreed that it is damaging for children to be moved often and is known to have an adverse affect on their emotional stability and security. It also has a considerable impact on their education and learning.
NICE/SCIE guidelines for LAC (2011) Encourage warm and caring relationships between child and carer that nurtures attachment and creates a sense of belonging so that the child or young person feels safe, valued and protected. Emphasis on multi-agency working.
Every Child Matters - "Stability can make a positive difference to their [children's] lives, giving them the opportunity to form strong attachments with carers and friends, maximising their resilience, and improving their chances of achieving positive outcomes".
Dr Efun Johnson November 2013

9. Why is placement stability important?
Attachment
Importance of Relationships
Child Development (social, emotional, cognitive, physical)
Educational achievement
Interests and enjoyment
Community
Developing identity
Dr Efun Johnson November 2013

10. Why is it important that children form secure attachments?
Attain his/her full potential
Have a blue print for relationships
Think logically - executive functioning
Develop social emotions and conscience –Theory of mind
Trust others
Become self-reliant
Cope better with stress and frustration
Reduce feelings of jealousy
Overcome common fears and worries
Increase feelings of self-worth
Dr Efun Johnson November 2013

11. What is known to contribute to instability – Child factors
Child aggression
Mental health problems
History of maltreatment/abuse
Child’s perception that the placement is temporary
If been in residential care previously.
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12. Dr Efun Johnson November 2013
Local factors - child
Gang involvement/affiliation
Offending
Absconding / missing from care
Substance misuse
Risk of sexual exploitation
Not in education
Non-engagement with services
Dr Efun Johnson November 2013

13. Birth family risk factors
Parental substance misuse or alcohol abuse
Parental criminality
Death of a parent
Dr Efun Johnson November 2013

14. Birth family – local factors
Internet/ social networking
Loyalty to birth family
Unconscious manipulation/ sabotaging of placement
14+ years safeguarding plans may need to be reassessed
Parental mental health
Siblings at home
Parental relationships with new partners
Dr Efun Johnson November 2013

15. Placement risk factors
Siblings placed separately
Younger foster children in placement or recently moved in
Foster carer’s own children within similar age range
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16. Placement – local factors
Good matching
Timing – e.g. moving placement as transition to secondary
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Carer risk factors
Carer having unrealistic expectations (e.g. expecting gratitude/respect; challenging behaviour)
Carer stress – difficult life events
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Carer - local factors
Lack of flexible/adaptive parenting skills
Single/pair of FCS
Lack of family network
Carer life experience – unresolved trauma/abuse/life experience
Own extended family history of mental health problems
Language barriers
Dr Efun Johnson November 2013

19. Relationship risk factors - attachment
Child - SW
Carer - SW – clear communication
Child – Carer, e.g. eating, boundaries, seeking help
Child - birth parent
Dr Efun Johnson November 2013

20. Relationships – local factors
The match
Splitting of the roles: FC needing more support and SW hearing they can’t cope
System is feeling stuck, feeling hopeless
IRO consistency
Dr Efun Johnson November 2013

21. What promotes stability?
Child factors:
Placements that support intellectual/educational development
Meaningful friendships
Activities - consistent
Dr Efun Johnson November 2013

22. Local factors - children
Resilience and adaptive
Able to seek support when hurt
Ongoing Life story work to promote a coherent narrative
Emotional regulation/intelligence
Pro-social skills
Dr Efun Johnson November 2013

23. Protective carer factors
Carer with good family support – long-term partnership
Social support – friends, neighbours, colleagues, respite
Carer parenting ability - strong parenting skills
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24. Dr Efun Johnson November 2013
Local factors- carer
Genuine interest in children
Warmth
Humour
Patience
Energy
Open to novelty
Emotionally resilient/emotional intelligence
Good cook….
Dr Efun Johnson November 2013

25. Protective relationship factors
Role models
SW continuity
Positive child - SW relationship
Positive child - carer relationship
Managed contact with birth family
Education
Positive peer relationships
Sense of community
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26. Dr Efun Johnson November 2013
What are the outcomes of instability on child and psychological development?
Impact on an already disrupted attachment pattern
Emotional development- delay or dysregulation
Social development –theory of mind
Cognitive development – executive functioning
Behavioural problems – tantrums, challenging behaviour, aggression, oppositionality
Low resilience
Dr Efun Johnson November 2013

27. Social Care Perspective
Thorough assessment by SW
Informed intervention plan
Identification and matching of appropriate F/C
Need for multi-agency working and clear communication
Impacted on by varying standard of assessment
Lack of FC recruitment?
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29. Background, Outcomes , Pathways and Guidance
Looked After Children
Background,
Outcomes , Pathways and Guidance
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How Many Children?
Nationally – children in England
CLA in UK
England
Lambeth
Southwark
Lewisham
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Context
Child altogether in England - 11 million
Lambeth, Southwark, Lewisham ,000
Over 91,000 looked after children in the UK
England - 67,050 children looked after (31 March 2012)
Northern Ireland - 2,644 children looked after(31 March 2012)
Wales - 5,725 children looked after (31 March 2012)
Scotland - 16,248 children looked after ( 31 July 2012)
3,400 adopted
Dr Efun Johnson November 2013

32. Dr Efun Johnson November 2013
Trends
Significant
Fall in the No. of CIC over past 30 years, then
↑ between (overall increase almost 3%)
Increase in the No. of care proceedings in England following Baby P Inquiry (CAFCASS, 2009).
Children remaining in care for longer periods,
13% staying in the care system for more than 5 years (House of Commons, 2009).
Dr Efun Johnson November 2013

33. Who are the looked after children?
What are the reasons for being LAC?
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Reasons for being LAC
Dr Efun Johnson November 2013

35. Dr Efun Johnson November 2013
Reasons for being LAC
Abuse or neglect
Child’s Disability
Parent’s illness or disability
Family in acute stress
Family Dysfunction
Socially unacceptable behaviour
Poverty
Assent parenting/Child abandonment
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36. Dr Efun Johnson November 2013
What is fostering?
Fostering is a temporary arrangement
Allows a child to live with a family until circumstances enable the child to:
Return to their own family
Live independently or
Be placed for adoption.
Can be for a few weeks, months, or even years
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Foster carers are:
Always given an allowance towards the cost of keeping the child
Share the responsibility for the child with the agency
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38. Dr Efun Johnson November 2013
Private Fostering
Looked after by an adult who is not a relative for more than 28 days
Child under age of 16 (18 if disabled)
Private arrangement between parent and carer
Not Looked after by LA
Carer does not hold PR
Carer has legal obligation to inform their Local council of intention & when child leaves care
Most children are black and most carers white
Dr Efun Johnson November 2013

39. Children need to be safeguarded
Private Fostering
Often lack of information on child e.g. name
Lack of medical histories
Frequent moves
Abuse can occur
There can be cultural problems
Often it is with carers that have been turned down for fostering!
Children need to be safeguarded
Dr Efun Johnson November 2013

40. Dr Efun Johnson November 2013
What is adoption?
Legal procedure
All parental responsibility is transferred to the adopters
Once an order has been granted,
It cannot be reversed
An adopted child
Loses all legal ties with the birth family
Becomes a full member of the new family
Dr Efun Johnson November 2013

41. Adoption- pattern changed
Changes in social support has encouraged new thinking about:
which children are eligible for adoption
who is eligible to adopt.
Children
Adopters
Contact
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42. Dr Efun Johnson November 2013
Who can adopt?
Must be over 18
Show that they can give a child the care needed
Be able to afford to take in the child
The requirements vary from agency to agency
Focus is on needs of the child
Dr Efun Johnson November 2013

43. Adoption- who can adopt now
Married couple
Unmarried couple living in an enduring family relationship, same or different gender
Single person over 18
Married person where
spouse cannot be found,
separated, likely to be permanent
spouse incapable of applying due to physical or mental illness
Partner of parent of child
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44. Dr Efun Johnson November 2013
Why adoption fails
Information not clear or realistic
36% positive
33% negative
13% mixed
problems not fully recognised by agencies
anticipating the wrong problems
being deliberately misled increased disruption
Dr Efun Johnson November 2013

45. Dr Efun Johnson November 2013
Outcomes
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46. Dr Efun Johnson November 2013
Attainment snapshot
On average 58% of those LAC in the appropriate age group achieved level 2 at Key Stage 1 & 51% achieved level 4 at Key Stage 2.
The comparable %ages for all children were 85% & 82% respectively.
68% of LAC obtained at least 1 GCSE or GNVQ compared with 99% of all school children who achieved any qualification.
29% of LAC did not sit an examination of this type
Dr Efun Johnson November 2013

47. Continuing education, employment & convictions
At the end of school year 11,
73% of children remained in full-time education
14 were unemployed the September after leaving school.
9% of LAC aged 10 or over, were cautioned or convicted for an offence - 2½ times the rate for all children of this age.
Dr Efun Johnson November 2013

48. Dr Efun Johnson November 2013
Health outcomes
84% of LAC had immunisations that were up-to- date
86% had a dental check,
85% had an annual health assessment
5% of LAC were identified as having a substance misuse problem (60% received an intervention)
Dr Efun Johnson November 2013

49. Cautions and Convictions
9.6% of looked after children aged 10 or over, were cautioned or convicted for an offence during the year, almost 3 times the rate for all children of this age.
This rate has been similar over the past 3 years.
Dr Efun Johnson November 2013

50. Dr Efun Johnson November 2013
In summary
LAC have poor outcomes for:
Health
Education
Employment opportunities
Therefore
We need to provide a coordinated and comprehensive package of care to improve the outcomes for these children & YP
Dr Efun Johnson November 2013

51. Dr Efun Johnson November 2013
Issues/Risks for LAC
Mental health (30-50%)
Education
Learning difficulties (20-30%)
Risk taking behaviours
Maltreatment
Criminality
Poor outcomes
Dr Efun Johnson November 2013

52. Dr Efun Johnson November 2013
Health issues
Information collation
understanding of vulnerability and needs
Factoring in birth parents - inheritance
Information sharing
Consent and confidentiality
Seeing ourselves as corporate parents
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Why such problems?
Dr Efun Johnson November 2013

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Before Birth
Genetic
Parental learning difficulties, mental ill-health
Physical health – heart disease, sickle cell…
Antenatal
Maternal substance abuse
Infection, ill health, poor nutrition
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After Birth
Poor Care
Poverty
Abuse and Neglect
Parental ill-health, substance abuse,
Social exclusion, prejudice
Dr Efun Johnson November 2013

56. Where are they Looked After?
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57. Dr Efun Johnson November 2013
Placements ( )
76-79% in foster care (LSL)
26% placed in Southwark (Lew 40%)
60% < 7 miles of home address
83% <20 miles of home address
69, 12.6% moved > 3x in last year
21, 4% adopted in last year
Dr Efun Johnson November 2013

58. Guidelines and Legislation
Adoption and children’s Act 2002
National standards for Adoption
Intercountry adoption Health issues for Children
Promoting Health of Looked after children
Every child matters
Promoting quality of life of LAC (NICE/SCIE)
Dr Efun Johnson November 2013

59. Longstanding Legislation/Practice Guidance
Children Act (1989/2004)
Quality Protects (1998)*
Leaving Care Act (2002)
Every Child Matters (2003)
Healthy Care standards(2003)
Raising the educational attainments of Children in care (SEU 2003)
Working Together to Safeguard Children(2010)
“Care Matters” (2007)
Dr Efun Johnson November 2013

60. PHLAC (Statute)-LAC health role
Principles of Good Health Care
Health Assessment, Planning, Intervention and Review
Roles and Responsibilities of Councils
Roles and Responsibilities of the NHS
Health Promotion - Planning
Provision for Mental Health
Confidentiality, Information Sharing and Consent
Dr Efun Johnson November 2013

61. Role of Designated Professionals
Advisory role
Policy and procedures
Annual report
Clinical governance and audit
Training
Liaison
Monitoring and information management
Dr Efun Johnson November 2013

62. NICE/SCIE – Promoting quality of life
Qualitative review
Published in October 2010
Identified research on the views, experiences and preferences of children and young people about the care system.
10 databases searched
Data extracted from 50 studies
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Principles and values
Put the voices of C/YP and their families at heart of service design and delivery.
Tailor services to the individual and diverse needs of C/YP by ensuring effective joint commissioning and integrated professional working.
Develop services that address health and wellbeing and promote high-quality care.
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Principles and values
Encourage warm and caring relationships between child and carer
nurture attachment
create a sense of belonging
C/YP feels safe, valued and protected
Help C/YP to develop a strong sense of personal identity (maintain chosen cultural & religious beliefs)
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Principles and values
Ensure YP are prepared for and supported in their transition to adulthood.
Support the C/YP to participate in the wider network of peer, school and community activities
build resilience & sense of belonging
Ensure C/YP have a stable experience of education
encourage high aspiration
Dr Efun Johnson November 2013

66. NICE Guidance –LAC/YP needs
Evidence statements suggest they need:
Love & affection (often lacking in their lives)
A sense of belonging
To be supported
someone to talk to
continuity in their relationships with professionals
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Can we safeguard?
Through service provision & design for :
1. Children on edge of care
Keeping children on the radar &
keeping in contact with agencies especially in neglect
Children in care
Listen to children, and
look out for the signs / access to children
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68. Dr Efun Johnson November 2013
Keeping LAC/YP safe
Using
UNCRC and advocacy
NICE /SCIE guidance, ‘Promoting quality of life for looked-after children’.
and
Statutory guidance – Promoting Health of LAC
Publications e.g. Munroe review
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69. Dr Efun Johnson November 2013
UNCRC
Ratified in UK in 1991
Rights of the C/YP
42 articles
What the convention says about keeping looked after children safe
Dr Efun Johnson November 2013

70. Dr Efun Johnson November 2013
UNCRC
Article 19 – Governments should ensure that children are properly cared for, and protected from violence, abuse and neglect by their parents, or anyone else who looks after them.
Article 25 – Children who are looked after by their local authority, rather than their parents, should have their situation reviewed regularly.
Dr Efun Johnson November 2013

71. Dr Efun Johnson November 2013
UNCRC
Article 20 – Children who cannot be looked after by their own family must be looked after properly, by people who respect their religion, culture and language
Article 22 – children who come into a country as refugees should have the same rights as children born in that country
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UNCRC
Article 39 – Children who have been neglected or abused should receive special help to restore their self-respect.
Article 31 – All children have a right to relax and play and to join in a wide range of activities
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UNCRC
Article 12 – Children have the right to say what they think should happen, when adults are making decisions that affect them, and to have their opinions taken into account
You need
To involve C/YP in decisions
To seek their wishes and feelings
To be aware of their rights
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74. Dr Efun Johnson November 2013
Munro Review
Published 10th May 2011
Noted -‘Spending time with children is given too low a priority’
C/YP told the review that what they value most are:
good relationships with professionals they can trust and practice that focuses on their needs, and
Continuity
Dr Efun Johnson November 2013

75. Messages for practitioners
Spend time with C/YP
Treat C/YP respectfully
Provide continuity
Build relationships with C/YP
Provide services that focuses on C/YP needs
Maintain services beyond ‘crisis’
Advocacy services can be critical
C/YP may need to talk about abuse and harm
Remember C/YP have rights.
Dr Efun Johnson November 2013

76. Intercollegiate Framework
Definition of COMPETENCE : “ A set of abilities that enable staff to effectively safeguard, protect and promote the welfare of children and young people in care”
Dr Efun Johnson November 2013

77. Intercollegiate LAC Competence Framework - 5 levels
Level 1: Non clinical staff working in any healthcare setting
Level 2: Clinical staff with contact with C/YP/parents/carer
Level 3: All staff working with LAC/carer/parent
Level 4: Specialist roles Medical/Nursing/health advisors for LAC
Level 5: Designated professionals for LAC
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Levels 1/2
Level 1 – nonclinical staff in healthcare settings
Level 2 - staff with contact with Children/YP/parents/
carers
Aware of terminology
Aware of some legislature
Same as level 1
Understand consent/confidentiality
Specific LAC staff needs additional training
Dr Efun Johnson November 2013

79. Level 3 - All health staff working with Looked After Children
Staff groups: Universal services: HV, midwives, school nurses, children’s general and specialist nurses, CAHMS staff, paediatricians, CASH services, GPs, LD, forensic nurses/doctors
Dr Efun Johnson November 2013

80. Level 3 - core competence
Achieve levels 1 and 2
Able to respond to to impact of adverse life events
Apply knowledge of holistic health needs
Able to initiate interventions to improve resilience
Recognises impact of parental health concerns on C/YP
Understands interagency working & can contribute
Recognises own limitations and seeks advice from specialist
Able to share info appropriately
Empathic and supportive
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81. Dr Efun Johnson November 2013
Assessments
Dr Efun Johnson November 2013

82. Statutory Health Assessment
Identify unrecognised health needs
Identify mental health, behavioural and emotional problems
Recognise developmental or learning concerns
Plan appropriate action and ensure recommendations are carried through
Discuss life style issues
Plan follow up
Dr Efun Johnson November 2013

83. Statutory Health Assessment
Different Categories of assessment in guidance
Children less than 5 years old
5 – 10 years old
11 – 18 years old
4 different types of forms
IHA-C and YP
RHA- C and YP
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Health Care Plan
Written report and health plan for 1st review (4 weeks after coming into care)
Brief description of identified health issues
Clearly headed action points
Time-scales for action
Person expected to act
Statutory review at health assessments
Twice yearly for under 5s
Once yearly for over 5s
Integration in care plan
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85. Dr Efun Johnson November 2013
Is care good or bad?:
There are limits to what Care can achieve. Some children will always carry the scar tissue of their heredity, gestation and early experience
Nevertheless on balance Care contributes much to the happiness of those in it
There is reason to think that it could work better and more cost effectively but not that it requires root and branch reform
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86. Dr Efun Johnson November 2013
Evidence:
Sinclair I. Fostering Now: Messages from Research, Jessica Kingsley 2006
Beecham J. and Sinclair I., Costs and Outcomes in Children’s Social Care, Jessica Kingsley, 2006
Sinclair I., Baker C., Lee J., and Gibbs I.: The Pursuit of Permanence, A study of the English Care System Jessica Kingsley, 2007
Dr Efun Johnson November 2013