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

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Presentation on theme: "Stability & positive long term outcomes for Looked after Children Efun Johnson Designated Doctor for Looked after Children, Lambeth Dr Efun Johnson November."— Presentation transcript:

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 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 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 UNCRC Ratified in UK in articles What the convention says about keeping looked after children safe Dr Efun Johnson November 2013

5 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) Dr Efun Johnson November 2013

7 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. Dr Efun Johnson November 2013

12 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 Dr Efun Johnson November 2013

16 Placement – local factors Good matching Timing – e.g. moving placement as transition to secondary Dr Efun Johnson November 2013

17 Carer risk factors Carer having unrealistic expectations (e.g. expecting gratitude/respect; challenging behaviour) Carer stress – difficult life events Dr Efun Johnson November 2013

18 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 Dr Efun Johnson November 2013

24 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 Dr Efun Johnson November 2013

26 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? Dr Efun Johnson November 2013

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29 Looked After Children Background, Outcomes, Pathways and Guidance Dr Efun Johnson November 2013

30 How Many Children? Nationally – children in England CLA in UK England Lambeth Southwark Lewisham Dr Efun Johnson November 2013

31 Context Child altogether in England- 11 million Lambeth, Southwark, Lewisham - 600,000 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 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? Dr Efun Johnson November 2013

34 Reasons for being LAC Dr Efun Johnson November 2013

35 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 Dr Efun Johnson November 2013

36 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 Dr Efun Johnson November 2013

37 Foster carers are: Always given an allowance towards the cost of keeping the child Share the responsibility for the child with the agency Dr Efun Johnson November 2013

38 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 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 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 Dr Efun Johnson November 2013

42 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 Dr Efun Johnson November 2013

44 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 Outcomes Dr Efun Johnson November 2013

46 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 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 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 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 Health issues Information collation understanding of vulnerability and needs Factoring in birth parents - inheritance Information sharing Consent and confidentiality Seeing ourselves as corporate parents Dr Efun Johnson November 2013

53 Why such problems? Dr Efun Johnson November 2013

54 Before Birth Genetic – Parental learning difficulties, mental ill-health – Physical health – heart disease, sickle cell… Antenatal – Maternal substance abuse – Infection, ill health, poor nutrition Dr Efun Johnson November 2013

55 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? Dr Efun Johnson November 2013

57 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 Dr Efun Johnson November 2013

63 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. Dr Efun Johnson November 2013

64 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) Dr Efun Johnson November 2013

65 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 Dr Efun Johnson November 2013

67 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 2.Children in care – Listen to children, and – look out for the signs / access to children Dr Efun Johnson November 2013

68 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 Dr Efun Johnson November 2013

69 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 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 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 Dr Efun Johnson November 2013

72 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 Dr Efun Johnson November 2013

73 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 Dr Efun Johnson November 2013

74 Munro Review Published 10 th 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 Dr Efun Johnson November 2013

78 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 Dr Efun Johnson November 2013

81 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 Dr Efun Johnson November 2013

84 Health Care Plan Written report and health plan for 1 st 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 Dr Efun Johnson November 2013

85 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 Dr Efun Johnson November 2013

86 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


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