What do we know about children with complex needs? Rosemary Chesson Health Services Research Group

Fast lane assessment scheme in 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 childrens services Multi-disciplinary and multi-partner approach critical for local integrated mental health services Key national and local policy documents on children and young peoples mental health

National and local documents 1995Together We Stand (NHS Health Advisory Service) 1999Bright Futures: Promoting children and young peoples mental health 2000Strategic development of CAMHS in Grampian (Dempster) 2001Grampian CAMHS: Optional Appraisal (Laxton)

Referrals to scheme North Aberdeenshire Assessment 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 childrens 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. childs 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 childrens 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 childrens 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 A full copy of the report can be found on our website: