At any one time, some 60,000 children are looked after in England and about 90,000 pass through the care system each year (Department of Health, 2004). Looked after children display a high number of risk factors that predispose them to developmental, health and mental health problems (Lindsey, 2000; Hill and Thompson, 2003). Some of these are adverse life events that occurred prior to becoming looked after, others were the reason for entering care. Unfortunately, these risk factors are sometimes compounded by the care system (Richardson and Joughin, 2000).
In recent years, the difficulties seen in children placed for adoption and foster care have increased (Hill-Tout et al, 2003; Kelly et al, 2003), due in part to the fact that children are being placed at an older age and so present a greater number of difficulties (Howe and Fearnley, 2003). Sargent and O'Brien comment that:
... given the level of difficulties experienced by looked after children, it is not surprising that providing foster placements is a complex task which foster carers are unlikely to carry out successfully without support. (2004, p 32)
There are particular problems in defining mental health needs, however. Studies which use a broad definition that includes emotional and behavioural difficulties have shown high levels of need within this population. For example, Minnis and colleagues (2006) found that approximately half the children entering the care system were assessed by their foster carer as having considerable emotional and behavioural problems that needed attention from professionals. McCann et al (1996) investigated the adolescent looked after population in Oxfordshire and found high numbers of significant and untreated mental health difficulties, with an especially higher proportion among young people placed in residential care.
Mount et al (2004) found that carers perceived 70 per cent of the young people in their care to have mental health issues. There are similar elevated levels of difficulties in children who are adopted (see Rushton et al (2006) for a fuller discussion). Recently, the Department for Children, Schools and Families (DCSF) has requested that the Strengths & Difficulties Questionnaire (SDQ) (Goodman, 1997) be used as a measure of emotional well-being and as a mental health/screening instrument for all looked after young people aged four to 16 years who have been in care for one year. Since this is a performance indicator, the data will be collected nationally and so will provide more detailed information on these matters.
Emotional and behavioural difficulties have a pervasive impact on young people in all areas of their life, including school, family, communication and peer relationships. Such difficulties also affect carers and the ease with which they feel able to parent looked after children. Ironside (2004) describes how the challenging emotional experience of parenting a looked after child can cause foster carers to feel insecure and inadequate. Hill-Tout et al (2003) comment on how carers struggle to manage challenging behaviour and feel increasingly isolated until, finally, the placement breaks down. Herbert and Wookey (2007) report the helplessness that foster carers feel when faced with the high levels of challenging behaviour presented by some looked after children. While there is some suggestion that children with a greater number of difficulties prior to entry into care experience greater placement instability (McCarthy, 2004), it is also true that the experience of placement breakdown itself affects mental well-being and increases the young person's vulnerability to developing problems. In recognition of this, the Quality Protects initiative (Department of Health, 1999) has focused services upon increasing placement stability and providing support for foster carers.
Despite the high prevalence of mental health difficulties suggested in the literature, there is evidence that few looked after young people access mental health services. For example, Mount et al (2004) found that fewer than half the young people identified as having such problems were seeing a professional. This is supported by anecdotal evidence from professionals, both locally and nationally. Various authors have discussed why this discrepancy occurs and the reasons for it, such as failure to identify difficulties, placement moves or uncertainty, young people's reluctance to engage and paucity of provision (see Mount et al (2004) and Sargent and O'Brien (2004) for a fuller discussion). There is also general agreement that traditional Child and Adolescent Mental Health Services (CAMHS) models are not effective in meeting the mental health needs of looked after children. Rushton et al (2006) note the importance of adapting interventions to meet the specific needs of enhancing parenting and illuminating the 'meaning' of behaviour for adoptive carers, a situation that similarly applies in foster and kinship care contexts. Taylor et al (2008) develop this idea further and show how the beliefs held by the adult about the reasons for a child's behaviour influence how that carer responds to him or her.
The local model
Various models have been proposed to provide effective mental health services for looked after young people. For example, Odell (2008) argues the benefits of a strengths-based model. Arcelus et al (1999) describe a structural approach that provides flexible, direct access for looked after young people.
Street and Davies (2002) propose an intervention that views the child's behaviour in the context of their attachment patterns, care relationships, history and the care system itself. They stress the importance of considering these different levels when intervening.
Hill and Thompson (2003) point out that 'mental and physical health services have traditionally been separate. There are obvious pitfalls in professional separatism' (p 318). We are in an unusual situation in Northamptonshire because the local authority funds a specialist health service (Centre for Health). This is positioned within social services but primarily staffed by health professionals. For many years, the aim of this service has been to consider the needs of young people within a holistic context and engage the carers and the young person in a partnership agreement. The Centre for Health team works alongside a small group of professionals from the local CAMHS who have a particular remit for working with looked after children. This has led to the development of a range of services to address mental health needs, promote emotional well-being and provide physical health care. Hill and Thompson (2003, p 319) comment that:
... fundamentally, it is important that health practitioners are trained and aware of the mental health problems experienced by looked after children and develop integrated links with child and adolescent mental health services.
We would claim that our local service does this and facilitates the integration of physical, social and mental health dimensions in a unique way.
Since both teams have limited resources, we carefully developed an appropriate service model. We aimed to incorporate attachment models and ensure that young people were not expected to make and break more relationships than absolutely necessary. This led to a staged model (Figure 1) and a slow development of the service to ensure sustainability. The approach has been designed to provide a flexible, responsive service that carers can access directly and that will meet physical, emotional and mental health needs. As can be seen in Figure 1, the local model prioritises training and consultation as interventions of choice. While some young people may require direct interventions, this service aims...