The Mental Health of Children in Care

1. The Mental Health of Children in Care
The National Mental Healthcare Conference
27-9-2012
Fiona McNicholas MD FRCPsych Dip Clin Psychother
Consultant in Child & Adolescent Psychiatry, Lucena Clinic, Rathgar and Our
Lady’s Sick Children Hospital, Crumlin; Chair of Child & Adolescent Psychiatry,
UCD

2. Overview of the Talk
Issues regarding Mental Health in Children
Numbers of Children in Care in Ireland
Looked after Children and MH issues
International & Irish Studies
Deaths in Care
Future Directions

3. Definition of ‘Mental Illness’
• The experience of severe & distressing psychological
symptoms to the extent that normal functioning is
seriously impaired
• AND
• Help (medication, psychotherapy, lifestyle change) is
usually needed for recovery

4. Bio-Psycho-Social Assessment in psychiatry
‘IF ME’ Domains
Individual
Environment Family
Medical

5. Rationale for focus on Childhood MI
 Common:
 1 in 10 (10%) children have MI with some impairment (WHO)
 Most are unrecognised and untreated
 Significant morbidity & mortality
 Leading cause of lifelong disability
 Estimated by 2020 MI will be 1 of 5 most common causes of
morbidity, mortality and disability in children (US dept H)
 Risk of persistence into adulthood
 Large US study – half of all mental disorders emerge by 14 years and 3/4
by 25 years of age (Kessler et al. 2005)
 Impact on education and health, family, society
 Possibility of limiting neuropathology
 Cost implications
 Presence of MI during childhood leads to 10 X higher costs during
adulthood (Suhrcke et al 2008)

6. High Risk Groups

7. CAMHS MH Service Report
A Vision for Change
Oct 2009-Sept 2010 Oct 2010-Sept 2011
 55 community teams  56 community teams (goal 99)
 4 in-patient units: 52 beds  4 in-patient units
 Staffing 456 WTE (70%  Staffing 465 WTE (64%
recommended level) recommended level)
 New cases seen 7,651  New cases seen 7,849
 25% >15  10% >16
 69% within 3 months  70% within 3 months
 DNA rate 16%  DNA rate 20%
 LAC  LAC
 SS contact 14% (N=933)  SS contact 1o% (N=795)
 LAC 4.5% (N=299)  LAC 3.2% (N=256)

8. Definition
‘Looked After Children’
Introduced by the Department of Health, UK
(1989)
To describe all children in public care

9. LOOKED AFTER CHILDREN – How many?
2012:
N= 6,248 young people in care
Age:
37.1% 0-8
31.4% 9-13
31.5% 14-17
 Source: 62.4%
 Courts service Annual report July 2012
 HSE Stats
(http://www.hse.ie/eng/services/Publications/
corporate/performancereports/2012pr.html)

10. Numbers in Ireland increasing
 (The Office of the Minister for Children and
Youth Affairs (2008).
• 3,000 in 1996
• 4,040 in 2000
• >5,000 in 2006
• 6,160 in 2011
• N= 6,248
 Between 2010-2011
 Supervision order:
 N= 2,287 2011 wrt 1,046 in 2010 (increase
119%)
 Care order:
 972 2011 wrt 731 in 2010 (increase 33% )
 Aftercare:
18-21yo. N=1,053

 Annual report July 2012

11. RATES
Children in Rates per Age
care 10,000 band
Ireland 5,965 53.1 0-17
N Ireland 2,606 57.7 0-17
England 64,400 58 0-17
Australia 34,069 67 0-17
Wales 5,162 82 0-17
Scotland 15,892 143 0-18
A population rate of 53.1/ 10,000.

12. Year 2007 2008 2009 2010 % of
Report type Reports
in 2010
Increase in both Welfare and
Welfare 12,715 12,932 14,875 16,452 56.2%
Protection reports over the years
2007-2010 Physical 2,152 2,399 2,617 2,608 8.9%
abuse

Sexual abuse 2,306 2,379 2,594 2,962 10.1%
Emotional 1,981 2,192 2,125 2,500 8.5%
abuse
Neglect 4,114 4,766 4,677 4,755 16.2%
National 23,268 24,668 26,888 29,277 100%
Significant attrition between report and confirmed cases of abuse/neglect
2010: 12,825 reports yet only 1,556 confirmed (12%)
•Dept overload & redirection from welfare
•Stress for families
•Reclassified as welfare
•Reluctance to confirm

13. LACS & MH rates
Children in Care recognised as being one of the
most vulnerable groups in our society
Immediate and long term physical, psychological and
social adverse outcomes.
 (Utting et al., 1997; Roy, Rutter & Pickles, 2000):

14. Office of National Statistics UK
 3 major surveys carried out in England, Scotland and Wales in 2002
(Meltzer et al)
 11-15 year olds
 Methodological robust
 Prevalence of MH disorders significantly higher in children in care
(compared with those in private households)
 4-5 times higher than general population rate
 No significant differences across the three countries
 Rates higher in Residential care
 Northern Ireland:
 Teggart & Menary (2005) carried out in Craigavon and Banbridge
 Up to two thirds of LAC 11-16 years had diagnosable MI

15. Study:
SWs completed a SSQ relating
to all children within their care-
co-ordinated by the team leaders.
N=174 (56% RR)
Male: N=90 ( 51.8%)
Mean age = 11 yrs
Majority of the children were in
Foster Care: N= 136 (78.2%)

16. Number of Placements
Mean no 2.35 (SD 2.58)

17. rs
re >3y
a
in c
Duration of Placements , 65
.5 %)
= 114
2/3 (N
9.75%
3.04%
6yrs or more =72(43.90%)
17.68% 43.90% 3-6yrs=42(25.60%)
1-3yrs=26(17.68%)
6-12 months=5(3.04%)
25.60% <6months= 16(9.75%)
Total of 164 children (10 children were under supervision, never in care)

18. MH problems significant as a Reason for
Entering into Care System
Reasons N %
Parental alcohol abuse 16 31.37%
Parental drug abuse 14 27.45%
Abuse /Neglect 12 23.52%
Maternal psychiatric history 5 9.80%
Parents’ inability to cope due to ID or their own 3 5.88%
difficult childhood
Child’s behaviour out of control 2 3.92%
Reason for entering care was given in 51 (29%) of cases

19. Service Utilisation of Looked After Children
Service Contact N (%) ( Total N = 173)
Individual Social Work 145 (83.8%)
GP 125 (72.3%)
CAMHS assessment 61 (35.5%)
NEPS evaluation 59 (34.1%)
*On-going CAMHS attendance 50 (28.9%)
Probation/Prison Services 16 (9.2%)
Hospital Services 48 (27.7%)
Counselling Services 43 (24.9%)
Addiction/ Substance Abuse services 8 (4.6%)
Other Services 44 ( 25.3%)
* Significantly more likely if residential care: increased no. of placements

20. Prevalence of MH Training
N=97 (79% RR) Social care workers, SW
Work experience= 8.32 years
46 (50%) in residential care setting
Clinical exposure to MH:
 60.9% some clinical placements
 21.7% formal MH education while in college
 17.4% no experience in MH training
 97.8% requested training in specific MH disorders
Offered 2 half day MH training workshops. N=34
 Positive evaluation

21. Deaths in Care (ICDRG)
Report of the Independent Child Death Review Group
 Shannon G, Gibbons N
Cohort:
 Review of all deaths Jan 2000-April 2010
 Children in care
 Aftercare (18-23)
 Known to Services (open, closed in last 2 years)
Method:
 HSE case files
 Death certificate/Coroners report
N=196
 LAC = 36: Aftercare=32: Known to Services =128

22. Children in Care: N=36
19 natural Identified problems:
17 non natural  Significant delay in taking
children into care
80% >14
 10 placement problems
Reason:  15 poor standard of note
 5 drug related keeping
 5 suicide  15 no care plans
 2 unlawful  9 no medical evaluation
 11 no SW
 26/36 no critical incident
report on death

23. Deaths in Aftercare N=32
5 natural Identified problems:
 8 files ‘total disarray’
27 non natural
 Young person needing to
Reason:
request care
 14 drug related  32/32 no critical incident
 7 suicide report/review on death
 1 unlawful

24. Deaths known to Services N=128
60 natural Identified problems:
68 non natural  Cases closed despite
known SUD in parents
Reason:
 Many no allocated SW
 11drug related  Undue reliance on duty SW
 16 suicide  Lack of regular reviews
 13 unlawful  Lack of out of hours services
 Poor transfer of information
to other SW areas
 Poor communication with
families
 Difficulty accessing CAMHS

25. Recommendations
Establish a child death review unit
 Independent agency
Register of all deaths
Address systematic failure
 MH assessment in all
 Early intervention
 Routine care plans/review
 Improved communication with families
 Allocate SW

26. What can we do?
Additional resources:
 SW
 MH
 Dedicated MH LAC Teams
 Early MH intervention
 50 million earmarked for MH & primary care ? GONE
Current financial constraints
 ID named person from CAMHS to work with each CC area
 SW/CC placements on CAMHS (Training)
 Provide MH training to SW/CC
 Psycho-education on MH issues to all

27. Children’s Referendum

28. Government
Initiatives
Child First document,.,,,,,
 Statutory footing to report child abuse
 Child Death Review Unit…..
Child and Family Support Agency
 Provision of family support and child protection services
 Overseen by a single dedicated government Department
 The inclusion of mental health and community health services,
along with staff training are seen as crucial elements to this
comprehensive and novel approach.
 Now, more than ever, do we need to invest in the MH of our
nation’s children.
 Children in care are most deserving of such interventions.

29. Questions & Answers
Caution: MH services should not
be under the Child & family
Support Agency, but closely
linked

32. Legislation
 The Child Care Act, 1991 is the primary piece of legislation
 amended by the Children Act, 2001,
 the Health Act, 2004,
 the Child Care (Amendment) Act 2007,
 the Health Act, 2007 and
 the Child Care (Amendment) Act, 2011.
 The proposed Children First legislation focuses on the protection of
individual children about whom a report is made and other children
who may be at risk from an alleged perpetrator of abuse, it is at Heads
of Bill stage and thus is not yet in legislation.
 following Acts which may have an impact on children in care,
 the Protection for Persons Reporting Child Abuse Act, 1998,
 the Ombudsman for Children Act, 2002 and
 the Adoption Act, 2010.

33. References
 Blower, A., Addo, A., Hodgeson, J., Lamington, L., & Towlston, K. (2004). Mental health of ‘Looked After’ children: A
needs assessment. Clinical Child Psychology and Psychiatry, 9(1), 117-129.
 Department of Health. (1989). An Introduction to the Children Act 1989. London: HMSO.
 McCann, J., James, A., Wilson, S., & Dunn, G. (1996). Prevalence of psychiatric disorders in young people in the care
system. British Medical Journal, 313, 1529-1530.
 Richardson, J., & Lelliot, P. (2003). Mental health of looked after children. Advances in Psychiatric Treatment, 9,
249-251.
 Stanley, N. (2005). The mental health of looked after children: matching response to need. Health and Social Care in
the Community, 13(3), 239-248.
 Teggart, T., & Menary, J. (2005). An investigation of the mental health needs of children looked after by Craigavon
and Banbridge health and social services trust. Child Care in Practice, 11(1), 39-49.
 Office of the Minister for Children and Youth Affairs (2008). State of the nations Children, Summary 2008. Dublin:
Stationary Office
 Utting, W., Baines, C., Stuart, M., et al (1997). People Like Us: The Report of the Review of the Safeguards for Children
Living Away From Home. London: The Stationary Office.
 Meltzer, H., Gatwood, R., Goodman, R. & Ford, T. (2000) The Mental health of children and adolescents in Great
Britain.
 Meltzer, H., Corbin, T., Gatward, R., Goodman, R. & Ford, T. (2003) The mental health of young people looked after
by local
 authorities in England. London: Office for National Statistics.
 Meltzer, H., Lader, D., Corbin, T., Goodman, R. & Ford, T. (2004a) The mental health of young people looked after by
local
 authorities in Scotland. London: TSO.
 Meltzer, H., Lader, D., Corbin, T., Goodman, R. & Ford, T. (2004b) The

34. RATES DURATION
Care 1-5yrs Care >5 yrs
Children Rates Age
Foster care 1,202 (36%) 1,311 (39%)
in care per band FC w
10,000 Relatives 738 (45%) 618 (38%)
Ireland 5,965 53.1 0-17 Residential 145 (39%) 30 (8%)
N Ireland 2,606 57.7 0-17 Children
with extra
England 64,400 58 0-17 support 7 (30%) 12 (50%)
Australia 34,069 67 0-17
Wales 5,162 82 0-17
Scotland 15,892 143 0-18

35. Irish Study on the MH needs of children in care
 Rationale :
 High risk of MH problems in LAC
 Increasing numbers in Ireland.
 No previous research into the MH outcomes of LAC in the Rep of
Ireland.
 Aim :
 To describe the MH and placement histories of a sample of children in
care within two Dublin Child and Adolescent Mental Health Services’
catchment areas.

36. Study Team
 Prof Fiona McNicholas 1 2 3 : Principal Investigator
 Co-Investigators:
 Dr. Gargi Bandyopadhyay 4
 Dr. Mary Belton 5
 Dr. Brendan Doody4
 Dr. Ann O’ Donovan 5
Research Psychologists:
 Patrick Doyle 1
 Ms Joanne Nolan 1
1
Lucena Clinic, Rathgar, 2 Our Lady’s Hospital For Sick Children, Crumlin, 3 UCD, 4 Linn Dara CAMHS, 5 Lucena
Clinic, Dunlaoire

37. Study Team
1
Lucena Clinic, Rathgar, and ,
Dunlaoire 2 Our Lady’s Hospital For
Sick Children, Crumlin, 3 UCD, 4 Linn
Dara CAMHS,

38. Methodology
• Ethical approval granted from relevant bodies.
• Social Work Team leaders and co-workers within two Dublin CAMHS
catchment areas identified and contacted in relation to the study.
• SWs completed a study specific questionnaire relating to all children
within their care-co-ordinated by the team leaders.
• Study Specific Questionnaire (SSQ)
• Child’s age, gender, duration in care, type and number of
placements, reasons for entering care, mental health wellbeing,
educational attainment, contact with various services
• Family history and contact with family

39. Results - Demographics
 N=308 in care
 Information on : N= 174 (56.4%)
 Male: N=90 ( 51.8%)
 Mean age = 10.83 yrs (range : 2 wks - 20 yrs) (SD= 5.04)
 Children in Residential Care: mean age: 14.55yrs
 Children in foster care: mean age: 10.14yrs
 (One way ANOVA: F=7.069; df=3; p=<0.05)

40. Care Placements
 The majority of the children were in Foster Care: N= 136 (78.2%)
 1/3 (N=53, 30.4%) in Foster Care placed with a sibling
 26 (14.9%) fostered by relatives
 Of the 164 children placed outside family home
 Mean number of = 2.35 (SD=2.58)
 2/3 ( N= 114, 65.5%) in care for 3 years or more

41. Fig.1 : Care Placements
Overall 78.2% foster care

42. Fig.2 : Number of Placements
Mean no 2.35 (SD 2.58)

43. Fig.3 : Duration of Placements
9.75%
3.04%
6yrs or more =72(43.90%)
17.68% 43.90% 3-6yrs=42(25.60%)
1-3yrs=26(17.68%)
6-12 months=5(3.04%)
25.60% <6months= 16(9.75%)
Total of 164 children (10 children were under supervision, never in care)
2/3 (N=114, 65.5%) in care >3yrs

44. Reasons for Entering into Care System
Reasons N %
Parental alcohol abuse 16 31.37%
Parental drug abuse 14 27.45%
Abuse /Neglect 12 23.52%
Maternal psychiatric history 5 9.80%
Parents’ inability to cope due to ID or their own 3 5.88%
difficult childhood
Child’s behaviour out of control 2 3.92%
Reason for entering care was given in 51 (29%) of cases

45. Fig. 4: Abuse History
100
90
80
70
59.2
60 52.6
50
40
30
20 13.8 13.2
9.8
10
0
Any Abuse 103 Emotional Abuse Physical Abuse 24 Sexual Abuse 17 Multiple Abuse 23
(59.2%) 90 (51.2%) (13.8%) (9.8%) ( 13.2%)

46. Family Factors
Total No. of contact with biological parents : 143 ( 87.2%)
 Weekly: N = 66 (40.2%)
 Fortnightly: N = 20 (12.19%)
 Monthly: N = 29 (17.68%)
 Yearly: N = 17 (10.36%)
 Inconsistent contact: N = 11 (6.70%)
 Family member with mental health problem: 34(19.5%)
 Depression: 14
 Schizophrenia: 6
 Family member with drug or alcohol abuse: 35(20.1%)

47. Service Utilisation of Looked After Children
Service Contact N (%) ( Total N = 173)
Individual Social Work 145 (83.8%)
GP 125 (72.3%)
CAMHS assessment 61 (35.5%)
NEPS evaluation 59 (34.1%)
Ongoing CAMHS attendance 50 (28.9%)
Probation/Prison Services 16 (9.2%)
Hospital Services 48 (27.7%)
Counselling Services 43 (24.9%)
Addiction/ Substance Abuse services 8 (4.6%)
Other Services 44 ( 25.3%)

48. MH Assessment & Problems
 ‘Any’ MH contact: N=83 (50. 6%)
 M=F
 Increases with age (ANOVA: F= 7.069, df=3, 150, p<0.05)
 ‘Ongoing’ contact with CAMHS or Addiction Services :
 N=53 (32%), M>F
 SW perceived ‘Behaviour Problems’
 N=74 (43.5%)
 Violent behaviour: N= 35 (20.5%)
 including physically assaulting staff or fellow residents
 Arrested: N = 15 (8.9%)

49. Common Mental Health Conditions (N=53)
20.75% were on medication (typically for ADHD)

50. MH Contact by Placement
Foster Residential Placed At home: Total
Care Care with under
relative supervision
Hx of N (%) 49 (46.7%) 15 (83.3%)* 12 (52.2%) 5 (45.5%) 81 (51.6%)
Mental Expected 54.2 9.3 11.9 5.7
Health count
Contact SR -0.7 1.9* 0.0 -0.3
No N (%) 56 (53.3%) 3 (16.7%) 11 (47.8%) 6 (54.5%) 78 (48.4%)
Mental Expected 50.8 8.7 11.1 5
Health Count
Contact SR 0.7 -1.9* 0.0 0.3
Total 105 18 23 11 157
Significantly different from expected :X 2 = 8.52; df= 3;

51. Table:4. MH Contact with No. of Placements
& Duration of Care
Number of Previous Mental No Previous Total
Placements Health Contact Mental Health
(N=156) Contact
1 placement 35( 42.7%) 47 (57.3%) 78
2 – 3 Placements 27 ( 52.9%) 24 ( 47.1%) 51
≥4 Placements 20 (74.1%)* 7 (25.9%)* 27
Duration of Care
(N=154)
< 1 year in Care 6 (35.3%) 11 ( 64.7%) 17
1 -5 years in Care 23 (42.6%) 31 (57.4%) 54
5+ years in Care 50 (60.2%)* 33 (39.8%)* 83
* Significantly different from expected ( X 2 = 6.04 & 8.10; df= 2; p<0.05

52. Survey of MH training to
professionals working with LAC
Aim:
To establish the level of training in MH
Demographics:
N=97 (79% RR)
Social care workers, SW
All 3rd level education in social work/care
Work experience= 8.32 years (3 weeks-38years, SD 7.08)
46 (50%) in residential care setting

53. Results
Clinical exposure to MH:
60.9% some clinical placements
21.7% formal MH education while in college
17.4% no experience in MH training
Areas wish to receive further training in:
97.8% requested training in specific MH disorders
77.2% training in area and impact of abuse
Specific requests made for
 DSH, impact of parental MH problems on children, refugee
children, therapeutic modalities

54. Training method
89.1% formal training days
52.2% Regular meeting with CAMHS
<25% more training in college degree, peer support
Offered 2 half day MH training workshops. N=34
Question Mean value (range)
How useful was the session? 4.7 (3-5)
Did it change your attitude to child MH? 3.1 (1-5)
Will the information provided help you in your 3.8 (3-5)
work with children in your care?
Was the content of the workshop relevant to your 4.6 (3-5)
professional needs?
Was the material provided applicable to you in your 4.6 (3-5)
work with specific cases?

57. Australian National Survey of MH &
Wellbeing 2007
 26% of 16-24 year olds had
experienced a mental disorder in
past 12 months (affective, anxiety
or AOD disorder)
 23% of males and 30% of females
 Only 13% of these young men
and 31% of these young women
had used any professional
services for their mental health
problem
 Young men aged 16-24 with
mental disorder had the lowest
professional help-seeking of any
group
Deborah
Rickwood, Au