LTP Priority: Wider social impact: Health and justice interventions
Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service
Type of Interventions: Complex vulnerability service for children and young people
Major driver of health inequalities in your area of work
The Children and Young People Secure Estate (CYPSE) hold some of the most complex and challenging vulnerable children and young people in our society. These children and young people are held on youth justice or welfare grounds. There are a very small sub group in the CYPSE who create multiple system paralysis due to their level of disturbance, who are likely to have been in contact or challenged services including those:
- Who have created management problems across the CYPSE
- Who have had contact with low and/or medium secure units
- Have had a difficult placement with Local Authority services
- Are a Looked After Child
- Have experienced multiple moves or multiple placement breakdowns
- Have had difficulty with receiving education including having experienced multiple school exclusions
Complex Vulnerability service for children and young people.
The Complex Vulnerability service will act as a support to wider children and young people health services, for a group of children and young people who are currently falling through the gaps. The service will not seek to replace or de-skill other services, but would provide consultation, screening and support for this group of highly vulnerable children and young people, unless direct intervention was required.
It would be a formulation based approach for children and young people in the community who present with complex and significant need, and who:
- do not meet the threshold for Child and Adolescent Mental Health services or Learning Disability services, meaning that currently their needs are unmet;
- for whom current service models do not function well;
- who will/do not access current services;
- who may have a number of labels and/or or emotional and behavioural difficulties (attachment disorder, conduct disorder, ADHD, ASD), but whose needs require consideration as a whole (including physical health needs), based on their presentation, rather than on any one diagnosis.
Sitting within specialist mental health and learning disability services and county based, this facilitative model of care will provide a consultation, assessment, and transition for this highly vulnerable group of children and young people, as well as transition out to specific services already in existence when and where required. It will use the trauma and psychologically informed Framework for Integrated Care as an integrated intervention (based on SECURE STAIRS), extending the Framework’s use outside the children and young people secure estate.
- Collaborative working: the team will need to know what the care pathways are locally and who are their key partners are to ensure positive and supportive working relationships.
- Trauma-informed care: the team will need to have an in-depth understanding of the effects of trauma to ensure a fully embedded trauma-informed way of working.
- Psychologically-informed care: practitioners within the team will receive psychological support to ensure they work in the best way for the children.
- Relationship with the cyp: the nature of the relationships established between the cyp and practitioner will be key in maintaining engagement, trust and supporting mental health.
- Wrap-around care: the team will ensure adequate support is in place for children to access the appropriate community care and to navigate the complex health and social care system.
- Speech and language: the team will ensure children are supported to improve and better understand their speech and language needs where appropriate. This will ensure staff are able to communicate with the children more effectively and support them with appropriate strategies.
- Family support: the team will engage and support the family wherever possible.
Impact on reducing inequalities
- Improved and more timely access for key groups of children and young people i.e. females, children and young people with Learning Disabilities etc.
The cohort of children and young people in contact with or at risk of contact with Health and Justice commissioned pathways, experience some of the highest levels of health inequality in the population. Providing health care that meets their needs has the potential to reduce the inequality gap.
Figures below, taken from the Annual Report of the Chief Medical Officer 2012, Our Children Deserve Better: Prevention Pays show the level of complexity of the children and young people in contact with Health and Justice commissioned pathways. Although there is a lack of more up to date and robust published data, the common consensus amongst stakeholders that work with this group, is that the level of morbidity and complexity amongst this cohort is increasing.
- The rate of suicide in boys aged 15–17 who have been sentenced and remanded in custody in England and Wales may be as much as 18 times higher than the rate of suicide in boys aged 15–17 in the general population.
- Some 18% of 13–18 year olds in custody have depression, 10% have anxiety, 9% have post-traumatic stress disorder and 5% have psychotic symptoms.
- Of children and young people on community orders, 43% have emotional and mental health needs
- Over a quarter of children and young people in the youth justice system have a learning disability.
- Some 60% of boys in custody have specific difficulties in relation to speech, language or communication.
- Looked-after children make up 30% of boys and 44% of girls in custody.
- One in 10 girls in custody have been paid for sex.
- Around 39% of children and young people in custody have been on the child protection register or experienced neglect or abuse.
- One in eight children and young people in custody have experienced the death of a parent or sibling.
- Some 40% of children and young people in custody have previously been homeless.
- Over half of children and young people who offend have themselves been victims of crime.
The Health and Justice and Specialised Commissioning Children and Young People Mental Health Transformation workstream has made change, established strong foundations, and improved the quality and range of health services that are needed for these children and young people. However the evidence gathered from the workstream shows there are still significant service gaps.
- Secure stairs delivers a whole system approach to a Framework for Integrated Care within the Children and Young People Secure Estate. It uses a formulation based approach and draws from evidence based interventions like Trauma Systems Therapy, Enabling Environments and Psychologically Informed Environments. There is already positive evidence for SECURE STAIRS emerging from settings where it is fully mobilised.
- Thirteen Community Forensic CAMH services (FCAMHS) currently provide a specialist service for high-risk young people that would not otherwise be available. The services ensure there are clear links between youth justice and welfare provision (community and custodial), hospital secure or specialist settings for high-risk young people, and core provision whether within specific CAMHS or other services.
- Collaborative Commissioning Networks (CCNs) were set up to enhance pathways and bridge the gaps that children and young people can fall through when transitioning between health and justice commissioned services. The CCN project identified a group of children and young people who do not meet the criteria for standard CAMH and Learning Disability (LD) service thresholds or models of care, but who still need considerable help. Combined with this, evidence showed that pathways from Youth Offending Teams (YOTs) and the children and young people secure estate needed to be improved, leading to an opportunity to further develop the SECURE STAIRS Framework from CCN emerging practice, to ensure that the impact of SECURE STAIRS is sustained beyond the secure setting, to ensure more effective resettlement and transition for children and young people, and to include the YOTs in trauma informed training. The Framework for Integrated care will also be used to make wider links with Liaison and Diversion services, services for Looked After Children and other community services.
Children and young people in contact with the youth justice system are more likely to have mental health problems than those who are not. They are also more likely to have more than one mental health problem, to have neurodevelopmental and learning disabilities/difficulties, to have problematic drug and alcohol misuse and to have experienced a range of other challenges, such as exclusion from school, homelessness, bereavement, trauma and being in care. Unmet needs persist into late adolescence/adulthood and can lead to a wide range of adverse outcomes, such as continuing/worsening mental health problems, unemployment, teenage parenthood, marital problems, suicide and self-harm and further criminal activity.
This level of complexity, where children are experiencing issues in multiple domains, serves to potentially place them at risk of significant longer term health harm as they grow into adulthood, with the very real risk of a reduction in their life expectancy. The level of inequality among this cohort of children is extreme.