I have recently been involved in writing the ACP response to the scope NICE have proposed for their review of the guidance for Looked After Children. To put this in context: NICE are undertaking a two-year review with a committee of experts on the topic, and this stage is just about deciding the scope of the review rather than our input to the guidance itself. I have volunteered to be our representative throughout that guidance review process. The committee assembled by NICE will review the evidence and write an updated version of the guidance, which will then go out for comments once again before formal publication. The final NICE guidance document is only set to be published in 2021.

Although this is unpaid work, it is very worthwhile as NICE guidance has an impact on how services are delivered, and it is important that we demonstrate the value that clinical psychology can bring to services working with this population. Policy work can be boring, time-consuming and frustrating at times, but it has an impact on a wider scale than the work we do with individuals, families or local services. I am happy to represent clinical psychologists working with children involved with local authority children’s services for ACP-UK as I have been involved in developing the previous NICE guidance on Attachment for this population. I have also contributed to BPS responses to consultations and been doing a lot of policy work in this area, most recently giving evidence to the Select Committee Inquiry into the funding of children’s social care services.

At every stage I will try to incorporate the comments of other ACP-UK members who have an interest in this population group, and I hope that I have captured the comments submitted to me with regard to the scope. I generally felt like the scope document was a good basis to start from, but I raised the following comments:

• This is a very complex and high need population in which there is increased likelihood of various poor outcomes over the lifespan. This is due to the high level of adverse childhood experiences and lack of protective attachment relationships so we cannot see their mental health needs in isolation from their experiences (or the wider socio-political context of pressures on the lowest socioeconomic groups and cuts to community and preventative services).
• Clinical Psychologists know a lot about this group and have already made best practice guidance that we want to draw their attention to.
• Psychological services for this group need to extend to age 21 for young people “Staying Put” and 25 for Care leavers, and to be integrated with local authority social care services, not held in a separate silo that restricts entry to services for diagnosable treatable mental health conditions, as the needs in this group are broader and more interwoven than this, and the level of need so high in this group (75% having recognised psychological needs). Integrated and universal services also reduce stigma, and help to increase the training and support available to carers and social care staff, supporting them with secondary traumatisation.
• We need to assess these children and young people and understand their needs better, so we can do more effective work with them. We particularly need to focus on psychological needs, which are likely to be critical determinants in the later outcomes for young people who have been through the care system, and at present are disproportionately represented in many adverse outcomes (e.g. homelessness, inpatient mental health services, involvement with the criminal justice system, domestic violence, substance misuse, and various health risks).
• The guidance needs to link to the Attachment guidance that NICE has already produced in relation to this same population. We need to create trauma-informed services, but with a focus on ensuring children have the opportunity for healthy attachments. Interventions, especially with younger children, need to be dyadic and involve their primary caregiver whenever possible.
• The guidance needs to include Ofsted in its target groups; this is because they are the only quality control for placements and yet Ofsted inspectors often know little about how to evaluate the psychological elements of care and require training for this.
• Not all children leave Care to independent living, and it needs to be understood that a proportion will need continued supported living as adults.
• No reference is made in the guidance to foetal alcohol or substance misuse, and this is a significant subgroup whose needs should be addressed.
• More reference needs to be made to children involved with the criminal justice system as a population subgroup, as they may have specific needs and/or require specific services. The Secure Stairs model led by clinical psychology has already set good practice guidelines for secure settings.
• Recognition of the prevalence of intellectual disabilities and neurodevelopmental disorder needs to extend beyond the heading of special educational needs, and be considered in placement, health and care elements of the services for Looked After CYP, with screening to pick up needs as they are often attributed to poor care or missed education.
• We welcome recognition of the specific needs of young people who have been sexually exploited, as this experience impacts on them differently to other types of trauma, threat and abuse.
• We welcome recognition of the specific needs of unaccompanied asylum seeking minors, who have extraordinary rates of PTSD. We would want more recognition of other Looked After immigrant children, including those taken into Care, as they are also frequently traumatised, and the system with which the UK currently treats immigrants can currently compound this.
• When thinking about mental health, we need to think about wider psychological needs and not just specific conditions. Defensive boundaries to services or reliance on a medical model are not the most helpful approach here.
• Do not just defer to the NICE guidance on PTSD when thinking about the trauma needs of this population. This guidance for PTSD does not cover multiple incident trauma, and this form of complex developmental trauma is highly prevalent in Looked After children and young people.
• We note the lack of mention of service user involvement and co-design, and would like the scope to include this.
• We hope they will look beyond RCTs and explore emerging forms of therapy and practice that are promising, but haven’t yet been evaluated for this population, such as third wave, narrative and dyadic therapies (and conversely will be wary about extrapolating from international studies that might have been delivered to a somewhat different population in a somewhat different context and might not translate as effectively to our Care system).
• We need to start by having effective measures that address the breadth of need, and learning more about what the needs are within this population and what is effective in addressing them. The SDQ has major limitations and is not used in a way that makes it useful on the ground. The BERRI may be promising in this regard.

The full response can be accessed here

My blog about policy work in this sector can be read here

Miriam Silver
Consultant Clinical Psychologist