Photo: Seventyfour/Adobe Stock
By Rachel Hiller
Recently, alongside academic and clinical colleagues, we launched a national report aimed at improving evidence-informed mental health services for children in care.
Our goal was to develop short- and long-term actionable recommendations, rooted in evidence and current best practices.
The report incorporated input from care-experienced young people and adults, and frontline social care and health professionals.
Its focus was on improving access to mental health services (regardless of sector), but also about improving the quality of provision provided.
Our recommendations spanned commissioning, integrated provision, referral and assessment practices, and workforce training and are freely available via the UK Trauma Council website.
‘Rising use of pseudoscientific approaches’
Community Care featured this report on its website, highlighting the author team’s concerns over the rising use of pseudoscientific approaches in services, and the simultaneous de-prioritisation of best-evidenced mental health care.
At the heart of this issue is the need to clearly identify and name the mental health needs of children in care, but the general ongoing reluctance to do so.
Decades of research have shown that care experienced children and teenagers have far higher rates of mental ill-health than their non-care-experienced peers. These are not mysterious unknown needs, but known common and trauma-related conditions, such as depression, anxiety, post-traumatic stress and conduct problems.
‘Ambiguous terms without agreed definitions’
Despite this, diagnostic and symptom-specific language is often avoided in practice and growing research evidence is demonstrating the consequences of this for access to care.
In place of more specific language, there is often a focus on generic or ambiguous terms like “attachment problems” or “developmental trauma”. These terms lack agreed definitions and do not lead to clear, evidence-based treatment pathways.
We frequently hear about costly “attachment assessments” or “trauma assessments” being commissioned with no obvious link to intervention or support planning.
‘A reluctance to use evidence-based strategies’
Mental health services sometimes reject referrals, stating that the child “does not meet threshold” or that the issue is “a social care matter,” often without a comprehensive mental health assessment.
Arguably, at the heart of all of these issues is the reluctance to use basic evidence-based assessment strategies to understand the mental health needs of children in care. This must change and indeed it can – there are growing examples of excellent practice, even in the context of funding and resourcing problems.
Decision-making that reflects children’s needs
Of course, while we are focused on mental health, it is also true that a comprehensive assessment should include screening for neurodevelopmental and speech and language difficulties, which are often under-identified in this population.
The need to be using evidence-based language is not just about ‘labelling’ or diagnosing; sometimes this will be needed, sometimes not. It is about having a shared understanding of need around the child and treatment decision-making that reflects the individual mental health needs of the young person.
Our report also addresses the growing concern around pseudoscientific practice, which refers to unevidenced approaches, both in assessment and treatment. Research shows that children in care are less likely to receive best-evidenced mental health treatments.
The availability of evidence-based care
A common and understandable objection is that many such treatments haven’t been tested specifically in children in care. While this can be true, it is also true that many evidence-based treatments have been studied in young people with complex needs or complex living circumstances.
Trauma-focused cognitive behaviour therapy (TF-CBT), for example, is a highly effective treatment for post-traumatic stress disorder. Contrary to common belief, its efficacy is not limited to children who’ve experienced single traumas in stable environments. In fact, most trials are with children with multiple or complex trauma histories, including children in foster care and those who have experienced abuse.
While we continue to call for research directly involving children in care, we must not withhold existing effective treatments in the meantime. Children in care are children first.
‘Beware of silver bullet promises’
Of course, innovation and the centring of lived and professional experience are essential in service development. But innovation should start from a foundation of best-evidenced care and agreed, evidence-informed language, and also must be rigorously evaluated.
Services be cautious about interventions that sound appealing but lack scientific backing. In the trauma field especially, ideas can be dressed up in convincing language yet offer no real benefit (or even unintentional harm).
We urge services to be wary of “silver bullet” promises – programmes claiming to work for all children, or interventions that promise to “rewire the brain.” The same applies to frameworks or pyramids that place a single intervention at the top. There is no one-size-fits-all solution.
Developing shared understanding between practitioners
As highlighted in our recommendations, mental health and social care professionals may benefit from co-located training to develop a shared language, discuss and challenge misconceptions, recognise potential biases in referral decisions, and advocate for best-evidenced mental health support. A better-shared understanding across systems can improve access to effective services and reduce the likelihood of young people falling through the cracks.
It is important to note that the report is squarely focused on mental health service provision – that is, professional mental health services (whether CAMHS, social care or voluntary or private sector based). And we also must acknowledge the huge amount of pressure our services are under following decades of under-funding and funding cuts.
‘A right to high-quality mental health care’
There are clearly many other aspects of a child’s life that will be important for their wellbeing and that should also be recognised and prioritised. But this does not take away from the need for direct evidence-based mental health interventions where need is indicated – particularly if our goal is to support children to sustain improvements in their mental health and live a fulfilling and happy life long term.
It should not be controversial to state that children and teens in care have a right to access high-quality mental health support; that when they do access support they can be confident that they are being offered the best-evidenced support for their need; and that support does not wait for a crisis but addresses their needs as early as possible in their care journey.
Rachel Hiller is professor of child and adolescent mental health at University College London and co-director of the UK Trauma Council, run by Anna Freud
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