Mental Health Interventions and Services for Vulnerable Children and Young People

Panos Vostanis

• Publisher: Jessica Kingsley Publishers
• Year: 2007
• Print ISBN: 9781843104896
• eBook ISBN: 9781846427220
• Topic: Social Sciences
• Subtopic: History & Theory in Psychology
• Index: Social Sciences

This book provides a model which offers guidance on effective and appropriate therapeutic interventions and services for vulnerable children and young people (commonly children who have experienced trauma, abuse, domestic violence or neglect).

By addressing practice, theory and policy, the book enables professionals working with vulnerable children to choose the right intervention for each individual child. Contributors examine best practice across the UK, the US and Europe and compile the findings in a way that can be incorporated into everyday practice.

Mental Health Interventions and Services for Vulnerable Children and Young People will be an invaluable tool for those working with vulnerable children and young people including child mental health and welfare professionals and agencies, as well as social workers, policy makers and academics teaching or studying child mental health.

PART I

Evidence, Policy and Legislation

CHAPTER 1

Introduction

Panos Vostanis

Are some children more vulnerable than others? If so, do we really need to think of them in a different context? More importantly, should we be developing different interventions and planning different services at a time when child and adolescent mental health services are slowly taking off around the world in their own right? A recent national UK policy was called Every Child Matters (DoH 2003). It may have stated the obvious: that all children and young people are important, and that we should ensure them the best possible help and support to reach their potential; however, it is more likely that the policy was driven by the same principle of this text, that is, neither that some children matter more than others, nor that any policy-makers or practitioners over the years thought otherwise. What it has tried to highlight is a simple public health and welfare philosophy: that some groups of the population have multiple needs, which are not necessarily met by conventional services.

In order to meet the needs of these population groups effectively, we should first understand: why they are particularly vulnerable; why their difficulties can be particularly severe and entrenched, and hence not easy to break; why these difficulties cannot be addressed by any single agency; why they cannot easily engage or access what is on offer, and consequently, how we should best use available evidence and adapt therapeutic frameworks, interventions, and generic services to reach and help these young groups of the population. A number of related approaches and initiatives during the last decade, across societies with different health and social care systems, allow us to be optimistic that we are ready to implement this knowledge and thus generate evidence-based and sustainable service models.

It is, of course, difficult, and ultimately pointless, to categorize children and young people in ‘boxes’, since they will always overlap on some characteristics and differ on others. Many underlying risk factors will be inter-related, for example children exposed to domestic violence, followed by family disruption, homelessness, and loss of their supportive networks. Also, children and families move between these categories, such as those young people leaving public care who are excluded from education and who become homeless.

Despite this need to remain cautious in using such definitions, some children and young people are inevitably ‘more vulnerable’ than others, in particular, where the impact of trauma, abuse or neglect, family, and other adversities is chronic and compounded by secondary effects. These, in turn, lead to loss of friends, schooling, stability, and other protective influences for children’s development and emotional growth. In addition, the impact of their initial needs on their mental health, that is, maladaptive behaviours, emotional distress, and social relationship difficulties can be followed by school exclusion, offending, sexual exploitation, and substance abuse.

Vulnerable children and young people have several characteristics, and it is essential that these are taken into consideration by practitioners and service-planners. They may have multiple and changing carers, such as foster families and residential staff, and frequently changing circumstances. These characteristics are likely to increase insecurity, lack of trust, and uncertainty for the future. In parallel with the number of carers, there are several agencies involved, often not in co-ordination, and several transfer points, that can increase the sense of despondence and rejection. There are also difficulties in distinguishing between children’s mental health, social care, developmental, and educational needs, as these are usually inter-related, and fluctuate concurrently. Children’s mobility between geographical areas may adversely determine service responses, and may be compounded by their lack of advocacy, either because of the absence of parents to undertake this fundamental role, or because of the emotional fragility and capacity of their parent(s) to do so.

A number of young client groups fulfil these characteristics to varying degrees. Children in public care (those ‘looked after’ by local authorities) readily come to mind, with an already large body of therapeutic knowledge on working with foster carers, residential units (children’s homes and other residential establishments), and care leavers, although albeit rather limited evidence on their specificity and effectiveness. The number of refugee and asylum-seeking families has steadily increased in recent years within Western societies, with particular concerns for unaccompanied minors in relation to ethical dilemmas, child protection, and successful re-integration in their new communities. Homeless children and young people are a heterogeneous group with several underlying causes and routes to homelessness. On the whole, homeless families are victims of domestic violence or neighbourhood harassment; they have different needs from single young homeless people, with the latter often overlapping with leaving care, the judicial system, and substance misuse. Young offenders may not initially be thought of as a vulnerable group per se. However, there is now strong evidence that a substantial proportion of young people who come into contact with the courts have longstanding adverse family, community, and school experiences, as well as exposure to trauma and abuse. Policies and service objectives have recently reflected the importance of addressing their needs at different levels. Other groups of children and young people do not share all the above patterns, in particular the lack of stability, but can be affected by similar vulnerability factors. Examples constitute children with complex physical and developmental disabilities, and those who have been adopted. For these overarching reasons such groups of children, young people, and their carers are discussed throughout this text, both in relation to specific needs, such as working with foster carers or interventions for young offenders, and when considering issues that are common across these groups, for example stigmatization and ethics.

We are now also in a better position to understand the nature, severity, and complexity of the mental health problems and related needs of vulnerable children. A lot of evidence and conclusions may be drawn from the general child mental health research literature on the cumulative impact of acute stressors and chronic adversities on children’s emotional well-being. These have been confirmed by specific evidence on studies with high-risk young groups selected from all the populations previously mentioned, including ‘looked-after’ children, young offenders, homeless young people, and refugees. The findings from a range of small- or larger-scale designs, descriptive or in-depth studies, using rating scales or detailed interviews, point to the same direction of evidence. This suggests that vulnerable children and young people have significantly higher levels of mental health problems than the general population, including children living in socio-economically deprived, albeit stable, circumstances. These problems are likely to be more severe and entrenched, and are consequently more difficult to manage in isolation from their other developmental, social, and educational needs. In contrast to what places children at risk of mental health problems, there is strikingly less evidence on what protects them from such difficulties, particularly in the face of adversity.

Despite the strong evidence of high levels of mental health and related needs, the reverse – and apparently contradictory – finding has been established for the utilization of mental health and related services by children and young people, predominantly because of poor access and engagement. When looked at in more detail the reasons are closely related to the characteristics of these children, and what makes them vulnerable in the first instance. In other words, vulnerable children often do not conform to existing service structures and operational criteria because of their mobility, lack of consistent adult advocacy, and multiplicity of needs. This paradox has always acted as my personal motive in working with vulnerable children and young people over the years, and for my seeking alternative types of interventions and services which take into consideration these features rather than merely replicate services designed for the general, and mostly stable, population.

The lack of evidence on effective therapeutic interventions for vulnerable young groups is less surprising, since this is still relatively limited for child mental health problems and disorders as a whole, with the possible exception of more structured modalities, such as parent training and cognitive-behavioural therapy. Not withstanding the methodological, pragmatic, and ethical difficulties in designing and evaluating interventions for groups such as looked-after children and young offenders, there are also specific conceptual reasons which, again, relate to the core characteristics of vulnerable children. The indications for therapeutic work are not as clear as for other children with more homogenous mental health presentations; therapy cannot be considered separately from environmental factors; this interface is not static but can change quickly, irrespective of the therapeutic plan; different agencies can deliver different levels of therapeutic work, but can also construe variable definitions and expectations of therapies. Taking into consideration the wealth of knowledge from the main therapeutic schools (psychodynamic, social learning, attachment, family, cognitive therapies), the current challenge is how to best translate and apply these modalities for children, young people and carers who may not often conform to the norms of the generic population in contact with child and adolescent mental health services. This was the key rationale for this book.

Despite the relatively limited and systematic evidence on ‘what works best’ for different groups of vulnerable children and young people, policies and services are increasingly being guided by common principles. These include a combination of generic components and lessons learnt from generic services for all children and young people, and their adaptation to the specific needs of the targeted group. Principles consist of joint working between agencies, clear definition of each agency’s remit within an integrated care plan, availability of therapeutic interventions at different levels (from prevention to treatment), interventions that allow some flexibility in their delivery, quick response, and accessible as well as engaging services. There are increasing numbers of examples of service initiatives and innovative practice in this direction, as well as emerging new evidence. The challenge now is to incorporate this emerging and diverse body of knowledge and experience when formulating rationalized, consistent, well-resourced, and evidence-based models of interventions and services, rather than the ad hoc delivery of individually driven practice.

Few experts in this field are better positioned than our chapter authors to contribute to existing knowledge on mental health interventions and services for vulnerable children and young people. I have been fortunate to have known and worked with most contributors over the years, in their practice, academic and policy capacities. Having learnt a lot from their sound knowledge and innovative work with vulnerable groups, I am sure that these skills will come across throughout this text, and will be of interest to our readers. Their key messages and rich material should be relevant to all agencies working with vulnerable young clients. I do hope that this will stimulate even further interest in improving practice and services for the benefit of very needy children and young people.

Department of Health (DoH) (2003) Every Child Matters. London: Stationery Office.

CHAPTER 2

Developing a Policy Framework for Vulnerable Children with Mental Health Needs: Challenges and Possibilities

Miranda Wolpert

National policy, in relation to any given area, aims to articulate a vision for future development that helps to prioritize and inform resource allocation on the basis of the latest research findings and expert consensus. At its best, policy can provide a common language that can inspire future service developments, clarify key objectives, and provide a useful framework for assessing progress. At its worst, misguided or poorly formulated policy can lead to poor use of resources, creates confusion, and deadens innovation.

Policy development in relation to the mental health needs of vulnerable children is still in its infancy. Only a handful of countries have an articulated national policy in relation to children and young people with mental health problems. Of 191 countries sampled in 2003, 14 (7%) had produced a policy in this area (WHO 2005). What policy there is in existence is preoccupied with trying to focus on the needs of the most vulnerable children. However, policy-makers struggle with the challenge of how best to conceptualize which children should be deemed most ‘vulnerable’ in a given context; how best to prioritize competing needs between and within groups; how best to help those once identified; and how to evaluate progress meaningfully.

This chapter explores how policy development in relation to the mental health needs of vulnerable children might start to rise to these challenges, in relation to the following:

•assessing need

•developing evidence-based policy

•creating a framework for assessing progress.

As alluded to earlier, a range of factors can make it appropriate to categorize children as ‘vulnerable’ because of their circumstances. Children will be defined in national policy as ‘vulnerable’ or ‘in difficult circumstances’ depending on their national context, and the particular priorities and preoccupations of the government at that time. Children who are orphaned by AIDS, living in extremes of poverty, and are vi...

Table of contents

• Cover Page
• Of Related Interest
• Title Page
• Copyright
• Contents
• Foreword
• Part I: Evidence, Policy and Legislation
• Part II: Applied Interventions for Vulnerable Children, Young People and their Carers
• Part III: Applying the Evidence and Therapeutic Principles to Different Welfare and Health Systems, Cultural Contexts and Social Circumstances
• Subject Index
• Authour Index