Delivering therapeutic care to children. By Andrew Smith

All about the legal, political, and organisational context for delivering therapeutic care to children.

This article will explore the legal, policy, and organisational context in which therapeutic services for children in care is delivered.  The article is divided in to three parts, exploring themes relevant to each of the contexts; legal, political, and organisational.  The argument is that the legal system does not address in any coherent way the need for therapeutic recovery for children in care, and thus, arguing the need for therapeutic recovery for children in care can be problematic.

  1. Uncertainty, social control, and perpetual change

The legal context for children in care is complex, with many statutes existing, and regular revisions taking place, usually as a result of Child Death Inquiries (Parton 2005).  In addition, most Acts are geared towards a need for agencies to work collaboratively in order to safeguard children, yet this is exactly the challenge which child protective services in particular struggle with (Morrison and Horwarth, 2007: 57).  In a way, even twenty years ago we were grappling with the same issue (Morrison, 1996: 127), and have repeatedly made the complaint/lament for multi-agency working, yet no-one has found the solution to make this a practical reality (Darlington et al, 2010): 1087).  This is essential to consider for anyone providing therapeutic care.

More recently, criticisms have been levied about the interface between the political and the legal, and in particular how childcare legislation has begun to condone and support issues such as surveillance (Penna, 2005; 144). In terms of the Children Act (1989), criticisms have been levied around failure to protect human rights (Munro and Calder, 2005), too much uncertainty, and delays (Herring, 2014: 14).  The panacea that the legislation endeavours to be does, at times, fall short of the mark (Herring, 2014: 15).  Indeed, at times others have also documented criticisms of the term ’concern’ due to it being a trigger for State intrusion, and an excuse for Big Brother type monitoring (Penna, 2005: 114).  Overall, it would seem that further work on legislation is required.

Much of children’s legislation appears to have evolved out of the tragic deaths of specific children, i.e. the Soham murders (Parton, 2005), and Every Child Matters (E.C.M.) evolved subsequent to the death of Victoria Climbie (Cheminais, 2009).  Issues within E.C.M. in particular was around lack of specificity and it being aspirational rather than pragmatic (Roche and Tucker, 2007: 222).  However, one notable piece of work (Munro, 2011), albeit not legislation, did not emerge during a public inquiry, and, ironically, seems to have had less impact than others (Parton, 2012).  Also, given Munro’s report (Munro,2011) in particular has invited public commentary, there is a risk it could eventually end up as large as the Working Together (2015) ‘tome’, which some have indicated is now 55 times longer than its original version (Parton, 2012: 152).  It certainly does not appear that we are ‘there’ – i.e. with a base of fully functional and helpful legislation – yet.

Indeed, it is the Adoption Passport and funding via the Adoption Support Fund  (DfE, 2013) where comprehensive help or support for some children recovering from abuse lies, and is one which directly results from legislation (DfE, 2013).  Whilst this is exciting news for the Adoption industry, it does leave gaps for children not in adoptive placements, but with a similar level of need.  It is also perhaps noticeable that there is no similar fund available to support children remaining at home with birth family (yet still being ‘in care’).  CAMHS is still available to children in care with a mental health diagnosis, including other children in care, although this leaves the majority of children with emotional/behavioural difficulties as a result of abuse being left largely unsupported.  Legislation such as the Children Act does indicate the expectation that Local Authorities will provide help or support (The Children Act, 2004), but reality is often very different to expectations due to a lack of specificity.

There is also the perceived influence of legislation and Governmental guidance on performance.  This is a frequent complaint from social workers (Sagar and Hitchings, 2008).  Similarly, attempts by the Government to improve the performance indicators of adoption agencies (as an example) provided a focus purely on ‘safer’ issues such as timescales and report writing, rather than understanding and getting to grips with the minutiae and highly complex process within therapeutic disciplines (DfE, 2011: 16).  This is of concern given the levels of mental health difficulties in children, and the risk of children in care falling through both the remit for adoption support (which is well resourced) and therapeutic help for children in care or who have been in care (which is not as well resourced).

  1. Mental Health crisis; not helping the needy.

The World Health Organisation has described Mental Health as, “A state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”  It has been noted that there has been a decline in overall satisfaction with life, particularly amongst 11-15 year olds (Borg and Davidson, 2008: 20).  Mental Health in children more widely has also been described as being on the decline (Borg and Davidson, 2008:20), in particular, that 3% of those children surveyed in 2004 who did not have a mental disorder, had one in 2007 (Borg and Davidson, 2008: 20).  There have been improvements in help provided to children in care and/or children in permanence (Borg and Davidson, 2008: 22), but there are still only 23%-53% of Local Authorities that have comprehensive provision to Children in Care (Borg and Davidson, 2008:22).  Edbrooke Childs et al (2017) provided advice on how to respond to different kinds of mental health disorders.  However, what they don’t account for is if either being in care or the experiences of abuse contribute to such a diagnosis.

There is recognition from many organisations that mental health recovery from abuse is still not as good or as comprehensive as services wished it could be (Borg and Davidson, 2008:9).  Some organisations (The Learning Trust, 2016) have provided their own guidance in an attempt to support commissioners in making decisions regarding the purchasing of therapy for children.  Wider reaching reports have noted that it is not an individual approach which is required to support the growth of children’s mental health, but a systemic, multi-agency, multi-functional approach (Davidson, 2008: 10).

Some reports have indicated a level of liability for schools (The Learning Trust, 2016: 3), and direct advice and guidance was offered to schools when commissioning services, suggesting a certain level of caution and risk aversion within the industry.  This particular report also advises schools to ensure there is an evidence base for commissioning any therapy (The Learning Trust, 2016: 8), when in reality there doesn’t seem to be an empirical ‘evidence base’ for many of the key therapies currently in use, and those that have supporting research, this is of a poor quality and anecdotal in nature (DfE, 2016).

Davidson (2008) asserted that, “ Mental health and psychological well‑being are not the preserve of one profession or another, or of one government department or another.  Children and young people need to be supported by professionals who help each other out and by a truly joint approach, that is child and family-centred, from the Government at national level as well.” (Davidson, 2008: 6).  In many ways though, Policy makers are still formulating the questions rather than arriving at any answers.  As an example, guidance which is designed to support researchers who are asking questions of the way in which children in Care are supported has been published (LGA, 2012).  It has been proposed that particular methods and questions are utilised in commissioning help for children in care (LGA, 2012).  Whilst ostensibly helpful to researchers, it provides little in the way of supporting commissioners or families in seeking good quality help.

Over a third of children and young people with a learning disability, also have a diagnosable psychiatric disorder (Borg and Davidson, 2008: 21), and there does not appear to be any specific legislation or Green Papers in the pipeline to help address this specifically.  It is likely that a large proportion of these children are also in care (Simonoff, 2012).  Public organisations and policy makers have helpfully sought to define the concept of mental health as a way of then rationalising the provision of services, although there is such an inconsistent application of thresholds for services, that it is impossible to give clear or unequivocal advice to families (Rao et al, 2012).  Presuming mental health difficulties in children do not necessarily exist without any history of trauma, one would argue that the term ‘mental health’ is used as a term to deny access to some to services, and to allow others ‘entry’, based on spurious decisions around capacity rather than need.

Traditionally, advice for commissioners of mental health services – either adults or children – has focused upon perceived recovery rates and savings, rather than efficacy (NHS, 2011).  This distorted approach to supporting children’s recovery is an approach common to other pieces of legislation and policy (Farmer et al, 2010).  With the presence of OFSTED being ‘embedded; within the system, concerns have also been raised that, should services be deemed ‘inadequate’ or ‘requires improvement’, this will lead to commissioners being led by OFSTED rather than need in choosing services for children in care (OFSTED, 2015: 5).

There are public organisations which provide advice to individuals working/living with children affected by abuse and/or have lived in Care, although this appears to be somewhat generic, and lacking in specificity (NICE, 2012).  The Care Inquiry (2013b) did make attempts to extract and understand the voices of children and young people in their Inquiry, and the Care Inquiry (2013) reported how to best find and keep permanent homes for the most vulnerable of children, i.e. those in care.  A range of methodologies were employed in order to elicit the voices, in particular focus groups, surveys, and online questionnaires (The Care Inquiry, 2013b; 2).   Recommendations were made, in particular around support, with no focus on the concept of therapeutic recovery, especially from abuse (The Care Inquiry, 2013a: 16).  Whilst there is an increased focus upon relationships (The Care Inquiry, 2013a: 22), any focus upon recovery is lacking, with a seeming focus upon containment and stability being preferred (The Care Inquiry, 2013a: 23).

The Department for Education has provided advice and recommendations to commissioners in working with children in care (March, 2015).  There is a presumption within the field, that all health services – including mental health – should be commissioned subsequent to statutory health reviews (DfE, 2015: 15), and to use that framework as a trigger.  However, what is happening currently – particularly for children in adoptive and S.G.O. placements, is that such therapeutic help is being commissioned by families themselves, with assistance from Local Authorities, and with no formal oversight from, say, Clinical Commissioning Groups (Clinical commissioning groups (CCGs) are NHS organisations set up by the Health and Social Care Act 2012, designed to provide a formal oversight and structure to commissioned health services)

within the NHS (DfE, 2015: 22).  This lack of regulation, consistency, and oversight, potentially leads to exploitation of the system.  However, the term ‘mental health’ is also used as a term to deny access for some to services, and to allow others ‘entry’, yet very few, if any, mental health conditions exist without abuse or traumatic histories (and logically children in care should have automatic access), and yet such a framework prevails within the UK.

  1. Doing it ourselves; working alone, and muddling through

For insight in to the impact on families affected by care, and the struggles they experience, it is the specialist agencies who are commissioning research which explores the challenges in a pragmatic way (Pennington, 2012).  No such agencies exist for birth families.  It is here, though, where meaningful and accessible information is provided, in particular around how therapy can help the permanent family, not the child in care (Pennington, 2012: 5).  Themes of particular importance being difficulties in accessing support, time to wait for support, information provided on what help they can access (Pennington, 2012: 7).

When families were asked what services they were needing and what were missing, most frequently this was CAMHS or therapeutic services (Holmes et al, 2013: 22).  Again, it is the individual and voluntary organisations which are producing research which truly presents the voice of the people directly affected.  Notably, there is no such research exploring therapeutic help with birth families, in particular when a child in care has been returned.

The Government has explored the concept of placement stability, but seemingly to draw statistics around performance, rather than understanding in a robust way how children and young people are helped to stabilise, post-removal from their birth family. (DfE, 2013). Indeed, the Adoption ‘world’ has adopted alternative approaches for children who have been in care.  Again, such approaches are often motivated by the organisation’s own socio-political context, i.e. increasing the flow of adoptions (Coram and Barnardo’s, 2013:2).  Some research from organisations provide an approach to support general commissioning processes, but provides very little information around the vast range of therapeutic modalities that there are available (The Learning Trust, 2011: 13).

Farmer et al (2010) researched family finding processes for children affected by permanence, attempting to evaluate effectiveness, costs, and efficiency. (Farmer et al, 2016: 1).  Whilst providing qualitative judgements on matches there was no mention at all of what perceived support would have strengthened or developed the quality of either the matching or placement process, again evidencing a heavily political component to the process of helping children in care (Farmer et al, 2016: 8).



To conclude, the political/legal/organisational context for helping children in care recover from abuse is in a state of flux; new legislation and policy recommendations are being made continuously, and there is a postcode lottery for children who will be able to access specific help, and this is based on the kinds of orders the child is the subject of rather than need.  Whilst comprehensive help is being offered to families affected by adoption, this does exclude birth families, and there is no consistent regulation of the support being commissioned, other than from OFSTED and individual agencies, which are not specialist therapeutic services in themselves, and there are obvious limitations with how such an agencies can approach the therapeutic industry.

There seems to be implicit expectations that providers of therapy to children in care are required to make decisions on therapeutic approaches themselves, without much support, advice, or guidance from the state.  This leaves a certain level of vulnerability regarding the validity or reliability of any specific treatment approaches.

Thus, there is a need to formulate a clear understanding of entitlement, and challenge the inequality present in the landscape.  There is also a need for providers of therapeutic care to have a legal/political/organisational framework that embeds the strong need for therapeutic support within their guidance. Therapeutic recovery should be a central to becoming accommodated, not an afterthought.



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