Child in Care Pathway October 2017

Child in Care Pathway October 2017 Learning Disability and Challenging Behaviour Care Pathway March 2016

Index 1.0 Introduction to the child in care pathway 2.0 Thrive Model diagram 3.0 Definitions and diagnostic criteria indicating appropriateness for pathway 3.1 Eligibility 3.2 Access 4.0 Coping/Getting Advice 4.1 Need 4.2 Risk 5.0 Getting Help 5.1 Need 5.2 Referral 5.3 Getting Help with the HYM Team for Children in Care 6.0 Getting More Help 6.1 Need 6.2 Referral: 6.3 Assessment: 6.4 Interventions: 6.5 Documentation and Correspondence Points for Getting Help & Getting More Help 6.6 Reviewing Service Effectiveness 6.7 Review 6.8 Extensive Outpatient Provision 6.9 Inpatient Provision 6.10 Review 7.0 Getting Risk Support 7.1 Getting Risk Support in the HYM Children in Care Pathway 7.2 Review 8.0 Audit 9.0 Staffing 9.1 Training 10.0 Discharge/Transition 10.1 Provision for 18+ 11.0 References

1.0 Introduction A care pathway, also sometimes referred to as a clinical pathway, integrated care pathway or care map can be defined as a tool which is used to manage the quality in healthcare concerned with the standardisation of care processes. Care pathways seek to promote organised and efficient client care which is built upon evidence based practice. Evidence shows that the implementation of care pathways significantly reduces the variability in clinical practice and improves outcomes (Panella, 2003). The Specialist Children in Care Pathway is a broad treatment pathway capturing the emotional, behavioural, interpersonal and developmental difficulties that children and young people in the care system present with. While the Care Pathway and the THRIVE model define difficulties utilising a diagnostic model, this approach to definition of presenting problems for the looked after population is less helpful due to their experiences of neglect, developmental trauma, disrupted attachment and attachment difficulties, neurodevelopmental difficulties, learning difficulties and impact of contextual factors such as placement instability, ongoing loss, separation and contact with birth family, that result in a complex range of presenting difficulties, in respect of dysregulation, anxiety, low mood, behavioural problems, self harm, post trauma symptoms, voice hearing, engagement in risk taking and anti-social behaviour social and communication difficulties, concentration, hyperactivity and impulsivity difficulties co-morbidly. This document presents how Trafford Healthy Young Minds (HYM) works together with partner agencies and commissioners to meet the needs of children, young people (CYP) and their families presenting with particular emotional well-being and mental health difficulties. In line with the recent and on-going service transformation, the care pathways detailed have been conceptualised in a manner consistent with Thrive, a model of service delivery for CAMH services developed by The Tavistock and The Anna Freud Centre (Wolpert et al., 2014). Key to providing the most effective service for Children in Care( CIC) is the need to embed the Specialist Pathway within the Social Care Context. By building understanding and promotion of emotional well-being needs of CIC within their care experience (Bazalgette et al, 2015) to increase the system Social Care and Education s understanding of the emotional well-being and MH needs of CIC to promote their ability to THRIVE and to COPE within the journey through care. Training to the carers and to social workers to enable early identification of MH need and build capacity and skills of carers and Social Worker to provide support to CIC who are coping using Evidence Based models from a range of Psychological Perspectives including Attachment Theory, Social Learning Theory, Cognitive and Behavioural Theory, Trauma, Systemic and Developmental Perspectives. (Education committee 2016; NICE Guidance, Bazalgette et al, 2015, Dept. of Health & NHS England, 2015; Silver et al 2015) The THRIVE model (see fig 1 below) of CAMHS sets out a service delivery model whereby service users needs are conceptualised within four key domains. These include:

3.0 Definitions and diagnostic criteria: Indicating appropriateness for pathway 3.1 Eligibility: The Child in Care Pathway sits within the HYM Service and is dedicated for Children Looked After by Trafford MBC up to their 18 th birthday. The pathway covers those children and young people who are under the care of Trafford MBC,that is, on an Interim Care Order, Full Care Order or voluntarily accommodated by Trafford CYPS. Children requiring assessment and treatment most live in or within travelling distance of Trafford in order that an effective service can be provided. The pathway encompasses the universal services available to Children in Care presenting with a range of emotional, behavioural, developmental, attachment difficulties and complex trauma as well as the specialist services for those children presenting with the most severe, complex and persistent child mental health problems/disorders, within a multi-disciplinary/agency setting. The pathway also covers the systemic needs of the social care and education system to build a more psychological understanding of the mental health and emotional wellbeing needs of Children in Care. As all children in care presenting with emotional, behavioural, developmental difficulties and developmental trauma and attachment difficulties will be on this pathway due to their status as looked after there is a breadth of clinical presentation appropriate to this pathway. These difficulties to include: Mood and Anxiety Disorders Conduct Disorders Mixed disorders of Conduct and Emotion Hyperkinetic Disorders Developmental Disorders Complex Post Trauma difficulties Psychosomatic Disorders Deliberate Self Harm and Suicide Attachment difficulties Dysregulation 3.2 Access : Referrals are expected through the child or young person s social worker, in discussion with their manager, as they are the person who generally has Parental Responsibility. Referrals from other sources, e.g., GP s, Paediatricians, Residential

social work teams, foster carers, can be accepted in consultation and with the agreement of the social worker. Children and Young People in Care will receive an offer from the Children in Care Team while also having access to the other Clinical Pathways within the Trafford Healthy Young Minds Team. Children in Care will be offered assessment and intervention within the Children in Care Pathway, where the clinical skills and expertise are available and following the protocols of the existing pathways below. The dedication of a CIC Specialist Pathway is to facilitate faster access to services that are specialist in nature, co-located and utilize a contextual and systemic approach. Where children in care require access to a specialist pathway such as Neurodevelopmental or Serious Mental Illness, this will be facilitated by their case manager with the HYM Team for Children in Care. Trafford s Core and Specialist HYM Pathways are listed below. Urgent Pathway Neurodevelopmental Pathway Mood & Emotion Pathway Emotional and Behavioural Dysregulation Pathway Serious Mental Illness Pathway Intellectual Disabilities Pathway Eating Disorders Pathway 0-5 years Pathway Children with Chronic Health Conditions Pathway Attachment Difficulties Pathway Where children in care are referred with a presentation that would meet the criteria of the Core HYM Pathway, the Children in Care Team will deliver interventions to the young person, guided by the protocol of the Core HYM Pathway, e.g. assessment, intervention, outcome as appropriate and adapt the protocol to the specific needs and context of being a child looked after.

4.0 Coping/Getting Advice 4.1 Need: The THRIVE model indicates that this group includes children, young people on carer orders and their parents/carers & connected people who would be those adjusting to changes in circumstances, with mild or temporary difficulties, where the best intervention is within the community with the possible addition of selfsupport. There may also be CYP with chronic, fluctuating or on-going severe mood and emotional disorders, behavioural and attachment difficulties and difficulties with dysregulation who are choosing to manage their own mental health and/or are on the road to recovery: CYP described as Coping would be supported to manage their mild or temporary low mood or anxiety difficulties, their mild behavioural, developmental and attachments difficulties in the community, outside of a HYM service. There are already universal sources of support for young people currently provided by agencies across Trafford, including advice and monitoring of mental health by general practitioners and staff in education, non-directive supportive counselling services, early help support, and programmes to increase resilience in education. Specifically within Trafford this includes: Pennine Care s Healthy Young Minds website for signposting information (www.healthyyoungmindspennine.nhs.uk) Trafford Service Directory (www.trafforddirectory.co.uk) Self Help resources available online or through national organisations (e.g. Young Minds, Anxiety UK) MindEd resources and training programmes for parents, professionals and volunteers Non-directive counselling support provided through schools or other voluntary sector agencies Parent Line Helpline for parents Trafford Leisure s physical activity programme Trafford Talkshop - self referral / drop in GP and School Nurse advice and monitoring (11-18 years) Early Help Hubs for 0-11 and 11-18yr olds 42 nd Street (13-25 years) Teaching and pastoral support within schools HomeStart Salford Foundation Coaching Inside and Out Stronger Families team Social Care teams Blue Sci Psychological Wellbeing Service (16 to adulte) School based Healthy Young Minds teams Evidence based support offered through pastoral support within schools

Selective Prevention specifically for Children in Care: Annual Health Assessment with SDQ, where indicated re high SDQ will trigger HYM Review and consultation with Specialist HYM for CIC Practitioner to enable proactive early intervention for getting help Access to Specialist Community Nurse Virtual School & PEP + Additional Resources for all LAC kids Specialist LAC Designated Teacher in Schools Virtual School specialist Attachment Training to Schools. Social Worker Direct work around Child s Adjustment/Planning & Risk Management for Child in becomes Looked After. Life Story work and contact management. HYM Pathway for Children in Care can support professionals within an educational, social care or community setting in working with these CYP as follows: Consultation and liaison, including advice to social workers, teachers and carers on when a referral might be necessary Advice around education-based support/therapeutic groups and parent skills groups Guidance around accessing psycho-education including self-help resources, biblio-therapy, online materials, online resources e.g. Kooth Advice around guided self-help Signposting Supervision Advice and training around detection, assessment and active monitoring of symptoms of mood and emotional disorders, behavioural difficulties dysregulation and attachment needs including risk around self-harm and suicidality HYM Pathway for Children in Care also provides to carers and professional s supporting children Coping, specialist interventions to support ongoing coping High SDQ Consultation to SW for all CIC who score over 18 on the SDQ on their annual routine health assessment *HYM Early Intervention/ Prevention - Direct Resiliency Skills for Primary Children Bounce HYM Consultation to L.A. Children s Homes HYM Specialist Therapeutic parent training to F/C &F& F carers Nurturing Attachments Carers Parent Training Course HYM Specialist Behavioural Interventions to promote success - KEEP Support, a training and support programme for Mainstream and Family and Friends F/C HYM Specialist Parenting Support Groups

As part of developing the Systemic Capacity for CIC coping HYM Advice and Planning to Operational Management of LAC Services to plan for meeting EWB and MH needs of LAC Training to Social Care Teams, Permanence and Transition team and Family Placement Team to implement an Attachment Focus to enhance Placement Stability for Children in Care promote coping. HYM Case Discussion with Family Placement Team Supervising Social Worker s to enable them to support carers to continue to implement the Nurturing Attachments PACE approach with children in placement after training programme and cope. Provide Consultation to Social Care development of Fostering Plus and wrap around community foster care provision to enable sufficient provision for coping in community placements for children transition from out of borough therapeutic placements. *(currently not running due to lack of staffing) However, many young people in care particularly those with chronic and/or fluctuating difficulties where there are concerns about a significant deterioration in mood and/or deterioration in behaviour and where there is an increase in risks to self and others or where the care setting requires additional understanding and skills to meet the needs of the child in placement, the social worker and carers of the child will need a consultation with a HYM Team for Children in Care professional and an initial assessment within HYM. This will require a referral to the HYM Team for Children in Care see below. 4.2 Risk: Risk must always be assessed carefully when a low mood is present, regardless of the duration of symptoms. Where there are concerns about deteriorating mood, self-harm and/or suicidality, professionals are advised to contact clients who do not attend follow-up appointments, or are otherwise failing to attend services/provisions, e.g. school.

5.0 Getting Help 5.1 Need: The THRIVE model indicates that this group includes children, young people and families who would benefit from focussed, evidence-based treatment with clear aims, and criteria for assessing whether the aims have been achieved. This group includes Children and Young People in Care presenting with a range of difficulties, anxiety, mood and emotional difficulties, behavioural difficulties, adjustment difficulties that fall into the remit of related NICE guidance where the NICE guidance identifies short term / interventions would be helpful. Professionals with concerns about a CYP experiencing mild to moderate difficulties will need to consider how to support them to access direct help. The THRIVE model suggests that, wherever possible, provision for this group should be provided with health as the lead provider and using health language of treatment and outcomes. Within Trafford s commissioning arrangements, there are evidence based interventions outside of the Trafford HYM team for Children in Care and these are by Partner agencies who provide targeted support to children and young people who are in need of getting help within Trafford and these are listed under coping and highlighted in bold. 5.2 Referral: Access to Getting Help in the Children in Care Pathway is via Referral from the Social Worker to the HYM Team for Children in Care. This process ensures that the Social Worker and thereby the system around the child is aware and can support meeting the emotional and mental health needs of the child in care. All referrals are reviewed on receipt and risk assessed and where risk is not a priority are screened in consultation with the Head of Psychology for pathway progression on a frequent basis. Routine Referrals to HYM Team for Children in Care will be offered an initial Consultation Intervention within 4 weeks of acceptance of referral. This will enable a contextual/systemic understanding of the presenting difficulties to inform the clinical offer and Pathway allocation / pathway progression. All Consultations will be written up with Recommendations and Reports provided within 2 weeks of Consultation slot. Urgent/Emergency referrals will be identified at screening and HYM Team for CIC will offer immediate liaison with Social Care to support assessment and Safety Planning and the case will be offered risk management follow up. Where the child in care has experienced a hospital admission due to self harm, HYM Team for Children in Care will offer 7 day follow up as per the HYM protocol, unless the case is already open another HYM professional in the CORE HYM team. There will be a plan for Case Management to transfer from CORE to CIC TEAM if the case remains looked after. Internal within HYM inter-pathway Transfer: Some CYP will transition to the Children in Care Pathway from other pathways within CORE HYM, when they become accommodated by the Local Authority, for example, from the Consultation to Social Care Pathway, or from other CORE HYM pathways when the helping is at an appropriate stage to transfer.

Following consultation where cases meet criteria for the getting help or getting more help service they will be allocated to the Clinical Lead to case manage, while awaiting a choose and book appointment for the specified getting help or getting more help intervention. 5.3 Getting Help with the HYM Team for Children in Care HYM Team for Children in Care supports other professionals within an educational, social care or community setting in working with these CYP as follows: Providing in depth Consultation as an intervention (Consultation Intervention) to Social Workers, Teachers, carers and other services involved in respect of referred cases providing initial assessment & formulation including risk and a Report providing recommendations for actions by health, education and care system around the child in respect of meeting the presenting difficulties and the identified emotional well-being and mental health needs of the child. Offering an assessment Appointment for YP /Family to include a full assessment including risk HYM Team for CIC Provision of Short term direct work with carers and children. Outcome monitored, goal focused, NICE guided evidence based interventions. Offering directly or through advice, other short-term interventions guided by formulation e.g., psychoeducation, parental support Providing active case and risk management advice Offering advice, guidance or supervision in relation to short term psychological interventions provided by others.. Advice around support/therapeutic groups and carer skills groups Advice around detection, assessment and active monitoring of symptoms of mood and emotional disorders, including risk around self-harm and suicidality, behavioural difficulties, regulation difficulties. Referral for specialist assessment of ADHD, ASD and LD. Contributing to the EHC Plan Offering interventions via Emotional Well Being Worker in School referred at PEP and via Virtual School for CIC Providing HYM Advice around getting MORE HELP for specific longer term or therapeutic interventions that require longer periods of engagement.. Case Management while accessing another pathway within Core HYM, eg Play therapy or Psychiatry. The HYM CIC professional will facilitate this referral and maintain case management until the additional pathways are accessed and/or

completed. or is required in addition to assessment and direct work by Case Manager. As an outcome of the Consultation Intervention or following a short term getting help intervention, Children and YP may be referred for appropriate getting help or coping services in the community. Discharged or referred into Getting More Help if further intervention required.

6.0 Getting More Help 6.1 Need: The THRIVE model indicates this group of young people and their carers will benefit from longer-term treatment. Following the Consultation Intervention, some young people will be considered to have a moderate to severe presenting difficulties where there are concerns about a deterioration in their presentation and/or where there is are risks to self, others or placement breakdown. Getting More Help HYM Children in Care Pathway 6.2 Referral: Routine Referrals for this service will have received a Consultation Intervention via Getting Help and this will have indicated case transfer to getting more help for longer term treatment. Urgent/Emergency referrals: will be screened and seen within 7 days for Risk Assessment Follow Up. These may engage with Getting Help or Getting More Help Interventions dependent on the assessment / formulation and need. The CYP and carers are allocated a Case Manager within the HYM Team for Children In Care. The child/carers/ are contacted to Choose & Book an appointment for a clinical assessment / intervention. 6.3 Assessment: Assessment will have already begun with the Consultation Intervention via getting help. Individual Assessment: The majority of accepted referrals will be offered a clinical/therapeutic initial assessment undertaken directly with the CYP, by a HYM professional. This will usually involve carer(s) except in exceptional circumstances. The assessment follows The Trust approved assessment document (PAD) adapted for the CIC Population and will involve an exploration of recent and past psychosocial risk factors, including age, gender, family context and relationships, history of bullying and/or abuse, educational context, social functioning, drug and alcohol use, family mental health history, significant life events, ethnic and cultural factors, and factors known to be associated with an increased risk of presentation of psychological and developmental difficulties (for example, significant losses, adjustment to major life changes, family discord). Assessment will always aim to be sensitive and respectful of cultural, ethnic and religious backgrounds. An assessment of risk in terms of suicidality and/or harm to self, harm to others, exploitation and neglect will also be undertaken at this stage using the TARA. The outcome of assessment will include the development of a formulation, consideration of the diagnosis and severity of the presentation, and care plan with goals. It will also involve the completion of routine outcome measures RCADS, SDQ and other therapy specific ROMs, routine documentation and correspondence. RISK: Risk must always be assessed carefully when a mood disorder is present, regardless of the duration of symptoms, including exploration of themes of

hopelessness for the future and personal helplessness. CYP identified as having a mild clinical presentation following assessment will move into Coping or Getting Help with identified support in the community and advice around risk monitoring and management. 6.4 Interventions: The CYP case manager will develop an individual care plan with the young person and their family and liaise with other professionals involved. For CYP on this Pathway, evidence-based psychological therapies may be offered as recommended by NICE guidance. Please see HYM Pathways for detailed specification of Presentation/Disorder and Therapeutic offer. Within the HYM Team for Children in Care there will be an additional specialist offer that address the needs and vulnerabilities of the Children in Care population such as their engagement and motivation issues, universal exposure to separation, loss, sequelae arising from exposure to abuse and trauma, likely emotional and regulation difficulties, likely developmental delay and learning needs and ongoing disruptions in their placement experience. Evidence based interventions as recommended by NICE will be individually adapted to meet the clients/families needs and ability to promote the best access and more effective clinical offer. Further Specific Assessments (Cognitive Assessments) and ongoing reformulation HYM Team for CIC offer range of longer term Specialist interventions for more complex presentations, using Cognitive Behavioural Therapy, Systemic Therapy, Dyadic Developmental Psychotherapy, Trauma processing therapies, EMDR, Cognitive Analytic informed therapy, Third Wave Cognitive Therapies such as Acceptance and Commitment Therapy. (HYM Team for CIC & Trafford HYM to deliver DBT Skills training group). HYM Team for CIC case management where other assessments or interventions ongoing with other pathways via HYM Partnership Interventions. HYM Team for CIC liaison / consultation /interventions for Step down from Inpatient or specialist / clinical residential placements back into community settings. HYM Team for CIC involvement in specifying and identifying specialist placements and transitions to adult services for open cases. 6.5 Documentation and Correspondence Points for Getting Help & Getting More Help Client records are to be kept in accordance with Trust policy and to include case notes, completion of the adapted PAD and Trust approved risk assessment documentation, the TARA. Written client notes should include a formulation summary in the form of a diagram and/or narrative on completion of the initial assessment. Where relevant, Care Programme Approach (CPA) documentation should be

completed and managed by the case manager. The Referring agents, here the Social Worker CYP and their carer(s) are to receive a post-initial consultation letter within 10 working days. For the individual assessment for the getting more help, which may take several sessions, a brief letter to note that the CYP is being assessed should be sent within 10 days, followed by a detailed letter as soon as possible post- assessment. Letters will include details of presenting problems and formulation, assessed risk, care plans with goals and plans for review. Follow-up correspondence with a progress summary will be sent after a further 3 months, and 6 monthly thereafter, or when significant changes are made to the care plan. At discharge, a letter will be sent and should summarise the original presenting difficulties, interventions offered, progress made (including reference to goals at outset), outcomes and relapse prevention plans and be sent within 10 days after the final contact. 6.6 Reviewing Service Effectiveness Mandatory Routine Outcome Measures (ROMs) will be administered at initial assessment, mid-way and at the end point of any therapeutic intervention. Currently, these typically include: The Revised Children s Anxiety and Depression Scale (RCADS, Chorpita, Yim, Moffitt, Umemoto & Francis, 2000) The Strengths and Difficulties Questionnaire (SDQ, Goodman, 2001) The Outcome rating scale (ORS; Miller & Duncan, 2000) The session rating scale (SRS, Miller, Duncan & Johnson, 2002) The CHI Experience of Service Questionnaire (CHI ESQ, Astride-Stirling, 2002) CYP will set their own goals ( Goal Based Outcomes ) and progress towards these will be reviewed ideally at every session, but as a minimum every 3-4 sessions. Clients should be given an opportunity to complete session rating scales, and the CHI Experience of Service questionnaire should be routinely given out posttreatment. Supplementary measures may sometimes be useful clinically, for example, The Eating Disorders Examination Questionnaire. 6.7 Review Progress, including goal based outcomes will be reviewed every 4-6 sessions, with administration of ROM s at the mid-point of therapy. Across all disorders on the pathway, based on the outcome of the review, 3 actions will be possible; 1. CYP who have made progress and are on the road to recovery will be discharged for support at Coping or Getting Help 2. Continuation of therapy at Getting More Help, followed by a review after 6 further sessions where lack of a response or difficulties are explored in

clinical supervision and at case review meetings. 3. Severe and/or complex presentations where there are co-morbidities may require extensive interventions and/or pharmacotherapy and/or access to alternative pathways at Getting More Help. In these circumstances progress should be reviewed every 6-8 sessions. Where risk is significant and on-going, it may be appropriate to have a separate case manager alongside the psychological therapist. As such the case manager manages risk management plans and reviews in line with the CYP formulation, for example, multi-agency crisis management plans may need to be in place. Some CYP will require longer-term provision as follows: 6.8 Extensive Outpatient Provision Some CYP will need longer-term involvement with the HYM service, which could involve: Ongoing psychological therapy for complex presentations and/or co- morbidity Transfer to alternative therapy and risk management Ongoing case and risk management (including Inreach/Outreach provision where necessary) CYP moving onto a different pathway from an alternative pathway following reformulation/readiness for focus on a specific problem. 6.9 Inpatient Provision If it becomes unsafe to manage the CYP within the community due to the severity of their presentation and/or risk, an inpatient intervention might be required. 6.10 Review For CYP in Getting More Help, a joint review with all professionals involved will be helpful on a 3 monthly basis. For clients coming up to their 12 th session, progress will be discussed in supervision and at monthly case review meetings. At these meetings it can be considered what, if any, further work is required, whether a change in therapy is advisable, and whether there is a need for ongoing case and/or risk management on the same or another care pathway, for example.

7.0 Getting Risk Support Risk management is a consideration in every level of the Children in Care pathway, both physical and psychological risk. An increase in deliberate self-harm, suicidal thoughts and intentions are particularly relevant, as are risk arising from display of aggression by the YP (placement instability/ breakdown, criminalization) and risk around Child Sexual Exploitation. The THRIVE model emphasises several important points with regards to CYP whose care needs are best met by Getting Risk Support (Thrive, Wolpert et al., 2014): Supporting these young people should involve close inter-agency working, often with Children s Social Care taking a leading role. There should be clarity over which service is leading the support package offered. The language used should communicate clearly that a health treatment is NOT being offered. Some CYP will fail to benefit from interventions offered at the Getting Help and Getting More Help stages due to a wide range of factors, for example, difficult family circumstances and interpersonal factors. The degree of engagement, alongside other contextual factors, such as the CYP s age and the availability of other support mechanisms, will determine the exact procedure for working with CYP at the Getting Risk Support level. Indeed, for some CYP there is no current health treatment available, but they remain a risk to themselves or others (Wolpert et al., 2014, pg 2). For some CYP there will be ongoing case management within the service due to the level of risk and complexity of presentation necessitating the level of mental health expertise offered by HYM. 7.1 Getting Risk Support in the HYM Children in Care Pathway HYM Consultation to Multi Agency Teams around YP s needs re DSH Safety planning and Risk Management where ongoing Risk with Mental Health presentation and/or emergent personality difficulties of cases who have been open to HYM and who are not currently engaging in therapeutic interventions or where YP have not responded to treatment. HYM Consultation to professionals and engagement of YP back into interventions to support getting more help, getting help and coping HYM Consultation to Local Authority in respect of Placement planning for YP presenting with risk. HYM Consultation to Children in Care Permanence and Transitions Team Working Group on Placement Disruption For the getting risk support group, the main remit of this role will be risk management and liaison with other services. In line with the THRIVE principle, care at this level should not be considered a health intervention/treatment, so a case manager should be working towards involving more appropriate support services, and increasing the likelihood of a relatively safe discharge away from specialist

mental health services. Other CYP not engaged in an active health service treatment at this stage, or requiring ongoing case management by HYM due to the level of risk and complexity, but where there are ongoing significant concerns around risk can be supported by HYM as follows: 7.2 Review Support for multi-agency risk management strategies Consultation and liaison to other professionals Input to inter-agency work Signposting Supporting local safeguarding work alongside Children s Social Care Ongoing risk support with another partner agency leading Support to Accident & Emergency around assessment and admission CYP accessing risk support should be reviewed on a 3 monthly basis. Outcomes may be as follows: CYP who have made progress and are on the road to recovery will be moved into support at Coping or Getting Help CYP demonstrating readiness to make use of therapy can be moved back into one of the Getting More Help stages Ongoing risk support

8.0 Audit Regular audit will be undertaken to monitor the quality of the service on the Children in Care Pathway. Priorities for audit around accessibility and quality, to include: The treatment options are appropriately offered and provided as set out in the pathway. The treatments on offer are evidence-based, goal focussed and outcome measured. Minimum training criteria for professionals audited by the survey of staff and monitoring of CPD and supervision arrangements Analysis of data presented yearly via the Annual Report of the Services Delivered by HYM Team for Children in Care

9.0 Staffing 9.1 Training All staff to have the specialist post-graduate level training in their field to accurately identify, assess, case manage and offer interventions to CYP on the Children in Care Pathway. Supervision All staff offering interventions on this pathway will receive monthly clinical supervision in line with the Trust supervision policy. Therapy-specific supervision will be provided for staff qualified in a particular psychological therapy, and will meet criteria to maintain accreditation where necessary. A hierarchy model of supervision will ensure that all staff practicing a particular therapy are supervised by a clinician of higher level of qualification and/or experience. For senior clinicians this may take the form of peer supervision. Supervision paperwork will be maintained as per policy with particular attention to safeguarding and risk.

10.0 Discharge/Transition CYP making progress with a psychological therapy as evidenced by movement towards goals and/or routine outcome measures where appropriate will be moved out of the HYM service into Coping. Some CYP may be moved in to Coping where it is agreed to manage their own ongoing chronic needs, or Getting Risk Support where there is significant ongoing risk, with advice from HYM to the support system around them. For any CYP who fail to engage with the service, the Children in Care Pathway will augment the standard Trust DNA policy so that additional engagement opportunities can be promoted with this vulnerable and hard to engage population. Where it has not been possible to engage a CYP a discharge letter will be sent to the G.P. and the referring agent, and other involved professionals as appropriate and without exception, when there remain issues of significant risk. 10.1 Provision for 18+ For CYP already in service and accessing therapy, this will continue until treatment is complete, or be supported to transition to adult services if appropriate. CYP turning 18 who are on the pathway but have yet to start a formal therapy, or will require ongoing support, will be signposted or referred on to an appropriate provision in adult services. For those CYP referred post-18, again they will be appropriately signposted.

11.0 References Astride-Stirling, J. (2002) Development of methods to capture user views of Child and Adolescent Mental Health services for clinical governance reviews. Commission for Health Improvement: Project Evaluation Report Chorpita, B. F., Yim, L., Moffitt, C., Umemoto, L. A. & Francis, S. E. (2000). Assessment of symptoms of DSM-IV anxiety and depression in children: a revised child and depression scale. Behaviour, Research & Therapy, 2000, 38, 8, 835-855. Department of Health and NHS England (2015) Future in Mind: Promoting, protecting and improving our children and Young People s Mental Health and wellbeing Goodman, R. (2001). Psychometric properties of the strengths and difficulties questionnaire. Journal of the American Academy of Child & Adolescent Psychiatry, 2001, 40, 11, 1337-1345. Education Committee (2016) Mental Health and Wellbeing of Looked After Children. House of Commons Miller, S.D., & Duncan, B.L. (2000). The outcome rating scale. Chicago: Author. Miller, S.D., Duncan, B.L., Johnson, L. (2002). The Session Rating Scale 3.0. Chicago: Author. NICE 2017 Antisocial behaviour and conduct disorders in children and young people: recognition and management. https://www.nice.org.uk/guidance/cg158 NICE (2014) Anxiety Disorders. https://www.nice.org.uk/guidance/qs53 NICE (2016) Attention deficit hyperactivity disorder: diagnosis and management. https://www.nice.org.uk/guidance/cg72 NICE (2011) Autism spectrum disorder in under 19s: recognition, referral and diagnosis. https://www.nice.org.uk/guidance/cg128 NICE (2013) Autism spectrum disorder in under 19s: support and management. https://www.nice.org.uk/guidance/cg170 NICE (2009) Borderline personality disorder: recognition and management https://www.nice.org.uk/guidance/cg78 NICE (2015) Children s Attachment: attachment in children and young people who are adopted from care, in care or at risk of going into care. www.nice.org.uk/guidance/ng26 NICE (2005a) Depression in children and young people: Identification and management. www.nice.org.uk/guidance/cg28 NICE (2017) Eating disorders: recognition and treatment.

https://www.nice.org.uk/guidance/ng69 NICE (2010) Looked-after children and young people. https://www.nice.org.uk/guidance/ph28 NICE (2005b) Post traumatic Disorder: Management. www.nice.org.uk/guidance/cg26 NICE (2016) Psychosis and schizophrenia in children and young people: recognition and management. https://www.nice.org.uk/guidance/cg155 NICE (2004) Self-harm in over 8s: short-term management and prevention of recurrence. https://www.nice.org.uk/guidance/cg16 NICE (2011) Self-harm in over 8s: long-term management. https://www.nice.org.uk/guidance/cg133 NICE (2016) Transition from children s to adults services for young people using health or social care services www.nice.org.uk/guidance/ng43 Bazalgette, L, Rahilly, T., Trevelyn, G. (2015) Achieving Emotional Wellbeing for Looked After Chidren, A whole System Approach. NSPCC Panella, M. (2003). Reducing clinical variations with clinical pathways: do pathways work? International Journal for Quality in Healthcare, 15, 6, 509-521. Department for Education and Department for Health (2015) Promoting the health and wellbeing of looked after children Statutory guidance for local authorities, clinical commissioning groups and NHS England Silver, M, Golding, R and Roberts, C (2015) Delivering psychological services for children, young people and families with complex social care needs, The Child & Family Clinical Psychology Review, No.3 Wolpert, M. et al. (2014). The AFC-Tavistock Model for CAMHS. CAMHS Press