Staff looking after children in local authority residential units: the interface with child mental health professionals

Journal of Adolescence 1996, 19, 127–139

Staff looking after children in local authority residential units: the interface with child mental health professionals B. HATFIELD, R. HARRINGTON AND H. MOHAMAD Seventy-two members of staff working in children’s residential units in a Local Authority were surveyed, to elicit their experiences and evaluations of working with child mental health professionals. Whilst the majority of staff held few or no formal educational qualifications, they emerged as an experienced group, with a level of confidence in their knowledge and skill base. Support was identified as coming predominantly from within units themselves; relatively few staff had direct contact with child psychiatrists or psychologists, although many children received a service. Staff in general felt that child mental health services were not helpful to them in terms of their work with young people. However, the majority of staff indicated a need for greater direct involvement across a range of child behavioural and emotional problems. The findings are discussed in terms of the changing population of “looked after” children and the recommendations of the Warner  1996 The Association for Professionals in Services for Adolescents Report.

Introduction A series of recent reports upon well-publicized crises in the residential care of children has highlighted huge problems in the organization and delivery of such care (Levy and Kahan, 1991; Department of Health, 1991a; Department of Health, 1992). Whilst nationally the numbers of children looked after have markedly declined in recent years (Department of Health, 1992), the difficulties of organizing a residential child care service have been given an unprecedented prominence in professional debate. Children looked after by Local Authorities have been identified as some of the most vulnerable in society, and tend to come disproportionately from households characterized by deprivations such as poverty and lone parenthood (Bebbington and Miles, 1989). Commonly, the reasons for children being looked after by Local Authorities involve such experiences as serious abuse or conflict in families of origin, or the inability or unwillingness of families to care for them. Residential units continue to make a significant contribution to alternative care for children, providing care more frequently for specific groups within the “looked after” population (Berridge, 1985). Most notably, residential units cater predominantly for adolescents, with most authorities identifying foster homes as the placement of choice for younger children. Amongst these adolescents are some remanded to

Reprint requests and correspondence should be addressed to B. Hatfield, Mental Health Social Work Research Unit, 12th Floor, Mathematics Building, Manchester University, Oxford Road, Manchester M13 9PL, U.K. 0140-1971/96/020127+13/$18.00/0

 1996 The Association for Professionals in Services for Adolescents

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care in court proceedings for offences, and many with serious emotional and behavioural difficulties (Department of Health, 1992; Levinson and Minty, 1992; Kahan, 1994). The most recent comprehensive survey of residential care for children was undertaken in the wake of the abuses in Leicestershire children’s homes, followed by the conviction of Frank Beck, and is published in the Warner Report (Department of Health, 1992). This identifies that 64% of children living in Local Authority children’s homes can be described as emotionally or behaviourally disturbed and about a third are estimated to have been sexually abused. High levels are also recorded in the private and voluntary provider sectors. Some children looked after by Local Authorities have lengthy “care careers” with moves and disruptions going back into their early childhoods (Millham et al., 1986; Thoburn, 1988). The psychological damage to them, and the imprints upon their emotional and behavioural functioning, may be such that many children are unable to respond to high quality physical and emotional care. In addition, disruption in the lives of very young children leaves a vulnerability that is longstanding, and is not readily “repaired” by environmental improvements (Wolkind and Renton, 1979; Hodges and Tizard, 1989a, b). Also, the provision of “high quality” care has proved notoriously difficult in the residential sector (e.g. Colton, 1988). The vulnerability does not cease with the transition to adulthood. Emotional and behavioural difficulties in childhood and adolescence predict from greater vulnerability in adult life to both psychiatric disorder and criminal conduct (Rutter, 1989; Robbins and Rutter, 1990), and there is evidence that children who have spent significant periods of time in care are more likely to experience difficulties in parenting their own children (Quinton and Rutter, 1988). However, caution must be exercised in drawing conclusions about the impact of the care experience itself, as distinct from the experience which led up to it (Bullock et al., 1993; Wolkind and Rushton, 1994). The current population of children looked after by Local Authorities will have been influenced by practice under the Children Act 1989. The Act and accompanying guidance place emphasis upon the support of the birth family wherever possible, and if a child is to live outside of the birth family, placement in the wider family is encouraged (Department of Health, 1991b). An additional influence upon the population of residential units is the widespread practice of looking after children in foster homes wherever possible. Taken together, these trends are likely to mean that research findings derived from former care populations cannot be directly applied to children currently “looked after” in residential units. However, children looked after in Local Authority residential units are likely to be characterized by a high degree of vulnerability, in emotional as well as social terms. They will include a proportion of adolescents with long-standing problems, who continue to present serious difficulties as they move into adulthood. Experience of a particular region confirms the generality of this picture. Historically, staff employed to look after children in Local Authority units have been drawn from the ranks of people without formal qualifications: commonly these have been women, and remuneration has been modest (Parker, 1988). There has been a continuing debate from the early 1970s about the need for more systematic training and qualifications for residential workers (e.g. CCETSW, 1974); The Utting Report (Department of Health, 1991a) identified training of residential staff as a crucial issue in the quality of care, but points out that 70% of all residential child care staff did not at that point hold a relevant qualification, including 20% of unit managers. Furthermore, in terms of relevant

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qualifications, the picture was unchanged from ten years previously. The Warner Report (Department of Health, 1992) confirms that lack of qualification as such is the norm: the overall picture we see is a children’s homes’ workforce trying to cope with difficult and complex tasks for which most have not been trained and for many of whom there are no plans to provide adequate training in the forseeable future (Department of Health, 1992, p. 116).

However, this influential report recommends changes which focus predominantly upon work-based training for residential social workers, and acknowledges that more substantial changes would have unrealistic resource implications. There is also debate around whether the entire residential workforce needs training to the same level, whether there is not a positive role for “paraprofessionals”, and whether the Diploma in Social Work is in any case the most appropriate qualification to the tasks involved in residential child care (Brawley and Schindler, 1991; Department of Health, 1992). The Warner report also identifies the provision of child mental health service support to Social Services Department residential units, pointing out that staff in these units are likely to need “ready access” to services which include child psychology and psychiatry (Department of Health, 1992, p. 143) because of the high rates of emotional and behavioural disturbance in “looked after” children. Two levels of need are identified: need for support and direct work with individual children, and need for advice and professional support to residential staff working with these children. The survey shows a patchy provision throughout the country with substantial variation in the levels of child mental health input to residential units. This picture also emerges from a more recent survey of child mental health services (Kurtz et al., 1994). In this survey, Social Services Departments were asked their views on the general adequacy of resources available for child and adolescent mental health: almost half described them as “woefully inadequate” with a further quarter describing difficulties of access and concerns over referral priorities (Kurtz et al., 1994, pp. 24–25). Within Social Services Departments, priorities for therapeutic input were identified as, firstly children who had experienced abuse (49% of respondents) followed by support for children separated from their families (22% of respondents)—two groups heavily represented in residential units. Other areas were mentioned less often.

The intervention of child mental health professionals A Department of Health circular, following the report of the Warner Committee, requires Social Services Authorities to audit the needs of children’s homes for specialist mental health support, distinguishing between the needs of children and the needs of staff for training, development and support (LAC (93)15). Traditionally, child mental health services have offered assessment of individual children, and in some cases treatment, usually on an outpatient basis. This would generally involve parents or family carers, for children who live with these. However, for the child living in a residential unit, dialogue between child mental health professionals and front-line carers would be severely restricted by the existence of rotating “shifts” of workers, with complex communication systems. The Warner Report appears to suggest a greater degree of integration between the services, whereby child mental health professionals offer direct support and advice to care staff as a group, as well as to individual identified children—involving a different model of service

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delivery. Multi-disciplinary approaches exist (see for example Fahlberg, 1990; de Silveira, 1991) and are developing in Authorities in the local region, but are by no means universally available. The often lengthy history of stress and disruption in the lives of children who live in residential units precipitates a range of emotional and behavioural outcomes. Most commonly these can be categorized as emotional disorders or conduct disorders, or a combination of the two. The evidence from research and practice suggests that emotional problems in childhood and adolescence are more likely to respond to therapeutic help and less likely to have lasting consequences in adult life. The conduct disorders, on the other hand, have a poorer prognosis and are more indicative of lasting difficulties (Rutter, 1974; Robins and Rutter, 1990; Walker, 1992). Emotional disorders in children living in residential units generally need to be addressed in individual work with a skilled person acting as therapist. Conduct problems have a major impact upon daily living and daily relationships; residential unit staff may need skilled help as a group in developing appropriate approaches, for which a range of examples exists in the literature (see for example: Forehand and McMahon, 1981; Patterson, 1982; Patterson and StouthamerLoeber, 1984; Kazdin et al., 1987a, b; Patterson et al., 1989; Herbert, 1991). However, these examples have largely been developed in work on parenting skills and need careful translation to the residential context. They generally involve the conscious management of contingencies maintaining undesired behaviours.

The “Rivertown” survey Background “Rivertown” Social Services Department agreed to take part in a preliminary survey of its residential child care staff, to explore their experiences and perceptions of joint working with child mental health professionals. “Rivertown” is part of a large Metropolitan area, with neighborhoods of substantial social deprivation. It has 13 children’s residential units, ranging in size from six to 12 places per unit. The functions of units varies, some acting mainly to receive children admitted in crisis or for assessment, with others offering longerterm care, or helping young people leaving care. The town also has a team of child mental health professionals—psychiatrists, psychologists and social workers, based at the local children’s hospital, and offering a range of services to the local community.

Method All residential social workers working in Social Services Department units in “Rivertown” were circulated with a questionnaire, which on pilot had taken about 20 minutes to complete. Arrangements were made to collect the complete questionnaires direct from units, with a follow-up visit to “chase” those completing late. In total 72 questionnaires were returned from a potential pool of 109 residential social workers, a response rate of 66.1%. The remaining staff were either unable to complete the questionnaire in time, unavailable due to holidays or sickness, or unwilling to respond due to reservations about the survey. However, this rate of return is sufficient to enable useful comments to be made. Responses were pre-coded for computer entry, and SPSS was used to generate simple descriptive frequencies.

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Results Profile of residential staff. Equal numbers of men and women, 36 of each, responded to the survey. The median age of staff was 38 years, with a little over a fifth falling into the 20–29 age group. Overall the staff emerged as an experienced group, with two-fifths indicating residential child care experience in excess of 10 years, and only three people indicating experience of less than 3 years. Seventy-one percent had been in their current post for longer than 2 years, indicating a high level of staffing stability. Staff were asked to indicate their formal educational or professional qualifications, and these are summarized in Table 1 below. Although about a third of staff indicated that they had no formal qualifications, it is likely that most had received substantial in-service training. Only a handful held an appropriate social work qualification. About a third of staff indicated that they held a position in which they were responsible for supervising other staff—this included unit managers and deputies. The remaining twothirds identified themselves as front-line residential social workers. Support to residential social work staff. The survey asked whether individuals felt that the staff in their unit had the necessary skills and knowledge to work with the range of difficulties presented by the children in their care. Responses are summarized in Table 2 below. Despite the scarcity of relevant social work qualifications identified earlier, just over half of staff clearly felt reasonably confident that the skills and knowledge of their unit as a whole largely addressed the range of difficulties presented by the children looked after. The survey went on to ask respondents to identify sources of support available to them in their work with children with emotional and behavioural difficulties. Replies are summarized in Table 3 below. What is apparent from this breakdown of support received is the heavy reliance upon the personnel of units themselves in approaching the emotional and behavioural problems children manifest. This may reflect the immediacy and continuity of this sort of support, Table 1

Qualifications of residential staff

Formal qualifications

Number

%

6 4 10 26 25 1

8.5 5.6 14.1 36.6 35.2 —

DipSW/CQSW/CSS Bachelors/Masters Degree/Professional A-Level/HNC/B-Tech/O-Level CSE/GCSE/City & Guilds No formal qualifications Not recorded

Table 2

Skills/knowledge of Unit staff as perceived by respondents

Do unit staff have skills/knowledge to work with children’s difficulties Yes, definitely Yes, mostly To some extent No, mostly No, definitely

Number

%

7 30 30 4 1

9.7 41.7 41.7 5.6 1.4

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most likely to be available at times of stress and crisis for children and workers. Support from field social workers and fieldwork managers is perceived as fairly limited, possibly reflecting other priorities within their workloads, or the assumption that it is not part of their role to become involved in the direct care of children. The level of support identified from child psychiatrists and psychologists was also limited, with over half of all respondents identifying no support received by staff. This does not necessarily mean that there was no child mental health involvement with children, but probably reflects a pattern of service operating on the basis of individual child referrals, and support to children. Workers were asked in general whether they felt there was sufficient support to residential staff in working with children with emotional and behavioural problems. Figure 1 indicates the responses. Despite the support identified earlier coming from within units, the majority of staff surveyed indicated that they felt levels of support were in general insufficient.

Experiences of involvement with child mental health professionals. Staff were asked how many children in their unit had, in their view, “serious emotional and/or behavioural problems”. Only two staff indicated no children who they would describe in this way, with all of the remainder indicating some. Most indicated between two and six children currently with such problems. Staff were in general caring for some children who had been assessed by psychiatrists or psychologists, although 14 staff indicated that no current children had been assessed. Just over half of staff could identify children who had received ongoing sessions of direct work from a child mental health professional following assessment—this was more commonly a psychiatrist than a psychologist. However, only 19 staff (26%) had themselves had face-to-face contact with child mental health professionals in respect of children currently looked after. Others said there had been contact via letter or telephone. If staff were caring for children currently who had received help from child mental health professionals, they were asked to rate the “helpfulness” to the children of the intervention. Rating are summarized in Table 4 below. Table 3

Levels of support received from a range of sources

Source of input

Unit manager or deputy External line manager Field social workers Fieldwork managers Other residential workers Training sessions External consultancy Child psychiatrist Psychologist Other

Level of support received A lot

Some

Little

None

No. %

No. %

No. %

No. %

51 (72.9) 5 (7.1) 2 (2.8) 0 43 (59.7) 4 (5.6) 2 (2.9) 0 0 2 (2.8)

11 (15.7) 33 (47.1) 18 (25.0) 8 (11.8) 16 (22.2) 30 (41.7) 8 (11.4) 9 (12.5) 8 (11.4) 4 (5.6)

7 (10.0) 21 (30.0) 35 (49.3) 25 (36.8) 7 (9.7) 32 (44.4) 16 (22.9) 21 (29.6) 15 (21.4) 5 (6.9)

1 (1.4) 11 (15.7) 16 (22.5) 35 (51.5) 6 (8.3) 4 (5.6) 44 (62.9) 41 (57.7) 47 (67.1) 61 (78.4)

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Yes mostly 7.00/9.7%

No definitely 23.00/31.9%

To some extent 22.00/30.6%

No mostly 20.00/27.8%

Figure 1. Do you feel there is sufficient support to residential staff?

Whilst the largest group indicated that they were “unsure” of the helpfulness of the intervention to the children concerned, of those indicating a more certain view, the majority perceived the intervention as positive. A further question enquired as to the helpfulness to staff of child mental health interventions to looked after children. The notion here was that feedback and advice on aspects of daily living and management of children from child mental health professionals might help residential staff in their care of children with emotional or behavioural problems. Responses are summarized in Table 5. A similar proportion, about 1 in 5, again rated child mental health interventions positively. However, a much more substantial proportion of staff rated the interventions to children as “not helpful” to residential staff. (Only staff currently looking after children who had contact with child mental health professionals are included in Tables 4 and 5.)

Help for specific behaviours. Residential social workers completing the survey were presented with a checklist of child behaviours which they were likely to encounter Table 4

Staff perceptions of “helpfulness” of child mental health services to children

Perception of “helpfulness” of service

No

%

Very helpful Helpful Unsure Not helpful

2 9 36 7

3.7 16.7 66.7 13.0

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with varying frequency in looked after children. For each behaviour, they were asked the following: If a child looked after in your unit exhibited the behaviour to a persistent and/or extreme degree, indicate whether you think help should be sought from outside the unit, and if so, where you think the help should come from.

The range of responses is indicated in Table 6. Respondents could indicate any or all sources of help for each behaviour. In Table 6, “within unit” means only that response was given; “SSD manager or fieldworker” means only that response was given in addition to “within unit”; “child mental health professional” means that a psychiatrist or psychologist was mentioned, either alone or in addition to other sources. The category “other/not recorded” included all other responses. Two particular behaviours emerged as being perceived by three-quarters of survey respondents to justify referral to child mental health professionals. These were “deliberate self-harm” and “bizarre or strange behaviour”. Only four respondents in each case felt that these behaviours could be addressed within units. Around half of respondents felt that referral to a child mental health professional would be appropriate in response to “depression/weeping”, “withdrawal/isolation”, “inappropriate sexual behaviour”, “tantrums”, “aggression”, “violence” or “eating insufficient or excess”. Less than one-third of staff responding to the questionnaire felt that referral to a child mental health professional would be appropriate in the case of “bullying/cruelty”, “truancy”, “absconding”, “drug/alcohol misuse” or “failure to care for self”. However, truancy, absconding and drug/alcohol misuse were commonly seen as being appropriately referred to “other” help sources: specifically mentioned were police, educational welfare agencies, schools, and specialist drugs or alcohol helping agencies. These behaviours were also likely to be referred outside of units to Social Services Department managers or fieldworkers. Of the 14 child behaviours listed, workers responding suggested that on average six would appropriately be referred to a child mental health professional as a source of help. The average was a little higher for workers with more than 5 years experience compared with their less experienced counterparts (6.1 and 5.7 problems, respectively); higher for those with higher educational achievements compared with those with lesser educational achievements (6.3 and 5.6 problems, respectively); and higher for those in supervisory roles compared with “front-line” staff (6.1 and 5.8 problems, respectively). More marked differences in rate of suggested problem referral to child mental health professionals emerged between units than between individuals. Table 7 below shows the average number of problems suggested to be referred to child mental health professionals, per unit staff member. A three-fold difference between units with the highest and lowest rates of suggested referral to child mental health professionals is evident. Table 5 Perceptions of “helpfulness” to residential staff of child mental professionals’ involvement with children Perceptions of “helpfulness” of service (to RSWs)

No

%

Very helpful Helpful Unsure Not helpful

1 9 19 23

1.9 17.3 36.5 44.2

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The nature of child mental health service delivery. The final part of the survey sought to elicit from residential staff the nature of child mental health services they currently had access to, and the forms of service they thought ought to be available. This was in order to obtain “pointers” as to the model of service residential workers might find most useful. Responses are summarized in Table 8. (Percentages do not sum to 100%—more than one response possible.) Interestingly, less than a third of all staff completing the questionnaire indicated that they were aware of the current availability of any of the services listed—this may well be a Table 6

Perceptions of appropriate sources for help with specific child problems

Problem

Source of help Within unit

Deliberate self-harm Depression/weeping Withdrawal/isolation Tantrums Bizarre/strange behaviour Aggression/ uncooperativeness Violence to others Bullying/cruelty Truancy Absconding Drug/alcohol misuse Inappropriate sexual behaviour Eating insufficient or excess Failure to care for self

Table 7 Unit A B C D E F G H I J K L M

SSD Manager or fieldworkers

Child mental health professional Other/not recorded

No.

%

No.

%

No.

%

No.

%

4 15 15 25

5.6 20.8 20.8 34.7

5 10 15 12

7.0 13.9 20.8 16.7

52 37 36 34

72.2 51.4 50.0 47.3

11 10 6 1

15.3 13.9 8.3 1.4

4

5.6

8

11.1

54

75.0

6

8.3

16 16 22 8 14 5

22.2 22.2 30.6 11.1 19.4 6.9

19 19 20 23 32 19

26.3 26.4 27.7 32.0 44.5 26.4

33 29 21 20 10 15

45.8 40.3 29.2 27.8 13.9 20.8

4 8 9 21 16 33

5.6 11.1 12.5 29.1 22.2 45.9

6

8.3

17

23.6

38

52.8

11

15.3

20 46

27.8 63.9

7 10

9.7 13.9

31 12

43.0 16.7

14 4

19.4 5.6

Average rate per person of suggested problem referred to CMH professionals Average No. problems referred to CMH professional/staff member 4.5 6.0 4.5 6.4 6.0 5.9 7.2 3.2 6.8 2.7 8.2 7.6 8.3

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matter of access and prioritizing of scarce specialist resources in the N.H.S. The most commonly identified service currently available was “ongoing sessions to appropriate children”. In terms of what they felt should be available, about three-quarters of respondents indicated “visits to the unit” and “advice and support to residential workers about individual children”. This perhaps reflects the issue identified earlier, of residential staff having relatively little direct contact with child mental health professionals.

Discussion The “Rivertown” survey of residential child care staff reveals a picture of experienced staff, from across the adult age ranges, with a reasonable level of confidence in the service offered by their units to children, with a range of difficulty. Residential child care in “Rivertown” cannot be described as “women’s work”: men and women are equally represented in the sample, and there is evidence of a workforce that is stable over time. Staff indicated overwhelmingly that they were caring for some children they would describe as “emotionally or behaviourally disturbed”, yet the majority of staff lack formal professional qualifications of any kind. This mirrors the national situation outlined in the Warner Report (Department of Health, 1992). In “Rivertown”, support in the work of caring for children was identified as coming mainly from within units themselves; this may be reflective of a positive ethos of collective support but also carries the attendent risk of attitudes and practices that may consolidate without the benefit of sufficient external expertise. Practice within units may also be mediated by the involvement of an external manager, and by the development of staff knowledge through the in-service training programme. Substantial proportions of survey respondents indicated that they received “some” support from these sources, and these will involve personnel with relevant qualifications. However, support from the child mental health services was only indicated by a small proportion of staff. Not surprisingly, only a handful of respondents found that they were helped in their direct work with children by the involvement of psychologists and psychiatrists, and many had no direct contact with the child mental health services. This is reflective of a model of service based upon individual referral: for children living in Local

Table 8

Residential staff perceptions of child mental services received and needed

Service from child mental health professionals Telephone advice Crisis assessment Visits to unit Ongoing sessions to appropriate children Help getting another placement Advice/support to RSWs about individual children Advice/support to RSWs about general management of children

Available now

Should be available

Not necessary

No.

%

No.

%

No.

%

17 13 11

(23.6) (18.1) (15.3)

50 50 55

(69.4) (69.4) (76.4)

2 2 4

(2.8) (2.8) (5.6)

21 14

(29.2) (19.4)

46 41

(63.9) (56.9)

0 7

(9.7)

17

(23.6)

54

(75.0)

0

14

(19.4)

48

(66.7)

4

(5.6)

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Authority accommodation, this effectively “by-passes” most front-line staff unless someone takes responsibility for passing on advice and information. The majority of staff surveyed were receptive to the notion of child mental health service involvement with the children and young people looked after, and perceived a range of problems as being appropriately shared. The propensity to refer to child mental health professionals was slightly higher for staff “further on” in terms of their own professional development, and markedly higher in some units than others, suggestive (tentatively) of an ethos within which external expertise is more valued in some units. In terms of the model of service delivery offered by child mental health professionals, residential child careworkers indicated most frequently the need for “visits to the unit” and “advice and support to residential workers about individual children”, reflecting a need for a greater level of direct engagement. The need for more general support for residential workers in their work with children was also identified. This certainly echoes the Warner Report recommendations for the more systematic integration of child mental health input to residential units, and suggests a multidisciplinary approach. Clearly the form of such an approach needs to be determined at a strategic level between health and social services purchasers, and would involve some re-consideration of priorities within the child mental health services (Health Advisory Service, 1995 (in press)). Child psychiatrists and psychologists are an expensive and scarce resource, and in the current climate, the efficient and effective use of such resources is a paramount consideration. Working across discipline and organizational boundaries may also present some difficulties for more integrated joint working with children and young people looked after in Local Authority units. Different levels of training, qualification, recognition and pay militate against the notion of equal professional partnerships, but an effective relationship between disciplines needs forging for the skills of child mental health professionals to have an impact (Silveira, 1991). Differences in the structure and culture of different occupational and professional groups can impede this process (see Huntington, 1981); residential social workers, although largely untrained, share the social work culture which values teamwork, improvization and negotiated solutions. The effective involvement of child mental health professionals may involve something of a culture shift for residential workers, in the acknowledgement of a body of knowledge and expertise about “daily living” with children and young people.

Conclusions The survey described in this paper provides support for the proposals of the Warner Committee, for the greater involvement of child mental health professionals in residential units for children and young people looked after by Local Authorities. An approach which addresses the needs of staff for advice and support, in addition to direct services for children, is indicated by residential social workers as being needed.

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