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Introduction

This national practice guidance is published as part of the national multiagency strategy for children and has been developed through wide scale engagement with stakeholders. Delivery of this practice guidance should be a wholly joint endeavour between health, social care, education and voluntary sector, with plans for how to communicate across service boundaries.

This practice guidance sits within a wider policy landscape for babies, children and young people. The guidance necessarily narrows its focus to therapeutic support for care experienced children and young people only. However, it is important to view the guidance in the context of alignment to other Welsh Government strategies that are detailed in the annex.

Please note that this document does not entail a funding commitment or action to procure or create new services, it is instead practice guidance to inform the future direction of existing services, ensure equity and continuity of provision across Wales and inform the Regional Integration Fund’s ‘Supporting Families’ model of care.

Identified gap in provision

There is currently a gap in the provision of therapeutic support for care experienced children and young people in response to emotional and behavioural needs resulting from the experience of trauma and adverse childhood experiences.

Whilst some of these children and young people may receive a mental health diagnosis, many will not and may not receive clinical intervention through Child and Adolescent Mental Health Services (CAMHS).

These care experienced children and young people, either without a mental health diagnosis or waiting for one, who require therapeutic intervention because of their needs and experiences are the target group for this guidance.

What do we mean by therapeutic support?

In this context therapeutic support should be understood as support that has a positive impact on a child or young person’s emotional wellbeing, resilience and behaviour. In the form of evidence-based wellbeing or mental health support, delivered by experienced, qualified and caring trusted adults in a multi-disciplinary team.

This therapeutic support should be delivered in the context of a foundation layer of therapeutic intervention targeted at adults around the child or young person to ensure that physical and emotional safety is present. This enables relationships to develop and the possibility of meaningfully engaging with daily life opportunities and therapeutic work.[footnote 1]

Purpose

This guidance focuses on one of two key elements that comprise the Regional Integration Fund's (RIF) supporting families model of care, namely, therapeutic support for care experienced children.

The components of the national model should inform the design of services and projects working with care experienced children and young people. The services/projects will offer a holistic approach that provides therapeutic support for their emotional, behavioural, mental health and wellbeing needs. 

This guidance is focused on a support service for care experienced children rather than residential services, however the principles of this guidance could be used in a therapeutic residential setting. 

Services within the model will build upon existing provision across Wales, in order to provide continuity and equity of support across the country.

Population needs and inclusion criteria

The Social Services and Wellbeing Act identified a number of population groups whose needs would be prioritised for integrated service delivery across Wales.

This guidance meets the needs of one such group: children and young people with complex needs.[footnote 2]

Studies demonstrate that a higher proportion of care experienced children and young people have complex needs.

Specifically, this guidance includes provision for children and young people who:

  • are care-experienced
  • have complex mental health and wellbeing needs, including those caused by childhood adversity and trauma (including complex trauma)
  • are under the care of a Welsh local authority

This population group may also:

Edge of care

This guidance is based on delivering therapeutic support to care experienced children and young people, including those who have been adopted. Services delivering this guidance will, therefore, focus most of their delivery to this cohort. However, there should be scope within the service model to enable services to work flexibly with families on the edge of care where they and children’s services deem their expertise can make a difference.

Age

This guidance outlines the need for services to deliver flexibly according to need rather than age, enabling local variation depending on other systems that provide support throughout the life course. Whilst this guidance does not cover working with babies, we do not wish to rule out services working to the guidance including infants in their work if it is practicable on a local basis. We have not applied an upper age limit, but expect services to work to age 25 should individual needs demand.

Scope

Approach and values

Services within the model will incorporate the following: 

  • The voice of the child in the design and delivery of the service.
  • A person-centred and children’s rights-based approach focusing on strengths.
  • Community-based support.
  • A trauma-informed approach as set out by the trauma-informed Wales framework: understanding behaviours within the context of adverse childhood experiences (ACEs) and the context of normative child development.[footnote 4]
  • A multi-agency staff team with a partnership approach, including CAMHS, children’s services, youth justice, education and, where relevant, third sector as intrinsic partners in delivery.
  • Work holistically with the system around the child or young person to ensure a nurturing, empowering, safe and trusted ‘nest’. This should include identifying and working closely with the child or young person’s trusted adults such as youth or playworkers, education staff, sports coaches, residential staff, foster carers, special guardians, adoptive parents, youth justice workers, advocates etc to ensure the wider determinants of mental health and wellbeing are realised.[footnote5]
  • Service planning and delivery underpinned by the NEST/NYTH framework.
  • Use a social model of disability approach whilst developing a culture of inclusion and empowerment.

Aims and objectives

The aims and objectives are to:

  • Provide an integrated health, social care, third sector and educational response for care experienced children and young people with emotional and behavioural needs.
  • Ensure a valued and skilled multi-disciplinary workforce through specialist training and opportunities for continual professional development.
  • Enhance children and young people’s emotional and relational skills and improve their confidence and resilience.
  • Reduce the need for care experienced children, young people and families to repeat their stories.
  • Work long-term and flexibly with care experienced children and young people (and where relevant, their birth families and/or carers).
  • Provide appropriate and timely crisis support to prevent escalation of need and/or risk.
  • Reduce the incidences of health harming behaviours of care experienced children to self or others and reduce levels of risk accordingly.
  • Provide transition support from out-of-county placements to local community placements in family contexts.
  • Improve and enhance the mental health and wellbeing of care experienced children and young people via therapeutic, wellbeing and practical support.
  • Carry out therapeutically informed, comprehensive, holistic assessments, where possible in conjunction with, and if not, shared with (dependant on consent of the child), CAMHS, educational psychology, education and children’s services (where those agencies are also working with the child or young person) to prevent children and young people repeating their story and avoid duplication of effort. These assessments should also be shared with courts as requested by children’s services (and with consent of the child) to inform legal proceedings in relation to children and young people’s support.
  • Use a range of developmentally appropriate, evidence based therapeutic mental health and wellbeing interventions, including life story work.
  • Adapt interventions to meet the needs of neurodivergent young people and those with foetal alcohol spectrum disorder.
  • Ensure multisector assurance and governance is in place to oversee delivery which is fully invested in the ethos and values of this guidance.

Component description

The component description is to:

  • offer and discuss different options for therapeutic support with children and young people so they can make informed choices and co-produce treatment plans
  • ensure the child’s need for therapeutic support, and resulting actions and support to meet the need, is identified in the child’s care and support plan under the Social Services and Well-being (Wales) Act 2014 and regularly review the plan to monitor progress and make any necessary changes to the plan
  • offer consistency of staffing, with good staff retention, achieved through strong staff wellbeing and support packages, with supportive working culture and competitive rates of pay
  • ensure adults who care for and work closely with the child (including foster carers, special guardians, adoptive parents, social workers, family support workers, teachers) are informed about the therapeutic support and given information and training about the intervention and how to respond therapeutically to the child to ensure support is not delivered in isolation
  • have appropriate data sharing processes in place and, where possible, ensure case management systems are compatible across sectors
  • develop joint protocols to bring social care, health, education and voluntary sector provision together in caring for care experienced children and young people; including sharing assessments (where child’s consent is given) to avoid duplication and children having to tell their story lots of times
  • ensure support offered is flexible and responsive to the emerging needs of the individual, which may include not closing cases and working long-term throughout childhood and adolescence, particularly during significant change or transition points
  • deliver services in the young person’s language of choice where possible and make the ‘active offer’ of Welsh
  • prioritise quality of service delivery and fidelity to guidance over numbers of children supported
  • manage transitions between services (for example, where location of residential placement changes) or changes in staffing sensitively, ensuring contact remains with trusted adults for as long as the young person benefits from it
  • provide out of hours support for children, young people and their families (birth families, foster carers, kinship carers, special guardianship carers, adoptive families and residential workers)
  • deliver services in trauma-informed, enabling, neuro-affirming environments
  • provide transition support into adulthood, with support continuing until the young person is ready to leave

Demand management

It is acknowledged that due to demand and system pressures it is likely that services operating under this guidance may have waiting times for support. In these cases:

  • those with the most complex needs and highest risk behaviours should be prioritised for support
  • initial consultation should be undertaken while children and young people are waiting for support, to develop a sense of the child’s needs and who in the system is best placed to meet these needs, so meaningful and planned support can begin while on the waiting list

Workforce

The following should be noted, should workforce expansion be considered, alongside this guidance:

  • The workforce should be recruited from a range of sectors including youthwork, playwork, childcare, education, health and social care.
  • Values based recruitment, paired with a joint training approach as detailed in this guidance should be utilised to ensure diversity and child centred practices. This should also ensure vital skills are not lost in already limited areas such as health and social care.

Outcomes and performance measures

Outcomes and performance measures should be determined by regional strategy and commissioning. However, commissioners and services may wish to consider the following measures.

Regional Integration Fund outcomes and performance measures that can be used for therapeutic services include:

Outcomes:

  • therapeutic support improves and enhances the well-being of care experienced children
  • people’s well-being needs are improved through accessing coordinated community-based solutions
  • local prevention and early intervention solutions support people to avoid escalation and crisis interventions

Other suggested outcomes include:

  • therapeutic support that is shown to improve and enhance the resilience of care experienced children
  • care experienced children experiencing a reduction in risk behaviours, mental health and well-being concerns, and self-harm incidents
  • more children experience placement stability where placements are suitable to their needs
  • more children return or remain with birth families where it is safe to do so
  • more children experience practical or well-being support in line with a corporate parenting role that helps them to feel safe and secure enough to effectively access therapeutic support
  • increased cohesion across the support system around the child or young person
  • care and support plan outcomes reviewed regularly through the child looked after review meetings

Performance measures:

  • number and percentage of children and young people who feel they have a good relationship with a trusted adult
  • number and percentage of people reporting improved emotional health and well-being
  • experience of therapeutic support that is delivered in accordance with the NEST/NYTH framework
  • number and percentage of people who report being able to identify and approach suitable services (at the right time) for help and support with their emotional and mental health

Other suggested indicators and performance measures:

  • number of referrals and average time on allocation of support list
  • NEST/NYTH self-assessment tool maturity ratings and assessments
  • fewer children escalating to secure units
  • fewer applications for deprivation of liberty orders in relation to children and young people with complex needs
  • number of professionals receiving training on brain development, attachment, impact of trauma, and trauma-informed approaches
  • use of a standardised individual outcome measurement tool
  • number of professional consultations held (providing advice to social workers, teachers, residential staff, foster carers)
  • satisfaction feedback from the child or young person and that child’s support system, such as foster carers, parents, and other trusted adults

Services should capture children, young people and families’ stories, feedback and experience of their service in the way that best suits the child, young person or family.

All outcomes and performance measures should be understood in the context of quality of service and fidelity to service model being prioritised over number of children supported.

Consideration should be given to long-term performance measures and an acknowledgement of individual outcomes fluctuating due to experiences of adversity and trauma. 

Quality standards

What matters statements will be developed with care experienced young people and be published alongside this guidance. They will offer a guide to the outcomes that young people want to see from therapeutic services.

Annex

Relationship to other programmes and influences, including:

Perinatal mental health, parent-infant relationships and first 1,000 days

There has been significant debate around the inclusion of therapeutic work with babies in this guidance. It is crucial that bonding and attachment work to promote parent infant relationships in the first 1,000 days and beyond is carried out with families who need it. Whilst there were differing views expressed on if this work should be included in this guidance, we have reached the conclusion that it should not be included for the following reasons:

  • working with parents of infants and early years requires different training, skill sets, and expertise compared to working with children and young people
  • the group of stakeholders is significantly different when working with infants and early years compared to those of children and young people
  • the scope of work may be too broad to be achievable

However, we do not wish to rule out services working to the guidance including infants in their work if it is practicable on a local basis. Nor have we provided an upper or lower age on the services, preferring instead to enable local variation depending on other systems that provide support throughout the life course. 

It is acknowledged that perinatal and first 1,000 days parent and infant mental health support is crucial to manage and mitigate trauma. However, this kind of support will be explored separately through the mental health and wellbeing strategy delivery plans and elsewhere and is therefore not detailed in this guidance. It would be expected that both services would work closely together to manage transition between these key phases.

Early intervention and prevention

Welsh Government are committed to ensuring that support around early intervention and prevention is offered to families who need it. This is covered by many policy areas and funds. Services delivering this guidance will support those with more severe and complex needs. It is nevertheless important that they forge good working relationships with wider early intervention and prevention services to ensure easy access to their expertise to prevent escalations.

Education

It is vital that education settings are part of the supportive ‘nest’ around a child or young person. Work is being undertaken to educate schools and other education settings to work in trauma informed ways. The whole school approach to emotional health and wellbeing is supporting schools to improve their understanding and action on wellbeing for all learners and staff. Education will be key partners in the holistic support offered and services working to this guidance should ensure close links wherever possible.

Violence Against Women, Domestic Abuse and Sexual Violence (VAWDASV)

The Welsh Government wants to enable a multi-agency approach ensuring that children and young people can access fast-tracked, specific and specialised therapeutic services if they have experienced abuse or violence, across health, education, local authority and Children and Family Court Advisory and Support Service (CAFCASS Cymru). 

Regional Integration Fund

The health and social care Regional Integration Fund guidance identifies a set of ‘key enablers’ that Regional Partnership Boards are expected to use in developing the 6 models of care. These are:

  • integrated planning and commissioning
  • technology and digital solutions
  • promoting the social value sector
  • integrated community hubs
  • workforce development and integration

In the context of this guidance, the enablers will contribute towards the 2 high-level models of care outcomes, which are:

  • services within the model are integrated across health, social care, local authorities, education, and the third sector
  • services provide a cohesive, coordinated, and co-operative approach using the NEST/NYTH framework to deliver therapeutic support

Co-design and engagement

This guidance has been developed through:

  • feedback and sharing of experiences from care-experienced children and young people
  • an analysis of health and social care RIF
  • progress reports from projects and programmes that are aligned to the supporting families model of care: this guidance seeks to build on the key elements and successes of those projects and programmes
  • discussions and engagement with the supporting families and NEST/NYTH community of practice, which includes practitioners and service managers from:
    • children’s services
    • health
    • education
    • youth
    • play
    • advocacy[footnote 6]
  • engagement with services already delivering support to care-experienced babies, children, and young people, and academics working in this field
  • engagement with Welsh Government colleagues in related policy areas
  • engagement with foster carers and adoptive parents

Issues highlighted during engagement

These are not the views of Welsh Government, they are an expression of lived or professional experience.

Care experienced children and young people report:

  • not wanting to wait for a diagnosis to get help: support should not be diagnostically dependent
  • wanting comprehensive, person-centred therapy and strengths-based wellbeing support
  • needing trusted, compassionate, loving, warm adults
  • services needing to recognise emotions and trauma responses within behaviour
  • services needing to recognise trauma and the results of trauma and respond
  • neurodiversity needing to be identified early and understood
  • a desire to reduce the number of times they need to tell their story

Foster carers and adoptive parents report:

  • service staff need to be well trained due to vulnerability of children.
  • staff need to be trauma- and attachment-informed
  • wanting early interventions to prevent needs from escalating
  • specialist support to understand differences between trauma and neurodiversity
  • education staff needing trauma-informed training and understanding of looked-after children’s additional barriers to learning
  • need for services to work co-operatively to support families when in receipt of multi-agency support
  • wanting to reduce the number of times they need to tell their child’s story and not having to recount it in front of the child

Services/professionals report:

  • frustration at a lack of flexibility within their project/commissioned scope
  • need to work long-term with children and young people
  • need for effective data sharing and joint working protocols in place between health and social care
  • need for integrated mental health and wellbeing assessments between health and social care
  • need for long-term funding to ensure sustainability

Academics/researchers report:

  • therapeutic support not being delivered in line with NICE guidelines
  • lack of evidence-based commissioning for evidence-based therapeutic interventions
  • having a stable placement should not be a pre-requisite for accessing therapeutic interventions: instead, the interventions should be flexible and allow the child or young person to engage when it is right for them
  • frustration at lack of specialist support for specific types of adverse childhood experiences such as sexual abuse and domestic abuse
  • misdiagnosis of care experienced children and young people

Footnotes

[1] This could include, for example:

  • multi-agency psychological formulation
  • reflective practice for residential staff to enable them to emotionally support the young person
  • direct therapeutic intervention for parents/carers

[2] Following changes made to the statutory guidance in relation to part 9 of the act, the definition of children with complex needs now comprises:

  • children with disabilities and/or illness
  • children who are care experienced / looked after children
  • children who in need of care and support
  • children who are at risk of being looked after
  • children with emotional and behavioural need

[3] This footnote contains 2 references:

[4] Trauma-Informed Wales (traumaframeworkcymru.com), this framework sets out practice principles and practice levels for trauma informed practice. ACE Hub Wales contains numerous resources to support understanding of adverse childhood experiences. Children’s behaviour can be seen through a problem saturated lens, when what they experience is wholly in line with their stage of development, or within the context of disrupted development due to trauma.

[5] This footnote contains 2 references:

[6] The health and social care RIF communities of practice, established in 2022, bring together groups of practitioners across sectors to promote productive discussion and encourage collaborative solutions to overcome common challenges. They also have an important role in contributing to the development and implementation of 6 national models of integrated health and social care, as set out in the RIF revenue guidance.