Transcript Sng

Yes, But What Works
with kids with high needs?
The Alternate Care Clinic
Therapeutic support for kids in care
Presentation by:
Dr Rebecca Sng - Unit Head, A.C.C. and
Dr Megan Chambers - Director, Redbank House
© Rebecca Sng. 2008.
After Entry Into Care
• The data we have suggests that children in
OOHC have ongoing, unmet mental health
needs(Bundle, 2001; Williams, Maddocks, Cheung, Love, & Hutchings,
2001)
• Some studies suggests that the rates of
psychopathology in the High Needs
population are comparable to the rates in
Juvenile Justice facilities and Psychiatric
Inpatient Units.
• Yet NSW did not have a single
multidisciplinary unit dedicated to the mental
health needs of this population.
© Rebecca Sng. 2008.
Core Question
How to deliver child and
adolescent mental
health services to
children in care?
© Rebecca Sng. 2008.
Introduction to the
Alternate Care Clinic
© Rebecca Sng. 2008.
What is the ACC?
• A joint project b/t DoCS and Dept of Health
• Services children/young people in long-term
out-of-home care (OOHC) with a high level of
complex needs
• Provides flexible and comprehensive
interventions with open time frames
• Seeks to co-ordinate and support services
involved with the client to ensure the highest
possible standard of care.
• Works on systemic, attachment based
framework.
© Rebecca Sng. 2008.
Who are the staff?
• Department of Health staff
– Psychiatrists
– Social Worker
– Clinical Psychologist
– Clinical Neuropsychologist
• Dept of Community Services staff
– Psychologists
– Psychology internship programme
© Rebecca Sng. 2008.
Therapeutic Model
Improve
Safety
Improve
Reflection
Improve
Functioning
Child
Medication to
decrease arousal
Coherent narrative
development
Problem Solving,
Affect Regulation,
Interpersonal skills
Carers
Build empathy/
Putting things in
decrease
developmental/
misunderstanding historical context
Training the carers
to teach the skills.
Inc skills of carers
Wider
System
Decrease anxiety
in the system
More coherent
system, clearer
communication etc
Long-term planning
(not crisis driven)
© Rebecca Sng. 2008.
Question 1
• How to deliver those services to high
needs young people who:
– Never attend appointments
– Are not “customers” for therapy
– Are emotionally and behaviourally unstable
– Periodically substance abusing
– Periodically in detention
© Rebecca Sng. 2008.
Psychiatrist Only Model
Example 1
© Rebecca Sng. 2008.
The Casual Attender
Problem:There are a number of adolescents in
care who are a source of high anxiety to their
DCS case managers.
• These adolescents may
– present to hospitals with psychotic
symptoms
– may be heavy substance users
– may be prescribed a range of medications
by multiple practitioners who see them in
multiple settings
– are high risk takers, impulsive and
potentially self-destructive.
© Rebecca Sng. 2008.
The Casual Attender
• Classically they are:
–Frequent absconders
–Have extensive trauma histories
–Come into care late
– Have difficulties with affect regulation
in multiple contexts, with resulting
police and juvenile justice
involvement.
© Rebecca Sng. 2008.
The Casual Attender
In terms of relationships they:
• Have very few stable
relationships.
• They are often in peer groups
which are alienated from adults.
• They usually do not tolerate
intensive intimate involvement with
adults.
© Rebecca Sng. 2008.
Is there any point referring these young
people for mental health assessment and
treatment??
What would be the purpose?
• After missed appointments
• Unavailability at crisis times
• Missed/abused/chaotic dosing of
medications
• The risk of alienating the young person
because of pathologising experiences.
© Rebecca Sng. 2008.
HOWEVER…..
There are potential
benefits if these
difficulties can be
managed…..
© Rebecca Sng. 2008.
1. Decreasing anxiety in the
carers
HOW?
• By predictable, and informed
involvement of the mental health
professional.
– This comes from regular appointments with the
key staff involved, which proceed whether the
young person is there or not.
• This can also be a risk management/risk
sharing strategy with case plans, including
mental health plans, and opinions which are
proactive rather than reactive.
© Rebecca Sng. 2008.
2. Improved ownership/coherence
in the health system
This can lead to
• Better crisis management
• Improved communication
• Less reactive prescribing
• Monitoring of compliance and
effectiveness of medications(via staff)
• More accurate diagnoses based on
longer-term assessments.
© Rebecca Sng. 2008.
2. Improved connection with the
young person (sometimes…)
This can lead to:
• Decreased anxiety
• Less pathologising
• Some openness to other contacts
• Familiarity with the place and the
process and (hopefully) not too
much reactivity to them
• Hopefully thoughtful listening to
their concerns.
© Rebecca Sng. 2008.
To do these things, a mental
health service must….
• Manage missed appointments,
sometimes not seeing the identified
patient for some time
• Manage being the focus of frustration
from other services
• Manage feeling relatively impotent, and
knowing that they can only contribute a
small ingredient of the young persons
case plan. © Rebecca Sng. 2008.
HOWEVER…
It is a systemically
coherence-aiding and
anxiety-reducing ingredient…
and hence can assist the young person
significantly.
© Rebecca Sng. 2008.
Question 2
• How to promote therapeutic
relationships with multiple carers
– Who have no background in attachment
and trauma frameworks
– Who are presented with extremely
challenging behaviours
– Who have unpredictable changes to their
work settings
– Whose agencies are operating in an
uncertain environment.
© Rebecca Sng. 2008.
Residential Care Worker
Training
Example 2
© Rebecca Sng. 2008.
Building a new house of
Behaviour Management
I trust adults to be
in charge
I can make mistakes
safely.
My feelings are OK I am a “good kid”
I have a good relationship with my carer
© Rebecca Sng. 2008.
RCW Training Programme
• 7 sessions of two hours each
• Made up of modules and concepts from a
wide variety of sources, as well as original
material.
• Based on the model that improvement
in functioning is based on improvement
in emotional/physical/relational safety
and an increased capacity to reflect and
process.
© Rebecca Sng. 2008.
RCW Training Programme
• Presentation of content material is not
enough.
– Training includes a variety of experiential
exercises.
– Most importantly, staff must be given time
to apply the concepts with adequate
support. One off workshops are not
effective in this way.
© Rebecca Sng. 2008.
How is different to training
Foster Carers?
• Often more complicated team dynamics
• Consistency is harder to achieve
• RCW’s often have had their relationship
with the child minimised
• Misunderstanding of professional
boundaries
© Rebecca Sng. 2008.
So why is it important?
• Pivotal to achieving emotional/relational
safety for clients. Without this,
functional improvement is impossible.
• This safety will only be achieved by:
– Attachment-based, sophisticated, well
understood behaviour management
– Complex comprehension of the young
person’s experience
– Emotional capacity to provide the
relationship environment that allows not
just management but also recovery.
© Rebecca Sng. 2008.
References
Bundle, A. (2001). Health of teenagers in residential care:
comparison of data held by care staff with data in community
chid health records. Archives of Diseases of childhood, 84, 1014
Williams, J., Maddocks, A., Cheung, W-Y., Love, A., & Hutchings,
H. (2001). Case-control sudy of the health of those looked after
by local authorities. Archives of Diseases of childhood. 85, 280285
© Rebecca Sng. 2008.