© rebecca sng. 2008. yes, but what works with kids with high needs? the alternate care clinic...
TRANSCRIPT
© Rebecca Sng. 2008.
Yes, But What Works with kids with high needs?
The Alternate Care ClinicTherapeutic 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/ decrease misunderstanding
Putting things in developmental/ historical context
Training the carers to teach the skills.Inc skills of carers
Wider System
Decrease anxiety in the system
Long-term planning (not crisis driven)
More coherent system, clearer communication etc
© 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 AttenderProblem: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 AttenderIn 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 have a good relationship with my carer
My feelings are OK I am a “good kid”
I trust adults to be in charge
I can make mistakes safely.
© 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, 10-14
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, 280-285