Summary of the impact

Prior to King's College London (KCL) research, social workers did not regularly assess mental health needs of Looked After Children (i.e. those in the care of their Local Authority). KCL investigations showed that 45% of British Looked After Children have mental health disorders, considerably pushing this issue up the policy agenda. KCL developed assessments that are now the statutory annual measures used by all Local Authority children's services in England. The assessments enable Local Authorities to identify the treatment needs of Looked After Children and plan accordingly. The Department for Education requires Local Authorities to complete the measures. The measures are used worldwide and are now key elements of treatment trials of social and psychological interventions to reduce the level of difficulties in Looked After Children.

Underpinning research

Children in the care of their Local Authority, known as Looked After Children, account for around 1% of the population but make up about 25% of prisoners and are also at high risk of school drop-out, substance abuse and teenage pregnancy. Research on this vulnerable population at the Institute of Psychiatry, King's College London (KCL) has been led by Prof Robert Goodman (1990-present, Professor of Brain and Behavioural Medicine) and Dr Tamsin Ford (2000-2008, Research Fellow). These researchers developed two measures of psychopathology — the Strengths and Difficulties Questionnaire (SDQ) and the Development and Well-Being Assessments (DAWBA) — that make it easier to assess children's psychological well-being and identify treatable mental health difficulties.

KCL researchers develop and trial novel questionnaires for Looked After Children
The SDQ is a brief behavioural screening questionnaire for 3-16 year olds with 25 items on psychological attributes including emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems and prosocial behaviour. Led by KCL researchers in 1997, the questionnaire development involved parents and teachers of 403 children drawn from dental and psychiatric clinics and validity was confirmed by comparison with a similar, but longer, questionnaire (1). KCL work also led to the DAWBA, a novel package of questionnaires, interviews and rating techniques designed to generate ICD-10 and DSM-IV psychiatric diagnoses on 5-16 year olds. The assessment collects rich, open-ended accounts from multiple informants (parents, youths, teachers). In the development study of the DAWBA, involving community (n = 491) and clinic (n = 39) samples, clinicians reviewed the information before making computer-aided diagnostic ratings. Excellent discrimination was found between the samples in rates of diagnosed disorder (2).

Further KCL analyses demonstrated that the SDQ was a useful predictor to determine which Looked After Children had mental health disorders. In a community sample of 1,028 looked after 5-17 year olds, the proportion with SDQ predictions of `unlikely', `possible' and `probable' psychiatric disorder were roughly a quarter, a quarter and a half respectively. The accuracy of the SDQ was compared with DAWBA-based diagnostic ratings and overall the multi-informant SDQs identified individuals with a psychiatric diagnosis with 80% specificity and 85% sensitivity (3). This accuracy is high enough to serve as a practical guide as to which children warrant more detailed assessment.

KCL-developed questionnaires identify unmet need
In 2002-3, three nationwide surveys of the mental health of British children and adolescents were commissioned by the Department of Health, Scottish Executive and Welsh Assembly. The fieldwork was carried out by the Office for National Statistics with academic leadership from KCL. To ascertain the prevalence of mental health disorders in this age group, the SDQ and DAWBA were used to investigate representative groups of Looked After Children from these surveys (n=1,453) alongside a representative group of 10,428 children living in private households to confirm validity. This established a prevalence of mental health disorders of 45% in Looked After Children, as compared with 10% in the household survey. Worryingly, 'Looked After' status was independently associated with nearly all types of psychiatric disorder even after adjusting for their high rate of educational difficulties and neurodevelopmental disorders (4).

A subsequent analysis in 2012 (with colleagues at the London School of Hygiene and Tropical Medicine) involving 1,391 children aged 5-16 demonstrated that the mean SDQ difficulties score in a group of Looked After Children is an excellent predictor of the prevalence of mental health disorders in that group. This finding underpins the use of the mean SDQ score as the statutory measure of the emotional and behavioural health of Looked After Children in Local Authorities in England (5).

References to the research

Details of the impact

Practitioners have probably always suspected that Looked After Children have high rates of emotional and behavioural disorders, but until recently the research evidence was weak and the mental health of Looked After Children was a low priority on the policy agenda. The development, use and dissemination of mental health assessments by King's College London (KCL) researchers changed that, with a positive impact at several levels.

KCL measures are disseminated to professionals, young people and families across the world
From the outset, the Strength and Difficulties Questionnaire (SDQ) was designed to meet the needs of researchers, clinicians and educationalists. Studies across the world have provided normative data so that the SDQ can be used within specific populations, with recent studies taking place in Italy (involving 3,302 children and young people aged 3-17) (1a) and in Spain (with a sample of 1,341 children from 54 schools) (1b). The SDQ has been translated into over 70 languages, with all versions being downloadable without charge for non-commercial use. The dedicated website provides free scoring and analysis of the SDQ (used for half a million children per year) as well as a downloadable computerised scoring and report-writing program (1c). The Development and Well-Being Assessment (DAWBA) is also available for researchers and clinicians. This has been translated into 28 languages as a paper version and 17 as an online version, with a full data recording and assessment service offered for a small fee (1d). These are all provided by YouthInMind Ltd, a private, family-run company website edited by Prof Goodman of KCL and aimed at professionals as well as young people and families who want psychological advice (1e).

KCL research influences UK policy
The findings of the 2002 and 2003 British surveys of the mental health of Looked After Children (Ford et al. 2007) have had an enduring influence on policy makers because valid measures were applied to large and nationally representative samples. In 2007, the Department for Education (DfE) produced the white paper `Care Matters: Time for Change,' which highlighted the need to improve the mental health of children and young people in care and provided the policy foundation for the current approach to looked after children. This report discussed the work KCL had carried out with the Office for National Statistics, published as Ford et al. 2007 (2). Following this, in 2009 the DfE and Department of Health (DH) published `Statutory Guidance on Promoting the Health and Well-being of Looked After Children,' referring to Ford et al. 2007 when discussing the evidence for the "prevalence of emotional and behavioural difficulties among Looked After Children" (3). KCL work has also been used at local level with regard to policy, for instance, the `Lewisham's Children and Young People's Plan for 2012-2015' uses figures from Ford et al. 2007 when discussing the high rate of mental health problems in looked after children (4).

KCL research impacts on monitoring the quality of services at Local Authority level
As Local Authorities' services to the children in their care can be variable it is important to monitor the mental health of Looked After Children at this level. From April 2008, all Local Authorities in England were required to provide information on the emotional and behavioural health of children and young people in their care. The Government's `Statutory Guidance' states that "the SDQ is a reliable and valuable screening tool for mental health problems" and discusses how Local Authorities "are responsible for making sure that an SDQ is completed for every child they look after aged between 4 and 16 inclusive" (3). The collection of data by Local Authorities through use of the SDQ was set out in a 2008 DfE guidance document that also provides the rationale and method of routine SDQ monitoring of Looked After Children (including links to the SDQ website) and advice on the use of the SDQ to guide referral for specialist treatment. Local Authorities have to report the mean SDQ score to the DfE (the SSDA903 return), with the intention that trends can be monitored over time and comparisons made between demographically matched Local Authorities (5).

National SDQ data on Looked After Children were first published in 2012 when SDQs were collected on 24,270 participants. This found overall a higher proportion of boys who scored 17 or above (39.6% compared to 31.6% of girls), which indicates a cause for concern with regard to emotional health. The fact that more than a third of Looked After Children were in the "cause for concern" range is a powerful antidote to complacency (6). Local Authorities can now set themselves targets in terms of an intended year-on-year change in the mean SDQ scores of their Looked After Children and obtain feedback on whether they meet this goal, as exemplified by Lewisham's 2012-15 plan (4).

KCL research impacts on assessing individual needs of Looked After Children
SDQ data also provides social workers with access to annual SDQs on children in their care which facilitates the recognition and referral of high-risk individuals for assessment and treatment (3). Independent evidence, for instance as detailed in a report from the Development Centre of the South West Region of England, has shown that "the development of an SDQ care pathway for Looked After Children can provide a framework for a more coordinated and thus effective approach to identifying and improving emotional health and wellbeing of children in care" (7).

The SDQ, along with the DAWBA, are used by the Centre for Excellence and Outcomes in Children and Young People's Services (C4EO), a best practice hub for 'what works' in children's services used by all Local Authorities across England (8a). C4EO present several examples of Local Authorities using these measures in practice. For instance, in Islington, the Adolescent Multi-Agency Support Service team used the SDQ to see how their interventions improved emotional well-being (8b). In Kent, the Multi-dimensional Treatment Foster Care team discusses how it uses DAWBA and SDQ "for every child prior to joining the programme" to give "a clear understanding of mental health difficulties" (8c). In Birmingham, Foster Care Associates & Core Children's Services used the SDQ to measure changes in the young people's functioning following training of foster carers in understanding the psychological reasons for children and young people behaving in the way that they do in foster care (8d).

KCL research impacts on the development of effective interventions
Objective research by KCL demonstrating high levels of mental health problems in Looked After Children led the DfE to launch an ongoing initiative to introduce therapies that reduce the level of difficulties in Looked After Children. SDQs played a key role in the evaluation of a new intervention called "fostering changes" for Looked After Children with significant problems; the randomised controlled trial of this intervention — which was carried out by KCL researchers and cites Goodman et al. 2000 and Ford et al. 2007 — showed that the SDQ problem score decreased more in the intervention than in the comparison group of this trial (9).

Sources to corroborate the impact

1) Measures

a. SDQ: Normative SDQ Data from Italy: http://www.sdqinfo.com/ItaliaNorm.html

b. Spanish norms for the Strengths & Difficulties Questionnaire (SDQ3-4) for 3 and 4-year-old schoolchildren http://www.sdqinfo.com/Spanish_norms_for_3-4_year-old.pdf

c. The Strengths and Difficulties Questionnaire: http://www.sdqinfo.com/

d. Development and Well-Being Assessment: http://www.dawba.info/

e. Youth in Mind website: http://www.youthinmind.com/

2) Department for Education — Care Matters: Time for Change (June 2007): http://www.official-documents.gov.uk/document/cm71/7137/7137.pdf

3) Statutory Guidance on Promoting the Health and Well-being of Looked After Children, 2009. Departments for Education and Health (Ford et al: pgs 12, 70) (SDQ: pgs 2, 27, 28, 37, 72): https://www.education.gov.uk/publications/eOrderingDownload/Promoting_Health.pdf

4) Lewisham's Children and Young People's Plan for 2012-2015 (Ford: pg 28) (SDQ: pg 29) http://www.lewisham.gov.uk/myservices/socialcare/children/Documents/CYPP2012-15.pdf

5) Department for Education guidance document, 2008:
http://media.education.gov.uk/assets/files/pdf/g/sdq%20guidance%20update.pdf

6) Department for Education statistical release — Outcomes for Children Looked After by Local Authorities in England, Dec 2012 (pgs 10, 11. Table 9):
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/191969/SFR32_2012Text.pdf

7) Development Centre of the South West Region of England SDQ project report (Jan 2011):
www.swpho.nhs.uk/resource/view.aspx?RID=90069

8) The Centre for Excellence and Outcomes in Children and Young People's Services (C4EO)

a. Website: http://www.c4eo.org.uk/about/default.aspx

b. The Adolescent Multi-Agency Support Service using an Intensive Community Outreach model with complex need adolescents and their families, Islington:
http://www.c4eo.org.uk/themes/general/vlpdetails.aspx?lpeid=249

c. Multi-dimensional Treatment Foster Care, Kent:
http://www.c4eo.org.uk/themes/general/vlpdetails.aspx?lpeid=291

d. `Adapt' (Attachment Difficulties and Parenting Therapeutically) — carer groups:
http://www.c4eo.org.uk/themes/general/vlpdetails.aspx?lpeid=426

9) Briskman J and Scott S (2012) Enhancing attachment security and reducing behavioural problems in fostered children: an RCT of the Fostering Changes programme. London: Department for Education Research Report DFE-RR237:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/183398/DFE-RR237.pdf