Child mental health: better services and outcomes for traumatised and vulnerable children

Submitting Institution

University of Leicester

Unit of Assessment

Psychology, Psychiatry and Neuroscience

Summary Impact Type


Research Subject Area(s)

Medical and Health Sciences: Public Health and Health Services
Studies In Human Society: Policy and Administration

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Summary of the impact

The Greenwood Institute of Child Health is a unique collaboration between the University and public service providers such as the NHS, which aims to improve psychological outcomes for children in high-risk settings. From 1993 to 2013, Greenwood's research has highlighted the increased risk of mental health, drug dependence and criminal activity among children who suffer trauma — through abuse, living in care, homelessness or war. Greenwood's programme of research has identified the complex and persistent needs of vulnerable children and contributed to changes in policy guidelines and service provision across social care in the UK (foster care / adoption, juvenile detention and homelessness) and abroad (war). Collaboration between researchers at the Greenwood Institute, service providers and practitioners has been instrumental in the establishment of clinically relevant and cost-effective care pathways, while community engagement has led to improved service provision and outcomes for vulnerable children and their families / carers in the UK and further afield.

Underpinning research

Common approach to a wide range of traumas

The Greenwood Institute, led by Professor Panos Vostanis, conducts research across different and increasingly diverse types of trauma: from long-standing studies concerning `looked-after' children, young offenders, homeless families and war-affected children; to more recent research into emerging groups such as young refugees, children with autistic spectrum disorder (ASD) and substance abusers. The Institute shares its experience in policy, practice, training and research with academics and practitioners in low-income countries, which have limited specialist resources, most notably the Occupied Palestinian Territories (OPT) but also Pakistan, Iran, Serbia, Nigeria, India and Turkey. The needs, policy provision, service requirements and possible outcomes of interventions for the above groups all vary greatly, but there is a common approach to all research undertaken by the Institute: to develop an evidence-base of needs; to understand the reasons behind poor service access and engagement, and to develop and evaluate interventions and service models designated to assist these groups.

Research projects in the UK

Looked-after children (in care, fostered and adopted) — The institute undertook two National Child Mental Health Surveys of deprived and non-deprived children living in private households in England, Wales and Scotland, and another for children in the care of local authorities (2005-2008). These were the first randomly sampled and nationally representative studies of looked-after children in the world (in collaboration with Kings College London and Peninsula Medical School). Leicester contributed expertise to the design and analyses of these studies (Professor Howard Meltzer) and the translation of the results for practice and service implications (Vostanis).

The third survey compared 1,453 looked-after children with 10,428 children from the above general population surveys. The finding, that 40% of looked-after children have a psychiatric disorder, compared to 10% of children in private households, highlighted the high level of mental health problems and disorders, the relationship of these to other social and health needs, and their limited access to support services (1).

The Institute has conducted a series of studies (2004-2013) with Leicestershire CAMHS (Child and Adolescent Mental Health Service) on predicting positive outcomes from services for fostered and adopted children, such as specialist input and group intervention for foster carers, and adoptive parents of children with attachment difficulties (2).

Young offenders — A systematic review (2005-2006) in conjunction with Nottingham University, examined the evidence on the prevalence and nature of mental health problems among young people in contact with judicial services (both custodial and in the community). It considered the effectiveness of interventions relevant to young offenders with mood or anxiety disorders, or problems with self-harm. The Institute's expertise and knowledge of best practice were fundamental to the review process, with staff contributing to the design, analyses and interpretation of the review's findings (3).

Homeless families — The inability of homeless families to access health services was established by a study (2005-2006) of Leicester's family shelters, together with collaborators at Warwick University (4). The study found that unless the whole spectrum of a families' needs were addressed, including benefits, housing assistance and child protection, attendance was likely to lapse, trapping families in a vicious cycle. Vostanis is now revisiting the family shelters (2013-2014) and developing a focused intervention for homeless children who have experienced domestic violence.

Research projects in developing countries

Pakistan — A study of school children (2012) reported rates of child psychiatric disorders (17%) which appear higher than in other countries (5). The findings emphasised the need to train teachers to recognise and manage common mental health problems in schools in the absence of specialist services. The Institute contributed research methods expertise to this study. Palestine — Studies in Gaza have established a high prevalence (35%) of post-traumatic stress disorder (PTSD; 6). Risk factors during exposure to trauma, the assessment of which is important for interventions and services, are measured by the Institute's widely used Gaza Traumatic Checklist, and subsequent behavioural and emotional problems by the Behaviour Checklist (BCL) and Strengths and Difficulties Questionnaire (SDQ). Other studies have investigated the prevalence of ADHD and mental health problems among high-risk children living in orphanages and working as labourers.

Integration of training with research and practice

The Institute offers part-time and distance learning degrees for those working in child and adolescent mental health, all over the world (Hassan and Thabet are former PhD students), as well as multiagency training in child and adolescent mental health. The Institute's trainers are experienced and practicing professionals and clinicians who work with children with mental health issues. This strengthens the training by making it clinically relevant, and by relating theory to practice. In 2012 the institute trained 953 people from services across Leicester and surrounding areas. The institute also offers a service to assist CAMHS staff with their research.

Key staff:

Leicester: Panos Vostanis, Professor of Psychology (1998 - present); Howard Meltzer, Professor of Health and Disability (2006 - 2013), Dr Sajida Hassan, Hon Research Fellow (2011 - 2013)

Other institutions: Dr M.Stuttaford and Professor G. Hundt (Warwick University); Dr E.Townsend, (Nottingham University); Professor R. Goodman (Kings College London); Dr T. Ford (Peninsula Medical School). Professor A.Thabet (Al-Quds University)

Clinicians: Dr Pradeep Rao, Dr Alvina Ali and Dr Jeanette Bowlay-Williams (Leicester CAMHS)

References to the research

1 Ford, T., Vostanis, P., Meltzer, H. & Goodman, R. (2007) Psychiatric disorder among British children looked after by local authorities. British Journal of Psychiatry. 190: 319-325.


2 Rao, P., Ali, A. & Vostanis, P (2010) Looked after and adopted children: how should specialist CAMHS be involved? Adoption and Fostering. 34: 58-72.


3 Townsend, E., Walker, D.M., Sargeant, S., Vostanis, P., Hawton, K., Stocker, O. & Sithole, J. (2010) Systematic review and meta-analysis of interventions relevant for young offenders with mood disorders, anxiety disorders, or self-harm. Journal of Adolescence. 33: 9-20.


4 Stuttaford, M., Hundt, G. & Vostanis, P. (2009) Sites for health rights: the experiences of homeless families in England. Journal of Human Rights Practice. 53: 257-278.


5 Hussein, S.A., Bankart, J. and Vostanis, P. (2013) School based survey of psychiatric disorders amongst Pakistani children: A feasibility study. International Psychiatry. 10(1): 15-17.

6 Thabet, A A, Karim K and Vostanis, P. (2006) Trauma exposure in pre-school children in a war zone. British Journal of Psychiatry. 188: 154-158.


Funding: NHS Research Infrastructure: Evaluation of attachment-focused groups for foster carers and adoptive parents (2011-2012) £30,000.

National Forensic Mental Health Research & Development: Systematic review of research relevant to mental health of young offenders (2005-2006) £50,000.

Gatsby Foundation: National evaluation of mental health service provision for young homeless people (2003-2006) £120,000.

Details of the impact


Attitudes to children and their mental health were moving from a biological to a psychosocial interpretation when the Institute was set up in 1993. Long before child-centred care was placed at the core of the NHS, academics at Leicester recognised that closer engagement with service providers and practitioners could lead to better care, resource allocation and psychological outcomes. The aim was to effectively translate academic theory and research into policy practice. Researchers, teachers and clinicians work alongside social workers, nursery nurses, housing officers, educators and youth/community workers. The findings of the studies reported in the case study have informed organisations working with or on behalf of vulnerable children, ranging from central government (e.g. DoH, DSS, DCSF) to local authorities (Leicestershire Partnership NHS Trust, Leicester City Educational Psychology Service) to the voluntary sector (BAAF, ADHD Solutions, Unicef).

Informing policy and practice

The philosophy of the Institute is to apply research and teaching to policy requirements, services and practice. John Simmonds of BAAF says: "The respect that has developed for the quality of this work because it links a valid and reliable description of the issues with a clear pathway for what can be done to improve the situation of those studied, cannot be overestimated." (A).

Miranda Wolpert of the Anna Freud Centre says: "It [the Institute's research] has made practitioners more aware of the evidence-base that applies to marginalised children and more able to evaluate and adapt their work. Every day I hear people talk about more interactive work and closer liaising with schoolchildren with mental health needs." (B).

Outcomes of research projects

Looked-after children — The evidence from the Institute's studies into looked-after and adopted children (around 80,000 at any one time in the UK) has informed the expansion of mental health services through major policy initiatives such as the National Child and Adolescent Mental Health Services (CAMHS) Review in 2008 (C), where Vostanis was an Expert Reviewer, and NICE Guidelines for Looked After Children in 2010 (D).The research provided the impetus to transform a long-held concern about the mental health status of looked-after children into a comprehensive approach, with formal assessment of a child's mental health and subsequent provision of appropriate services. This has resulted in closer working between local authorities and CAMHS, with CAMHS professionals being routinely integrated into looked-after children's teams. Research informed guidelines were embedded in the Adoption and Children Act 2006 and subsequent regulations in relation to adoption support.

Each year Dr Jeanette Bowlay-Williams, a clinical psychologist, uses the Institute's research findings to help around 30 adoptive parents and 60 foster carers to understand their children's behaviour through group training and to build a new level of acceptance. She says: "There has been a marked reduction in placement breakdown in recent years as a result." (E).

Young people in the criminal justice system — The research led to a Cochrane Review in 2003 that has been widely disseminated to Youth Offending Services and the Youth Justice Board (F), informing policy and service development, which is still in place in 2013. Young offenders, who number around 3,500 in the UK at any given time and who often experience mood and anxiety disorders and problems with self-harm, are now seen by mental health teams and receive assessment and intervention within two weeks of offending.

Homeless children and young people — The Institute's research into young homeless peoples' needs and how non-statutory and statutory services should be integrated to meet these, have been presented at national events hosted by the Department for Communities and Local Government. A 2010 report that acknowledges Vostanis' contribution has been disseminated to local housing departments and national organisations for homeless people (G).

A study establishing homeless families' perspectives on their health needs and barriers to accessing services has informed the 2012 consultation of the Leicester Council and helped sustain services (the family hostel at Border House, the Family Support Service and Corner Club) for homeless families in the current economic climate. The findings have informed the Standards of the National Faculty for Homeless and Inclusion Health (2013; H). The institute's Family Support Service, staffed by a dedicated team of five, extends support to families on leaving hostels to be rehoused, and is regarded as a model of excellence and innovation. In ten years to 2013, more than 2,500 children have been helped by this service. Dr Bowlay-Williams says: "The Institute's research into homeless victims of domestic abuse and PTSD helped psychologists working with this vulnerable group to understand and have the confidence to undertake symptom management, which led to a reduction in intrusive images and flashbacks, and better sleep patterns, and therefore increased access to education."

School children in Pakistan — Under the supervision of the Institute, Dr Sajida Hassan has set up the Husseini Foundation in Karachi, Pakistan, which has developed a training programme (handbook for teachers and mothers, trainers' manual and research evaluation tools) for early intervention in the identification and school-based management of less complex emotional and behavioural problems. Between April 2011 and June 2013, 400 teachers, 160 mothers and 3,500 children benefited (I). The programme has now been set up elsewhere in the country, with different levels of courses for teachers, psychologists and parents.

Child victims of war in Gaza — The Institute's studies and measurement tools have been used by local and international NGOs, such as MSF and Save the Children, for recruitment and training of staff and specialists; for fundraising and advocacy in their home countries; and for proposing services and evaluating their work. The Palestinian Ministry of Education established counselling units and trained teachers to recognise the symptoms of PTSD for referral. Al-Quds' School of Public Health's MSc in Community Mental Health has recently added Trauma as a module. Many leaders in the Ministries of Health and Education are graduates of this programme (J).

Sources to corroborate the impact

A. Letter from Director of Policy Research and Development at the British Association for Adoption and Fostering (BAAF)

B. Statement from Director, CAMHS Evidence Based Practice Unit, Anna Freud Centre.

C. Final Report of the National Child and Adolescent Mental Health Services Review: Children and Young People in Mind. Department for Children, Schools and Families, 2008.

D. National Institute for Clinical and Health Excellence (2010) Looked After Children and Young People: NICE /SCIE Guidance

E. Statement from Dr Jeanette Bowlay-Williams, Young Persons Team, CAMHS Leicester.

F. Report: Screening for Mental Disorder in the Youth Justice System. Youth Justice Board (2003)

G. Mental Health Good Practice Guide: Meeting the Psychological and Emotional Needs of Homeless People. Department for Communities and Local Government, May 2010.

H. Faculty for Homeless and Inclusion Health (2013) Standards for Commissioners and Service Providers. London: College of Medicine.

I. Progress report from Dr Sajida Hassan, Husseini Foundation, Pakistan. June 2013.

J. Statement from Associate Professor of Child & Adolescent Psychiatry, School of Public Health, Al-Quds University.