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For Scotland's children report

chapter 3 issues in current services - the experience of service users

The case studies and comments that follow demonstrate some of the recurring themes frequently raised by service users. (N.B. Some details have been altered to protect confidentiality.)

Some of these reflect an absence among staff of the most basic human courtesies - missed appointments, non-punctuality, poor communication. Some suggest disdain for the service user - perceptions of arrogance, aloofness, hostility. Others encompass more structural circumstances - the exclusion of so many, through
de-registration, school exclusion and eviction, at a time when social inclusion is so prominent a feature in the social policy agenda, and service thresholds set so high that the most needy are not receiving specialist services, including child protection.

Service users have themselves highlighted some of the major problems in the current service network:

• The need to repeat the same information to each agency.
• The absence of mutual awareness among service providers.
• Services pulling in different directions.

Service users themselves often suggest that it would be helpful to have one point of entry to services. Their main wishes, though, were for services to be responsive to their needs, for service users themselves to be fully involved in discussions, and for responses to be made quickly.

Early Information Sharing and Communication

"They need to make sure that everyone that needs to be is informed about cases, so you don't repeat yourself."

• The five-year-old child of drug-using parents did not attend school for almost one year. The education department knew nothing of the child's existence since child health surveillance records and other information from the NHS were not passed to education.

The child's existence was picked up by education services by accident, by which stage this five-year-old child had lost out on one full year of education at a critical developmental stage. During that time she had been living in extremely difficult circumstances and the negative emotional and physical situation of the child was probably exacerbated by her "invisibility" to services.

• A young mother seeking asylum from an African country accessed a voluntary service in her local community by self referral.

She had received a series of letters from various agencies, spelling her name in different ways, to which she had not responded.

The voluntary worker asked her name and she said "we have 2 names in my country and this is very important to us. No-one has ever asked me what name to use or how to spell it before. My name is the only thing I have left".

The young woman went on to say that she had lost everything and that in her culture the 2 names were a signal of her individual identity and existence. To dismiss them was to dismiss her and everything she was. She found it was difficult to access services when she felt treated as a non-person and where nobody cared enough to ask to find out the relevant information which was so important to her.

Access

"We were told by practice staff that, 'no explanation requires to be given prior to de-registration'"

• A young family had recently been permanently housed from temporary accommodation. Both parents were on a methadone programme and had been drug-users for many years. There had been a history of violence and several family break-ups. Their children were aged 1, 4, 7, 11, and 12 years.

The four-year-old had speech problems and was not attending nursery. No speech and language therapy was being provided. The seven-year-old was rarely attending school. The 11 year-old was occasionally attending school but was being bullied when there because of her hair and dirty clothes. The 12 year-old had presented serious behavioural problems from an early age but had no contact with specialist services. He had recently witnessed the death of his best friend when the pair were setting fires on derelict land. The friend was burned to death. Since that time he had no access to any help other than from within the family.

The parents originally had separate GPs. The father eventually managed to register with the local GP but the mother wished to remain with her previous GP as she felt that he was understanding and non-judgmental regarding her difficulties.

The local practice in the new area refused to register the children unless the mother chose to register with them. She was eventually persuaded to register with the local practice but when she attended to do so she was told that the methadone patient list was now closed. As she was then unable to register, that practice still refused to register their children.

Because local health visitors were practice attached, the children had no health visitor support. The children received no immunisation, no child health surveillance, and no access to universal service provision or specialist assistance.

• "The child's not injured yet."
• "It's not bad enough yet."
• A child of 5 attending a Special Needs School had attended over recent months with multiple unexplained injuries including burns. On one occasion the father was found drunk in charge of the child. On another, a taxi driver delivered the young boy home from school but no-one was there. Case Discussions took place. Despite cumulative concern that the family were vulnerable it was felt that Child Protection procedures should not be embarked upon.

Then a more serious injury occurred, a life threatening one.

A further Case Discussion and yet again no Child Protection procedures were instigated. A report was made to the Reporter to the Children's Panel by the GP urging immediate action as the child was at extreme risk. No further action was taken apart from a minor level of family support.

Some months later, after a referral was made to the police, the child made an allegation of severe sexual abuse over many years, associated with extreme physical abuse and chronic emotional abuse. The child has now been referred for counselling but the considered views of the professionals involved is that he is so emotionally disturbed it is unlikely he will make a full recovery. The threshold for being considered 'at risk' and having services provided seems to have been set too high to meet the needs of this child.

"A Child Psychiatrist only visits here every 6 months."

"The waiting time for a child and family psychiatry appointment is up to 16 months."

• A 6-year-old girl made allegations of child sexual abuse. No further action was taken as the allegations could not be substantiated. The suspect was no longer in the family and no assessment was made of the total family circumstances. A few years later, further allegations were made, this time including sexual penetration. At this time it came to light that mother has stayed with a series of high-risk perpetrators. One sibling lived with a grandmother and another 4 siblings shared the home with the child and mother. A full medical examination identified eating problems, weight loss, body image problems and deep emotional issues. The child was already embarking on drinking binges and becoming more aggressive with people. She was also sitting up all night watching videos unable to sleep. At the medical it was also identified that a few months prior, this child had discovered her younger brother hanging, having attempted suicide.

A psychiatric assessment was made of the brother but again no assessment was made of the family needs. A review appointment was given which was not attended. A letter was written to say it was assumed the problems had been resolved as they had not attended and if they didn't hear from the family in due course they would "close the case". On reviewing the records, the boy at the time of contact was difficult to interview, had stated he "didn't want to live," was hyperactive and disorganised and being bullied at school.

On further analysis of records the mother had previously been in care herself. Father had threatened to commit suicide and "to take the children with him" approximately 5 years earlier. There was bruising on another child 5 years earlier. The family had constantly moved addresses due to harassment from the natural father who had left the home. The family lived in an area of extreme poverty and social deprivation.

Social work notes revealed 8 years of known previous violent relationship and one child scapegoated in particular. The mother had terrible memories of violence against herself as a child. The oldest boy at times "hides his face and does not want to talk." "The younger boy has not been able to talk to anyone about what he is feeling."

Despite the history of problems and obvious risk, the family was receiving no specialist help.

Reliability/Continuity

"They failed to deliver on promises."

• A teenager described waiting 18 months for a wheelchair on which he was totally dependent. He criticised the inaccuracy of the information he received and the failure to "deliver on promises." When the wheelchair did arrive, one part was faulty and required replacement. He described his frustration that it took a further several months for the small part to be delivered.

"He had 22 social workers within a three-year period."

• A mother from an ethnic minority family told of services being discontinued after the death of one of her twins, both of whom had severe disability. She had already fought for services for a long time for both children, but on the death of one all services were withdrawn.

Inter-Agency/Professional Rivalries and Disagreements

By the age of 13 this child had been given 4 labels regarding behaviour problems which had existed for some years. These were:

• Attention deficit hyperactivity disorder (ADHD)
• Conduct disorder
• Clinical depression
• "Problems with parenting"

Despite these diagnostic labels there had never been a multi-disciplinary assessment of needs. The expertise of the professionals with whom the child had been in contact appeared directed towards diagnosis rather than intervention and there had been little or no direct work with the child or family over the years.

The girl's father approached the local social work department for assistance and they agreed to call an inter-agency meeting to review what services might be provided. This was scheduled for some weeks in advance. In the intervening time the child attempted suicide and was transferred for specialist opinion from a psychiatrist. During this journey a further crisis arose and the child was made subject to an order for compulsory detention within the terms of the Mental Health Act.

She was admitted to a psychiatric unit. There were no adolescent psychiatric in-patient beds available and so she was admitted to an adult psychiatric ward. Further evaluations were made by two different psychiatrists over the next few weeks. The first diagnosed an acute psychiatric problem while the second considered that there was no mental illness but extreme behaviour which required secure accommodation. This was sought but no secure places were available in Scotland.

At this stage of contact with services there had still been no multi-disciplinary consideration of the child's needs.

Poverty/Deprivation

"They have a limited menu for life."

• A teenager from a large urban population visited a counsellor for help with drugs. Despite living in the city all of her life she said that she had never had the opportunity to visit the city centre.

"I came from Possil, what hope did I have?"

• At age 18 months a child displays extreme sexualised behaviour in nursery. There is already known marked violence at home and the father has now left the home and the mother has a new partner. Mother has her own history of considerable abuse in her childhood. A paediatric assessment of the child after concerns raised by the nursery reveals developmental delay. The child subsequently alleges abuse by the new partner. The mother at that time confides to services about being depressed and having a drug problem and also reports mental health problems including flashbacks relating back to her own childhood experiences. There is a Case Discussion, some recommendations made but little intervention. Two years later mother presents as homeless. Her mental health problems have worsened. The child has marked emotional consequences believed to be due to the circumstances throughout the intervening period. The partner has had continued access and sexualised behaviour continues. Due to homelessness GP registration is difficult at a time when mother is in crisis with major mental health difficulties.
• A teenage mother goes to social work department for financial assistance. A small amount of money is given. No assessment is made of her circumstances. She later is picked up by a voluntary organisation working in a local community rather than by statutory agencies. There have been no health visitor visits for sometime due to non-allocation of a worker. The mother is found living alone in a furnished flat. There is absolutely no family support. Mother has learning difficulties. There are 3 children at home. The children are attending school intermittently. The head teacher and class teacher have concerns that children are attending school, lice infested, hungry and poorly clad. Professionals in the school were never confident about confronting mother as she was quite antagonistic to any conversation and the threshold for instigating Child Protection procedures was never reached. When visited by local community voluntary agency staff there was no gas in the house, no cooker, no fridge and smashed windows.

"The professionals who spoke to me made me feel ashamed."

"They didn't listen to me or ever let me finish my sentences."

• A young woman who had engaged with a local community voluntary organisation told of how she felt judged and therefore could not engage and share her problems with professionals who were charged with responsibility to identify need and deliver services. She therefore remained isolated, as did her children. Every day she worried about losing her children.

Drug Related Issues

"Drug services are reluctant to lift the stone on the circumstances of children in addict households...because what would be done if they explored the experience of these children?"

• An infant death occurs due to overlaying on the sofa. It transpires both parents were under the influence of drugs and were therefore unable to care for the infant.
• An infant is admitted to intensive care with an overdose of Methadone due to the chaotic nature of the household and the lack of supervision. The young child remained in a life-threatening situation for many days in hospital.
• A 3-year-old child presents with a needle stick injury and requires to be tested for HIV infection, Hepatitis B and Hepatitis C. The child had been left with unknown visitors to the home, all of whom were drug addicts. It appears the child was stabbed with a needle during the course of a party and it was uncertain whose needle this was and whether they were infected with HIV or hepatitis.
• A young child of 4 living at home with her single parent mother who is a heroin user finds her mother on the floor collapsed. The young 4 year old manages to reach a telephone and somehow gain help. The child lives with the consequences of the fear of losing her mother and the fear of doing something wrong at aged 4. Her mother goes into rehabilitation but comes home for only a short period and again starts heroin usage. The child is not presented for her necessary outpatient appointments.

The child again has no stability.

"Reaching the children is very difficult. The children who say least are of most concern."

Being Young in Scotland Today - Young People's Perceptions

The Action Team sought to meet with children and young people on all field visits conducted and also facilitated three sessions with young people which focused on gathering views on services and perceptions of how adults and service providers viewed children and young people today.

At the meetings young people discussed:

• How adults view children and young people in Scotland today
• What young people need from adults
• What services young people use or come into contact with
• Which services young people would recommend and why
• Things young people would change about current services
• The characteristics of an adult who young people might call their 'champion' or someone they felt was 'on their side'.

The meetings were designed to be both participative and safe for young people, many of whom were currently engaged with a range of services and in relation to a number of issues. The young people were aged between 11 and 17 years old.

A full report of the meetings is presented in Appendix 5 but to summarise:

• Young people were of the view that adults' perceptions of young people were predominantly negative. They felt that adults often "can't be bothered with young people" and that adult fears over the public presence of young people meant that "they always think that you're going to beat them up, adults will cross the road if they see a group of young people hanging about or coming toward them". Those who had used mental health services felt stigmatised by their involvement in these services and felt that adults saw them negatively, as one young woman said "other people's parents think you're trouble."
• Young people said what they needed from adults was increased service provision in terms of social activities, leisure and recreation. They also wanted adults "to change things" and "to give us a reaction, to listen to us."
• The participating young people were able to identify a broad range of services with whom they were or had been in contact. Those services which they identified they would recommend to other young people were predominantly those provided by the voluntary sector and in particular those which provided good advice and support services for young people, those which helped sort out problems with statutory sector agencies around issues such as benefits and those which, as one young person said, "gets you motivated and builds your confidence."
• Young people used the sessions to identify many things they would like to change about social work services, health services, schools, leisure and recreation, the police, housing agencies and the DSS/benefits agency. The predominant themes were about being treated with more respect, about agencies being better at communicating with young people and with each other, about agencies being less judgemental and more understanding, about trust and honesty, about getting services when needed and not after long waiting times, about the negative views of children who are looked after, about the need for agencies to see the whole child and to try to understand what might be going on in their lives.
• When asked for the characteristics of the kind of adult young people might perceive to be understanding, to be on their side, young people identified many aspects. The predominant theme was about the need for adults who listened and did not judge, who cared, who provided protection from harm, who could be funny, who provided safeguards and boundaries, who were never angry and who loved them.

See Appendix 5: Issues in Current Services - The Experience of Young People.

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