The FDAC assessment process

Summary points

 The FDAC team have developed a four-stage, ‘fair test’ approach to assessment in response to initial concerns about lack of clarity in their method.

 All professionals value the speed of the initial assessment and the majority regard the assessments as thorough, balanced, clear and helpful.

 There are ongoing concerns from some professionals about whether the FDAC assessment, carried out as a team, will be sufficiently strong as evidence if a case reverts to ordinary care proceedings. This would cease to be a problem if cases remained in FDAC.

 In 30% of cases which exited FDAC and reached a conclusion by the end of May 2010, further psychiatric or psychological assessments were ordered.

 There has been ongoing concern and confusion over the role of the FDAC team in relation to parenting assessments and when these should be carried out. In response, the FDAC team have developed a process for doing these.

 There are some continuing concerns that parents are allowed too long to gain control of their substance misuse. This is less of an issue than it was at the start of the FDAC pilot.

From the start of the pilot, the FDAC team’s method and process of assessment is the issue that has generated the most debate and disagreement among professionals. The assessment process has changed and developed during the pilot, in response to concerns raised about the lack of clarity about how the assessment was being

conducted and about its focus. Notwithstanding these changes, there are still differences of opinion about several issues.

The FDAC service specification envisaged that the assessment would be

comprehensive and quick and that it would be combined with supporting parents to access services. There was also an expectation that, having agreed that the case should be heard in FDAC, parties would not seek additional expert assessments.

At the point of referral, a lead member of the team will undertake an assessment, looking at the parents‟ substance misuse, its impact on parenting, the needs and wishes of the child, the family‟s history, environmental issues such as housing and money, past contact with agencies, capacity for change, and services

required. This assessment will be intensive, comprehensive and completed within 5 to10 days.

All parties will be encouraged not to commission separate expert assessments, but to sign up to the programme recommended by the FDAC team … the role of the team is to mobilise services in the two-week period between the second hearing and the first review. [FDAC service specification]

The FDAC team ‘fair test’ approach to assessment

The FDAC team see assessment as part of the process of engaging parents. Assessment is our chance to engage and motivate. We can use it as a relationship building exercise as well … it is the way you do it that matters … engaging is as important as getting the information. [FDAC team] An initial assessment is carried out within two or three weeks of the first hearing in FDAC. It covers the history of the parent’s substance misuse and the impact this has had on their parenting. A detailed family history is taken and local authority documents, including any other earlier records, are obtained and read. Information is collected, too, about any previous substance misuse treatment. The team members with a child and family social work background focus on the family and parenting parts of the

assessment, including the impact of substance misuse on the children. They use interviews and observation in the work with parents and use play, drawing and other approaches with children. The substance misuse workers focus on the history and extent of substance misuse and issues of mental and physical health. One or two team

members take the lead on this initial assessment but all of them, including the child and adolescent psychiatrist, are involved in the process.

Once information has been collected and analysed the team hold a formulation meeting, chaired by the child and adolescent psychiatrist, to agree their proposals for an

intervention plan. This is followed immediately by the Intervention Planning Meeting, chaired by the child and adolescent psychiatrist or the service manager, when the

proposed plan is discussed and agreed with the local authority, parents and the children’s guardian. The assessment and plan are then presented to the court at the next hearing.

The role of the adult psychiatrist in the assessment process changed during the pilot. Initially, he took part in the formulation meeting for each case but in the latter part of the evaluation period he instead met the team once every three weeks to give advice on particular cases where the team felt his expertise was needed. In some cases he also carries out an assessment of the parents.

There has been limited use of standardised measures as part of the assessment process. Substance misuse team members used the Treatment Outcomes Profile70 at the start and later developed their own assessment tool. The team considered using a measure such as the Strengths and Difficulties Questionnaire, used to measure the emotional well-being of looked after children and outcomes for children and young people in contact with CAMHS71 but, as the majority of children in FDAC cases are under four years old, it was not considered an appropriate tool. In the third year of the pilot the team received some training in the use of a recently-validated tool for measuring positive attachment between children and parents (Coding of Attachment Related

Parenting - CARP).72 This training subsequently informed their observations and other work but the tool itself is not being used.

In response to the early concerns about the precise nature of their assessment, the team developed an assessment model, with a four-stage process (see annex 4).

We‟ve developed the idea of an algorithm for every case … a basic algorithm, but with a number of variations on that according to needs. By algorithm we are implying that the decision-making process has identifiable steps and a sequence, with time limits for each. [FDAC team]

The first stage of the model has a focus on supporting parents to control their substance misuse within an appropriate time-frame. The second stage is about whether recovery can be sustained. The third stage looks at parenting and whether the parent has the capacity to meet the child’s needs and achieve satisfactory long-term outcomes for the child. The fourth stage is supported rehabilitation. The team are clear that the child’s needs, strengths and difficulties must be kept in mind throughout this four-stage process. There are no rigid timescales73 for each part of the assessment process as this depends on the age of the child and the particular factors of the case.

If the parent cannot achieve control of their substance misuse during the first phase (usually two or three months), the team recommends that the case exits FDAC.

70

This is the standardised measure developed by the National Treatment Agency for substance misuse services.

71

See www.sdqinfo.org/

72

The CARP is an observational measure of parent-child interaction based on attachment theory (Matias C,

Scott, S & O’Connor TG (2006) Coding of Attachment-Related Parenting (CARP). Unpublished manuscript,

Institute of Psychiatry, King’s College London, UK). The good reliability and validity of the measure are shown in studies evaluating the effectiveness of parenting programmes (see Scott et al, 2006, at http://www.adsscymru.org.uk/media/doc/3/i/What_makes_parenting_progs_effective.pdf). 73

The issue of timescales is considered in more detail below, in section C2.7 (about keeping the child in mind).

Controlling substance misuse will usually involve abstinence, though it is recognised that some parents will need to be stabilised on methadone before they can achieve this. If parents are able to control their substance misuse, the second stage takes a further three months (sustaining recovery), followed by another three months (on parenting). If it appears at any of these later stages that recovery cannot be sustained, or that the parent does not have the capacity to meet the child’s needs, the team will recommend that the case exits FDAC.

The team describe this as a ‘fair test’ approach, where parents are not only assessed but also given support to make a success of overcoming their drug and alcohol problems in order to parent their children safely. The support comes through the FDAC team working directly with parents and co-ordinating and monitoring the implementation of the

intervention plan which has been agreed by all the parties. Reports on progress are provided at the regular court reviews. Where changes to the intervention plan are

needed a review intervention planning meeting is held, involving all the parties as before, and an amended plan is agreed.

Views from others about FDAC assessments – the positives

Respondents were unanimous that the team’s substance misuse assessments are quick and very helpful, providing full information on the history of the substance misuse and any treatment and on the impact of the misuse on the parent and family. All used words such as „thorough‟, „balanced‟ and „clear‟. Many made specific comments about the team being knowledgeable about the type of drug and alcohol tests needed, when they should be carried out, and how results should be interpreted.

Their initial reports and analysis are outstandingly good and usually turn out to be spot on. [lawyer]

In those cases where things go wrong then the outcome is much clearer, the issues have been resolved more than in ordinary cases. [lawyer]

The assessments by the team were thorough and specific and allowed for a balanced judgement to be made about the progress and likely outcome of FDAC‟s involvement. [social worker]

The judges said the team assessments were of good quality and they considered that the independence of the FDAC team was a particular strength in helping to ensure an impartial assessment.

In just over two-thirds of the end-of-case forms completed by guardians the clarity and speed of assessment was noted as a benefit of the case being in FDAC. For over half of these cases the particular benefit was the early indication that parents would not be able to control their substance misuse within the child’s timescale. For the remainder, the quality of the assessment was deemed crucial in enabling parents to retain or regain care of their child. Linked to the assessment, what was also valued was the ability to set clear objectives for parents to work to, clear plans for a child’s permanent placement, and clear ideas about the extra help needed for children and adults if plans were to have the best chance of succeeding.

FDAC provided a structured and supportive framework with regular reviews and clear goals. This prevented the fragmentation of services and provided a positive co-ordinating role that allowed for a clear assessment of the parents‟ drug misuse and the impact on their care of the child. [guardian]

Views about assessments – the concerns

The particular issues or queries that have arisen include the following:

 the possible need for additional expert assessments because a particular discipline is not available within the FDAC team

 the ability of parties to seek additional expert evidence if they wish to do so

 whether the FDAC assessment will be sufficiently strong evidentially if the case exits FDAC and reverts to ordinary care proceedings

 whether individual team members can be called to give evidence if that becomes necessary, even though the assessment has been carried out by the team as a whole, and

 whether the team should be engaging in more detailed assessments of parenting and of children, including making recommendations about contact and children’s placements.

Experts additional to FDAC

In the first year of the pilot some guardians and lawyers felt it was unclear whether expert evidence, additional to the FDAC assessment, could be ordered by the court if it was felt by one or more party that the particular expertise needed was not held by the FDAC team.

The team say they would support this approach if the skills needed are not available in the team. The forms completed by guardians indicate that a clinical psychology

assessment was carried out in five cases while they were still in FDAC (see services section, B2). It seems that the issue of additional experts may have become less of a concern over time as it was not raised in the later interviews and focus groups, including those with solicitors acting for parents. The one exception was criticism from a social worker and her manager who had sought additional expert evidence (from a clinical psychologist, an adult psychiatrist, and a child psychiatrist) in the two cases they had been involved in as they felt that the FDAC team were biased in favour of parents.

Concerns about expert evidence Strength of the evidence

The main concern about the assessment process is whether it provides sufficiently strong evidence for cases exiting FDAC. This concern was expressed by the local authority lawyers, a small number of social workers and managers, a small number of guardians, and some solicitors acting on behalf of children. The majority of those raising this concern acknowledged that the initial assessment and report from the team was good and helpful but that problems arose if the case began to go wrong several months later.

The worry is that the absence of the kind of expert evidence normally presented in care proceedings might have a negative impact on the ability of the local authority to prove (once the case has transferred to ordinary care proceedings) that the parent would not be able to parent their child. In particular, an assessment by an adult psychiatrist would be deemed important, to give a prognosis of the parent’s capacity to change within the child’s timescales. For this reason, they felt that the adult psychiatrist should assess all FDAC parents and should also be asked to give a prognosis whenever a parent

lapses.74

Sometimes there are conflicts with the FDAC team because they can be quite reluctant to do psychological or psychiatric assessments. Especially for cases where you are doing parallel planning for a permanent placement outside the family, then you need all these assessments ... when we are clear it is a case for permanency outside the family then we have to demonstrate in whatever way we can that the parent is not an option. [social worker]

I was very disappointed when FDAC was first set up that there wasn‟t going to be an adult psychiatrist for FDAC. Although I don‟t question the abilities of drug- trained social workers, the reality is the courts are used to having psychiatrists give a diagnosis of what is a psychiatric condition [parental substance misuse] and give a prognosis, and the fact is that any parent who disagrees with FDAC will want an expert of their own challenging what could be seen as an opinion from a lower-level or a differently-qualified expert. Whereas, if the parent has agreed to an adult psychiatrist in the FDAC team making an assessment, they then don‟t have room to argue for another expert assessment. We are in forensic proceedings which are making serious decisions and the court will be reluctant to decide that a child should be removed from their parent if the evidence it gets is insufficient. [local authority lawyer]

The team, including both the adult and child psychiatrists, disagree that an assessment by an adult psychiatrist is needed in every case. They consider that the ‘fair test’

approach provides sufficient evidence in the majority of cases: if parents are not able to control their substance misuse over three months, despite considerable support to do so, they will not be able to show they can parent safely within the child’s timescales. They also point out that the team consult the adult psychiatrist when necessary. The findings on assessments (see services section, B2) show that the adult psychiatrist or clinical nurse specialist carried out an assessment of a parent in 14 out of 30 FDAC cases. The team acknowledge that a prognosis is important in those cases where parents control their substance misuse, move to the second stage of the assessment with its focus on parenting but then experience one or more lapses from abstinence. They say they do provide a prognosis in such cases, usually after discussion with the adult psychiatrist, but that they do not necessarily ask him to see the parent. There seem to have been a number of disagreements between members of the team and social

workers and local authority lawyers in relation to the appropriate response to a lapse and whether behavior constitutes a lapse or a relapse.

Lapse is used by the FDAC team to refer to a temporary lapse from control over substance misuse, as opposed to a relapse, which is used to mean a complete return to misuse.

A small number of guardians and lawyers took a similar view about the role of the child and adolescent psychiatrist. Whilst acknowledging that he was always involved in the assessment process, they would have preferred his involvement to be more direct. The view of the judges and the team is that the concerns about the evidential strength of the FDAC assessment stem largely from legal and social work practitioners being used to a particular approach towards expert evidence in care proceedings. The team are of the view that a multi-disciplinary approach to assessment is preferable to an assessment by a single expert.

The worry, I think, for lawyers is that the FDAC process doesn‟t cross every T and dot every I. It is more enabling. It focuses on the real issues, those which are relevant to this particular case – rather than looking at every possibility. The approach to expert evidence in normal proceedings may be the safest from the legal point of view but it is cumbersome, expensive, time-consuming and unsatisfactory. [FDAC team]

The judges consider that the evidence in FDAC cases was as strong as in ordinary care proceedings.

Are we falling short on evidence in FDAC? I don‟t think so. We have social workers, substance misuse workers, adult and child psychiatrists who have all had input into the process … We‟ve got to satisfy ourselves that the evidence for excluding a case is good, and if necessary deal with what is lacking ... I think that