This chapter should be read in conjunction with the following chapters: Children and Young People with Complex Needs; Children Looked After; Healthy Lifestyles and Long Term Conditions; Physical Disability; Learning Disability; Autism; Adult Unpaid Carers; Sensory Loss and Impairment; VAWDASV; Asylum Seekers and Refugees; Secure Estate

Recommendations

Cardiff and Vale University Health Board and Cardiff and the Vale of Glamorgan Local Authorities to:

• Adopt the NEST Framework and No Wrong Door approach
• Strengthen actions to ensure information is accessible to children and young people;
  and they are invited to co-produce services so they are person-centred, and help
  children and young people feel valued
• Monitor emerging literature on long COVID in children and young people
  Cardiff and Vale University Health Board to:
• Continue to promote preventative strategies including routine immunisations
• Continue to develop partnerships with Education services and embed the whole
  school approach to emotional health and wellbeing
• Increase funding available to mental health services for children and young people
  (25)
• Target waiting list times, especially for children and young people’s mental health
  services
• Develop Integrated Model for Emotional Health and Well-being for Cardiff and Vale

Overview

Children and young people will be considered in this PNA as those aged up to 18 years of age, although age cut offs and ranges vary between services and policies. Children and young people may be included within many of the other population groups within this report. Children and young people with complex needs are discussed in chapter 6, and children looked after in chapter 7.

Table 5.1 demonstrates the number of children and young people in Cardiff and the Vale of Glamorgan, by age group, and as a percentage of the total population of the local authority. Cardiff has higher numbers of children and young people, but for those aged 0-4 and 5-15, the proportion of the population is similar to the Vale of Glamorgan. Cardiff has a higher proportion of young people aged 16-24 years (see also Chapter 4: Demography).

The Pupil Level Annual School Census (for children aged 5 – 15 years) from 2020/21 identifies 51% pupils as male, 49% female in both Cardiff and the Vale of Glamorgan, as per the Wales average (26). In Wales, 13% of children aged 5-15 years identify as from a Black, Asian, or minority ethnic group. This is 11% in Vale of Glamorgan; whereas Cardiff has a notably more diverse population with 36% from a Black, Asian, or minority ethnic group Cardiff (26) (note that the Annual Population Survey reports that 20% of the total
population of Cardiff identify as from a Black, Asian, or minority ethnic group) (23).

Young carers
Young carers are children and young people under 18 years of age who provide care for someone else who has support needs, for example, due to a physical or mental health problem, a physical or learning disability, or substance misuse (27). Young adult carers are between the ages of 16 and 24. Their needs are considered in Chapter 15. The 2011 Census identified 1,579 young carers in Cardiff and the Vale of Glamorgan, but this is known to be an underestimation (28). The 2021 Census will provide updated figures when it is published in 2022. The YMCA Young Carers project supported 51 young carers in 2017/18, and 114 in 2020/21 in the Vale of Glamorgan (29). In Cardiff, the project supported 276 young carers in 2017/18, and 277 in 2020/21 (30). Of the 35 survey respondents, 11% (n=4) were young
carers.

Across Wales, in 2018/19, 895 assessments of need for support for young carers were
undertaken, of which 2 were in Cardiff, and 16 in the Vale of Glamorgan. This compares to
19 and 12 respectively in 2016/17 (31). Engagement Information for this chapter is taken from a range of reports and data sources. Thirty-five children and young people responded to the children and young people survey; and 30 respondents to the provider survey provided support for children and young people.

What has changed since 2017

Pre-COVID-19
The following national initiatives have taken place since the 2017 PNA:

• The Children’s Commissioner for Wales’s report, No Wrong Door, in 2020 (32)
• The NEST Framework in 2021 (33) – more detail provided below
• The Additional Learning Needs and Educational Tribunal Act, which was launched in
  September 2021, and places the needs of children and young people at the centre of
  decisions for education through Individual Development Plans, and sets out the
  rights for appeal for decisions (34)
• The Integrated Care Fund (launched 2016/17) has changed remit over its course,
  enabling the funding of additional work streams (see details in relevant subthemes).
  The Transformation Fund (launched 2018) aimed to promote innovation; however,
  remaining funds have since been redirected to COVID-19 (32)
  Regionally, the following have been implemented:
• Cardiff was the first city in Wales to develop the Child Friendly City Strategy in 2018.
  The UNICEF initiative includes the aims of empowering children and young people to
  understand their rights; and providing equality of opportunity and high-quality
  education (35).
• The Vale of Glamorgan Council supports the delivery of the Rights Ambassador
  programme which raises awareness of children’s rights with children and young
  people across Vale schools
• The Cardiff Children’s Services Strategy anticipates future challenges, and includes
  early help, social care, safeguarding, and children and young people with complex
  needs (36)
• The Vale of Glamorgan Children and Young People Services Service Plan includes
  social care, as well as early years such as Flying Start, the Youth Offending Service,
  and Families Achieving Change Together (37)
• In the Vale of Glamorgan, the Standards and Provision Service Plan (38) includes the
  Youth Service and the Rights Ambassador Programme, educational attainment
  including reducing school absence rates, and addresses issues arising from the
  impact of COVID-19 on schools and pupils
• The Cardiff Additional Learning Needs Strategy 2018-22 sets out a framework for
  action to implement the Additional Learning Needs and Education Tribunal (Wales)
  Act (39)
• The Vale of Glamorgan Additional Learning Needs and Well-being Service Plan (40),
  which implements the Additional Learning Needs and Education Tribunal (Wales) Act
  to support those aged up to 25 years who have additional learning needs. The Plan
  also includes safeguarding, partnership work to improve service delivery, and a
  whole school approach to promote well-being

COVID-19

The following themes were identified from the literature and engagement work as having been particularly impacted by COVID-19 or the restrictions, which were first introduced in March 2020.

Direct impacts of COVID-19
Between March 2020 to October 2021, 69 children and young people were admitted to hospital in Cardiff and Vale UHB with a primary diagnosis of COVID-19; of which 7 required high dependency or intensive care (41).

Long COVID describes the presence of symptoms four or more weeks after the original suspected COVID-19 infection, that were not explained by an alternative cause. Symptoms include weakness/tiredness, shortness of breath, and difficulty concentrating. The Office for National Statistics reports the numbers of people living in private households with self reported long-COVID by age group, for the UK: 20,000 children aged 2-11 years are estimated to have long COVID, 49,000 children and young people aged 12-16 years, and 142,000 people aged 17-24 years (42). No data are available for long COVID at a local
authority or health board level at the time of writing.

Service changes due to COVID-19 and restrictions
The Paediatric Emergency Department saw a marked reduction in attendances (21,317 in 2020/21, compared to 34,900 in 2019/20). Reasons for attending the Emergency Department also changed with fewer accidents, but more thermal injuries/burns, likely reflective of spending more time in the home due to lockdown and restrictions (43). Respondents to the provider survey articulated the increase in mental health needs, behaviours of concern, crisis presentations, and the need for respite. Providers reported
changes in service provision, with closure of some services and switch to virtual provision where it was possible. Staff were concerned for future service provision, being unable to recover from backlog, increasing waiting lists, and funding difficulties.

Mental health impacts of COVID-19 restrictions
The pandemic response has had a significant negative impact on children and young people in Wales on mental health and well-being; with loneliness, isolation, and parental stress contributing (44). More Welsh children have been exposed to Violence Against Women, Domestic Abuse, and Sexual Violence (VAWDASV), reflected by increased calls to helplines (44).

In Wales, adolescents were found to be particularly vulnerable to the mental health impacts of pandemic restrictions than younger children or older adults; as were young people not in employment, education or training, and people from more deprived areas (44).

Regionally, there were increased attendances to the Paediatric Emergency Department for mental health disorders such as self-harm, suicidal ideation or attempt, eating disorders, and increased behaviours of concern which parents and carers could no longer manage at home (43). Increased attendances have put strain on specialist services such as Child and Adolescent Mental Health Services (CAMHS) crisis teams (43). Figure 5.1 below shows the increase in admissions to hospital for an eating disorder amongst those aged 0-17 years (41). Note that these refer to admissions, not patients (there are 86 admissions in total
between 2016/17 – 2020/21, corresponding to 51 patients).

Cardiff and Vale UHB do not have any inpatient CAMHS beds; inpatient CAMHS services are instead provided by Cwm Taf Morgannwg Health Board unless there are exceptional circumstances. Children and young people who have an urgent physical medical need or are at risk from a physical health perspective as a result of a mental health diagnosis receive inpatient care in paediatric wards in Cardiff and Vale UHB (41).

The Director of Public Health for Cardiff and the Vale UHB examines children and young people’s mental health in detail in their 2021 annual report, with focus on the impact of COVID-19 (19). Supporting emotional well-being and mental health of children and young people is a key priority, with reference to the early years being a crucial period of development, and Adverse Childhood Experiences (ACEs) having a detrimental effect on adult mental health (19).

Overlapping and widening inequalities
The Health and Social Care in Wales update following COVID-19 identifies that often it is the same groups of children and young people who are negatively affected by policies implemented throughout the pandemic (25). Children who are most vulnerable include: children with additional learning needs; ethnic minority children; Welsh medium learners who do not speak Welsh at home; children who lack internet access; children with developmental delay; and children from deprived areas, especially those with no access to outdoor space (25).

The Children’s Commissioner for Wales identified the impacts of lockdown and restrictions including: social impact of not seeing friends and family; interruption of education; increased exposure to violence at home (reflected by a 50% increase in calls to help lines) (45).

Exacerbation of educational needs
Interruption of schooling was identified in the Children’s Commissioner for Wales’ ‘Coronavirus and Me’ survey as a negative impact of COVID-19 restrictions. Negative consequences include the impact on learning and education on children and young people from more deprived areas, who already suffered worse educational outcomes. Lockdown and restrictions have widened these outcomes gaps. In this survey only 11% of 12-18 year olds stated they were not worried about their education (45), with worries arising from the quality and unfamiliarity of the virtual learning environment and communication with
teachers and schools (44). Challenges around home learning included digital access, the home environment, and additional learning needs (45). The importance of school for access to emotional health and well-being support was observed; alongside the role of schools in providing food and shelter, and promoting a sense of community and belonging (44). The financial impact on families of lockdown and restrictions has increased the number of children suffering food insecurity (46), at the same time as decreasing access to school meals. Survey respondents were also concerned about the impact on their education.

Mitigating negative impacts and promoting positive impacts
In Wales, protective factors to mitigate the negative impacts of the coronavirus restrictions included routines, spending time outdoors, and understanding coronavirus and the mechanism of transmission (44). Some positive impacts of the COVID-19 pandemic were also identified including discovering and enjoying the outdoors; taking up new hobbies; spending more time with family; and reduction in pressure from social situations and bullying (44) (45).

What are the care and support needs?

The following areas were identified as care and support needs for children and young
people, from literature and engagement work.

Individual
Young carers
The 2016 Cardiff and Vale of Glamorgan ‘Young Carers Speak Out’ report identified a lack of awareness of support available to young carers. Professional leads feel that this has now improved. A Young Carers Awareness Day was held in Cardiff and the Vale of Glamorgan in January 2020. The Young Carers in Schools Programme established a Peer Review Panel of young carers across South East Wales, who review applications from schools applying for one of the three stages of the Young Carers in Schools Programme (28). Young carers have articulated needs with respect to mental health, wanting increased time for themselves to be a child or a young person, and support for their education.

Additional vulnerabilities
Some children may experience additional vulnerabilities if a parent or primary caregiver has experienced VAWDASV (see also chapter 17); is imprisoned (see also chapter 19); or has a substance misuse problem (see also chapter 18). Unaccompanied asylum seeking children are considered in chapter 20. These would all constitute an adverse childhood experience (ACE), which are associated with negative impacts across the life course (47).

Children and young people whose parent(s) are currently serving in the armed forces or have left military service (see also chapter 21) may experience both positive and negative impacts due to moving house, changing schools, making new friends and living abroad.

However, negative impacts were identified around worry for their parent(s) whilst they
were deployed, and missing their parent(s) (48).

Language and communication
English was an additional language in 17% of primary school pupils in Cardiff, 3% in the Vale of Glamorgan, and 6% across Wales in 2020/21 (26). In Cardiff, most (85%) of primary school pupils cannot speak Welsh, but 9% are fluent in Welsh. In the Vale of Glamorgan, 81% cannot speak Welsh, and 11% are fluent (49). The survey for this assessment asked what languages respondents spoke at home. Most spoke English (n=22, 85%); and three or fewer responses were received for speaking English using Augmentative and Alternative Communication (AAC), Welsh, Gujarati, and Romanian.

In Wales, during COVID-19, most children in both Welsh and English-medium schools have been able to continue Welsh. In Welsh-medium schools, only 8% aged 7-11 and 15% aged 12-18 across Wales have not been continuing education in Welsh, and 31% of 7-11 year-olds and 26% of 12-18 year-olds in English-medium schools were not receiving opportunities to speak Welsh (45).

It is known that speech, language and communication difficulties in early childhood are associated with poor employment outcomes and poor mental health as adults, and are more common amongst young offenders, and those in areas of higher deprivation (50). Improving language development is one mechanism by which to reduce inequities, and break the intergenerational cycle of poor communication skills (51). The national prevalence of speech, language and communication difficulties is not known, however, the 2020 school census in Wales identified that 20% of children had special educational needs, of whom one third had speech, language, and communication difficulties (51). Welsh Government
published ‘Talk With Me: Speech, Language and Communication Delivery Plan’ in 2020 (51).

In Cardiff and the Vale, Speech and Language Therapists (SLTs) provide assessment, diagnosis and intervention to children and young people who have difficulties with speech, language, communication and swallowing difficulties. Services are provided in the family home, nurseries and schools, and in healthcare settings. Support ranges from initiatives with Flying Start (a Welsh Government programme to improve outcomes amongst children under 4 years old living in disadvantaged areas in Wales (52)) which aims to prevent difficulties and to promote healthy eating habits, to multi-disciplinary specialist team support for families to manage the impact of complex and lifelong conditions such as deafness, learning
disability and autism (41)

Community
There were 2,940 and 821 assessments of need for care and support undertaken in Cardiff and the Vale of Glamorgan respectively in 2018/19. This is an increase of 580 and 190, respectively, from 2016/17. Of these, in 2018/19, 352 assessments led to a care and support plan in Cardiff (data not available for the Vale of Glamorgan) (31).

Emotional health, mental health, and well-being
Primary Mental Health (PMH) service demand (for mild to moderate mental health concerns) has been found to be cyclical and tended to be associated with return to school after holiday periods. The Child and Adolescent Mental Health Service (CAMHS) attend to patients with more severe mental health concerns. Referrals follow a similar pattern to Primary Mental Health. The Crisis service sees patients presenting to the Emergency Department who require urgent care (41).

Figure 5.2 demonstrates the number of referrals to PMH, CAMHS, and Crisis since April
2019, and figure 5.3 shows the waiting list length.

Amongst the 35 respondents to the PNA survey for children and young people, 12% rated their well-being as 3 or less out of 10, where 0 was the lowest and 10 the highest. Around half reported a score of 7+/10. The most commonly cited everyday problems experienced were emotional health (75% respondents); mental health (63% respondents); school (63%); and body image (45%). Two-thirds of survey respondents were worried for the future. Respondents were looking forward to taking part in sports/exercise; finishing college; gaining independence; getting a job and earning money; meeting new people and seeing new things; and “being happy”. Six respondents wanted additional support to help them reach their goals, including help from family, and developing further skills from specialist teaching staff. Note that these survey results are not representative, but do support the importance of mental health and well-being.
County Lines
The Cardiff and Vale UHB Safeguarding Annual Report 2020/21 identifies County Lines as a national issue, particularly affecting the most vulnerable. Children and young people can be targeted and exploited through grooming and threats; intimidating young people into drug related criminal activity, and associated violent behaviour such as knife crime. A multiagency approach including South Wales Police, Cardiff and Vale UHB, and education has been taken to provide training and raise awareness of when to suspect and how to manage this phenomenon (43). Chapter 19 has further information on youth justice.

Wider determinants of health

Deprivation
An evidence review of the human rights of children in Wales identified differential outcomes in health risk factors and outcomes, education, and wellbeing depending on socio-economic background (53). In terms of health, children aged 4-5 years in the most deprived decile were 76% more likely to be obese than those in the least deprived decile. Low birth weight and educational deprivation were also associated with income deprivation (54).

The most recent Welsh Index of Multiple Deprivation report uses 2016/17 data, and found that 28% of children in Wales aged 0-4 lived in income deprivation (range 17%-30%). This is the highest proportion by age group. Cardiff has the highest number of 0-4 year olds living in income deprivation (6,600 children) but sits just above the Welsh average at 29%; the Vale of Glamorgan has nearly 2,000 children in income deprivation (23%). Cardiff has both the most and least deprived middle super output areas in Wales, with income deprivation rates between 3% in Rhiwbina and Pantmawr, to 67% in Ely East amongst children aged 0-4 years. In both local authorities, this represents a decrease from 2012/13: where Cardiff had
33% and Vale of Glamorgan 27% of 0-4 year olds living in income deprivation (22).

Welsh Government published its review on socio-economic disadvantage and inequalities of outcome in November 2021, and identifies that the attainment gap is evident even in primary school. Disadvantaged children are less likely to complete qualifications, and have reduced education and financial outcomes compared to non-disadvantaged peers. This disadvantaged position is further exacerbated by housing inequalities, for example, through lack of suitable environment to complete homework. This is described as having a “cyclical” intergenerational impact (55).

Twenty-six respondents of the survey answered questions relating to the Family Affluence Scale, also used by the School Health Research Network (56). Questions include whether the individual has their own bedroom; the number of computers/smart phones in the home; and the presence of a dishwasher. The Scale identified 7 of 26 respondents as low affluence, 14 as middle, and 5 as high affluence.

Free School Meals
One-fifth of school-age children in Wales in 2020 were eligible for free school meals, but amongst students with special educational needs, 45% were eligible (57). In the three years to 2021, 21% of primary school pupils in Wales were eligible for free school meals, with 15% in the Vale of Glamorgan and 25% in Cardiff (26). Across Wales, three-quarters of those eligible took up free school meals in 2019/20. This is expected to increase with the end of the Government furlough scheme (57).

School exclusion rates are higher for those eligible for free school meals than those not eligible (53). Free school meals have been associated with improved nutrition, school attendance, and school achievements (46). The attainment gap in Cardiff between those eligible and not eligible for free school meals grows from 10% in Key Stage 2 to 31% in Key Stage 4 in 2018 (35). The attainment gap in the Vale of Glamorgan between those eligible and not eligible for free school meals grows from 12% in Key Stage 2 to 31% in Key Stage 4 in 2018 (58). Across Wales in 2017/18, the percent of pupils achieving A*-C was consistently
lower amongst those eligible for free school meals compared to those not eligible. For
example, 38% versus 70% in English; and 39% versus 71% in Maths (59).

Education and employment
Estimates from 2020 suggest between 9-11% of 16-18 year-olds across Wales are not in employment, education, or training (NEET) (60). Estimates for those aged 19-24 is 15%. This is the result of a gradual decrease in NEET for this age group following a peak of 23% in 2009-2012 due to the 2008 recession (60). Young people with disabilities, in particular those aged 19-24, are more likely to be NEET than those without disabilities. One fifth of disabled people are NEET at age 16-18; this is two-fifths at age 19-24 (60).

Careers Wales report on pupil destinations using an annual survey of school leavers. Table 5.2 shows the number of pupils reporting that they are NEET in summer 2020. Note that the survey is completed by school leavers, and may therefore underestimate the total number of young people who are NEET.

• Health worries: anxiety around a medical diagnosis, or recurrence of mental health problems
• Failure: not achieving exam success and the consequences; financial insecurity; “not achieving my dreams”
• The COVID-19 pandemic and the climate crisis
• Gaps in knowledge and understanding stem from gaps in locally-available data as well as
• evolving and emerging events on a local and wider scale. These include:
• Emerging impacts of COVID-19, lockdown and restrictions including long COVID
• The number and characterisation of young carers – results from the 2021 Census are awaited
• Associations of socio-economic status and care needs
• The prevalence of speech, language and communication difficulties in children and young people in Cardiff and the Vale of Glamorgan
• Bullying in schools, and associated characteristics, such as protected characteristics
• Accompanied and unaccompanied asylum seeking and refugee children, and associated outcomes in terms of health and education/employment
  

What are the range and level of services needed?

Prevention and assets
Healthy behaviours
The School Health Research Network survey reports the following amongst secondary
school pupils in Cardiff and the Vale of Glamorgan:

• 2% of male and female respondents report smoking tobacco at least weekly
• 8% of males and 16% of females report ever trying e-cigarettes; with 2% using them at least weekly
• 7% of males and 5% of females have ever used cannabis
• 10% of males and 5% of females have spent their own money on gambling (56)

The National Child Measurement Programme data 2018/19 demonstrates that most children aged 4-5 are of a healthy weight (80% in the Vale of Glamorgan; 76% in Cardiff). In Cardiff, 13% are overweight, and 11% are obese. For the Vale of Glamorgan, the figures are 9% and 9% respectively. Compared to 2011/12, this represents a higher proportion of children being a healthy weight. At a national level, there is an increase in proportions of children being overweight and obese with increasing deprivation. The fifth of children who are least deprived have the highest proportion of children who are a healthy weight (64).
Reduction and mitigation of Adverse Childhood Experiences (ACEs) comprise abuse, neglect, and household dysfunction (including parental substance misuse, violence, or separation), which have been associated with a variety of adverse outcomes across the life course, such as poorer health and wellbeing, worse educational attainment, and increased risk of incarceration (47) (65). Half of adults in Wales have had at least one ACE. One quarter of 49-year old adults with four or more ACEs have at least one
chronic disease, compared to 7% of those with no ACEs (47). ACEs can be intergenerational. Protective factors have also been identified, which mitigate or attenuate the association with ACEs. This means that there is opportunity to intervene within an early intervention approach to support children and their parents, or through taking an ACE-informed approach. Pilot routine “ACE enquiry” in three areas in Wales found high levels of first disclosure of ACEs (over 40% of caregivers) (65). Welsh Government have
prioritised ACEs in its programmes (47).

Vaccination
Public Health Wales data demonstrate that decreasing vaccine uptake of the 6 in 1 vaccine by 1 year of age in Cardiff, is currently below the 95% target. The Vale of Glamorgan is just above the target. Data on children receiving the first MMR dose by 2 years, two MMR doses by 5 years, and the pre-school booster by 5 years show that both Cardiff and the Vale of Glamorgan are below the set target for 2019/20 (66).
Analysis by Public Health Wales shows that socioeconomic inequalities are associated with smaller differences in uptake in younger children, with bigger uptake differences in teenagers in Wales (67).

Assets to support well-being
Amongst survey respondents, the most common source of support was a parent/guardian, with 83.3% of respondents having received help from them. More than half of those surveyed received support from friends (59%), school teachers (57%), or a GP (53%). Other sources of support included youth centre/youth workers, social worker, third sector, and online support, local clubs and groups, sports clubs, and social media.

Professional leads identified the Join the Dots service by Cardiff and Vale Action for Mental Health (CAVAMH) which supports children and young people to have an input into services. Support available for young carers include the following:

• The Primary Mental Health team provides support for young carers and their families
  for anxiety, depression, stress, and relationship difficulties (27)
• Meic Cymru provides information, advice and advocacy (27)
• Action for Children work with young carers known to Children’s Services; offer
  respite, and work to increase confidence and respond positively to challenges (27)
• Local authority support: in Cardiff, the Cardiff Family Gateway, and in the Vale of
  Glamorgan, Families First Advice Live provide information and signposting (27)
• The YMCA run Time 4 Me for young carers provides peer support (27)

Community services
Whole school emotional health
Advocated by the Together for Children and Young People 2 (T4CYP 2) programme, a whole school approach facilitates universal services and promotes joined up working (68). Welsh Government has published a framework on how to embed this approach to promote emotional and mental wellbeing (69). The 2021 annual report for the Director of Public Health in Cardiff and Vale UHB identifies that the education sector is well-placed for support provision, but recognises that local and national partners also have a key role, for example, through building resilience and positive behaviours (19).

Sustainable services
Professional leads identified that financial security for services is needed in order to maintain and build upon positive outcomes achieved so far.

Partnership approach
Person, not service, centred services Professional stakeholders have articulated the need for services to join up, and provide holistic support that is seamless between services. Stakeholders for this report have
identified that not all children and young people who have care and support needs will have a specified diagnosis. Services must be able to respond and support all children and young people based on their needs within universal services.

The NEST (Nurturing, Empowering, Safe, Trusted) Framework promotes a person-centred, values-led, integrated whole system approach; supporting early help, the right help, and at the right time with the aim of improved mental health and emotional wellbeing (33). Collaboration across services including public and third sector will facilitate whole system approach and provide inclusive services for all those who may need them, rather than specialist interventions for
specific groups. (3)

Figure 5.5. The NEST Framework (3)
In line with NEST, the No Wrong Door approach brings together services and asks services to wrap around children, young people, and their families, rather than asking those in need of care and support to understand a complex system (32). A focus group respondent wanted a service priority to be: “uncomplicating things”.

5.5 What is likely to happen in the future

The number of children aged 0-15 is projected to decrease in Cardiff by from 67,945 to 64,352 between 2020 and 2040, and increase slightly in the Vale of Glamorgan by from 25,000 to 25,207 between 2020 and 2040 (10). However, as a proportion, young people aged 15 and under were 18.5% of the population of Cardiff in 2020, and are estimated to make up 16.6% in 2040. For the Vale of Glamorgan, these values were 18.7% in 2020, and 17.2% in 2040. In line with this trend, the absolute number of young people aged 0-15 in Wales will decrease in the same time period, as will the proportion of the total population –
from 17.9% in 2020, to 15.9% in 2040 (10). The reduction in the proportion of under 16s is likely reflective of the decreasing fertility rate, and increase in the number of older people. Note that projections should be interpreted with caution as they are based on historical trends.

COVID-19 and the restrictions placed on children and young people will have direct and indirect impacts on children and young people’s health for some time to come; this has been considered in the Welsh Government update on Health and Social Care (25). Public Health Wales is researching the impact of COVID-19 combined with Brexit and climate change, called the “triple challenge”, which will have wide ranging, dynamic, and synergistic impacts across the wider determinants of health for children and young people (70).

Recommendations
Cardiff and Vale University Health Board and Cardiff and the Vale of Glamorgan Local Authorities to:

• Adopt the NEST Framework and No Wrong Door approach
• Strengthen actions to ensure information is accessible to children and young people;
  and they are invited to co-produce services so they are person-centred, and help
  children and young people feel valued
• Monitor emerging literature on long COVID in children and young people
  Cardiff and Vale University Health Board to:
• Continue to promote preventative strategies including routine immunisations
• Continue to develop partnerships with Education services and embed the whole
  school approach to emotional health and wellbeing
• Increase funding available to mental health services for children and young people
  (25)
• Target waiting list times, especially for children and young people’s mental health
  services
• Develop Integrated Model for Emotional Health and Well-being for Cardiff and Vale

Children and Young People with Complex Needs

This chapter should be read in conjunction with the following chapters: Children and Young People; Children Looked After; Healthy Lifestyles and Long Term Conditions; Physical Disability; Learning Disability; Autism; Adult Unpaid Carers; Sensory Loss and Impairment; VAWDASV; Asylum Seekers and Refugees; Secure Estate

Recommendations
Cardiff and Vale University Health Board, Cardiff and the Vale of Glamorgan Local Authorities, education providers, and third sector to:

• Promote universal and targeted early intervention and preventative services
  including parental support
• Undertake training to increase awareness and promote services accessible and
  comfortable for children and young people with neurodevelopmental disorders
• Work to ensure the T4CYP 2 programme is fully embedded
  Cardiff and Vale University Health Board and Cardiff and the Vale of Glamorgan Local
  Authorities to:
• Share good practice and learning
• Address data gaps
• Address gaps in service provision
• Promote early help and preventative approaches in line with T4CYP 2
• Embed the NEST framework and No Wrong Door approach
• Address the increasing waiting list for assessment
  Regional Partnership Board to:
• Lead on development and implementation of an integrated model for children and
  young people’s emotional health and wellbeing

Overview
Children and young people with complex needs includes those with disabilities and/or illness; those who are care experienced; those in need of care and support; those at risk of being looked after; and those with emotional behavioural needs (3). It should be stressed that the term “complex needs” refers to the fact the service provision required may be complex, and not the child or young person (32). This updated definition places additional focus on emotional health and well-being.

Children and young people with symptoms of autistic spectrum disorder, attention deficit and hyperactivity disorder (ADHD), or other conditions may be referred to neurodevelopmental assessment services for diagnosis. The neurodevelopment service in Cardiff and Vale University Health Board provides multidisciplinary assessment, intervention, information and support for patients and their families (71). For those who have received a diagnosis, post-diagnostic support may include multidisciplinary therapeutic
interventions which best meet the child’s needs (3). They provide support for the child or young person, as well as their families or carers. Inclusive support services are being developed so that children or young people who require support but do not have a diagnosis, and their families, are still able to receive the help they need.

There is no data source which provides figures for all children and young people with complex needs, in part due to the breadth of its definition. The Children Receiving Care and Support Census reports the number of children and young people receiving care and support services from a local authority (including children looked after), as well as some types of disability. Data are as follows:

The Children Act 1989 requires each Local Authority to establish a “register” to enable service providers to work together with children and young people with disabilities and additional needs, and their families. In both Cardiff and the Vale of Glamorgan, this is known as “The Index”. The Index provides support and local information on services and support, and helps service providers with planning (73). The Index is voluntary and therefore likely underestimates the true number of children and young people with disabilities and additional needs. This likely explains, in part, why the figure for Cardiff registrants is lower
than the Vale of Glamorgan.

The Cardiff Index, launched in 2016, had 806 children and young people registered in January 2022. Of those registered, the majority are registered for autism (n=259); developmental delay (n=138); and behaviour/emotional difficulties (n=121). These figures represent a large increase from 2017, when only 90 were registered (74). The Index in the Vale of Glamorgan has 823 children and young people registered; with 64 new registrations in the year 2020/21 and 27 children and young people deregistered for various reasons including becoming 18 (73). Over half (56%) live in Barry (45% in 2017). As per Cardiff, Autistic Spectrum Disorder is the primary reason for registration (36%); however, half of registrants have behavioural/emotional difficulties (75).

Engagement for this chapter comprises of eight parents of children living with cerebral palsy
(aged 8-11 years) from a focus group discussion. Their views will not be representative of all
children and young people, and their parents, guardians, or carers, but do provide lived
experience which complements other data sources.

What has changed since 2017?

Pre-COVID-19

The Integrated Care Fund, launched in 2014/15, released funds for children and adults with complex needs and children with learning disabilities in 2016/17, bringing the Integrated Autism Service within remit (32). The Integrated Autism Service was launched in 2017 and provides assessment and diagnosis for adults for learning disability and autism; and provides support to services users, their families and carers, and professionals (76). Since the 2017 Population Needs Assessment, the Autistic Spectrum Disorder Updated Delivery Plan 2018-2021 has been published (77), as well as the Code of Practice on the Delivery of Autism Services 2021 (78). The Code sets out the range of support services for assessment, diagnosis, health and social care and broader work around training and
awareness ranging. The Together for Children and Young People (T4CYP) 2 Neurodevelopment Support agenda sets out a vision for services, implements pathways and standards, and works to improve outcomes and support for children and their families. It took over from the original T4CYP
programme which ran from 2015-2019 (68). The programme supports the Additional
Learning Needs Act (34).

COVID-19
Welsh Government published its report ‘Locked Out: liberating disabled people’s lives and rights in Wales beyond COVID-19’ in 2021, which describes the impact of COVID-19 lockdown and restrictions on disabled people in Wales (79) (please see also Chapter 10). An intersectionality reference group, which included young people with disabilities in care, for the Locked Out report on people with disabilities and COVID-19 in Wales identified that young people were “falling through the gaps” in provision (79). This is echoed by the Care Quality Commission in England who document the impact of service disruption due to COVID-19 on children and young people, including the need to prevent gaps in care provision.

Transition to adult services were identified as a priority area (80).
In addition, the Care Quality Commission described how the COVID-19 restrictions have placed strain on care and support providers, as well as children, young people and their families and carers as described throughout this report. Mitigating the negative impacts of service disruption (such as the pause in face to face services and the switch to virtual modalities) must be a priority. This should include care where it is needed to prevent placement breakdown (80).

What are the care and support needs?

Individual
Supporting independence

Welsh Government report that some disabled children and young people feel unable to use public transport on their own, instead relying on parents (81). Travel training for young disabled people may help increase independence (81). Young people wish to have a voice in decision making locally as well as at a wider level. Vale Youth Speak Up enable young disabled people, aged 16-25, to participate in discussions and influence decisions, for example, around discrimination and bullying (81). The Children in
Wales Getting More Involved in Social Care project enables disabled young people to provide training for peers and professionals, which increases knowledge of children’s rights, and increases involvement in decisions (81).

A focus group with parents of children with cerebral palsy wanted their parent voice to be better heard, and to be more included within the decision making process.

Language and communication
The Vale of Glamorgan Index reports that 51% of registrants have communication and socialisation difficulties; and 39% have speech and language difficulties. In terms of methods of communication, 7% use Picture Exchange Communication Systems (PECS) and 3% use Makaton (73). The Cardiff Index reports that 5% of those registered have speech and language difficulties as the primary criteria for registering, and 54% of the 802 registrants have speech and language difficulties as an additional reason for registration. Of the total number of children and young people registered, 23% use Gestures, 14% use PECS, 10% use Makaton, and 0.5% use British Sign Language for communication (74). Welsh Government has published a Welsh language impact assessment on the Code of Practice for the Delivery of Autism services (82).

Community

Access to assessment, care, and support
The Neurodevelopmental team conducts assessments for children and young people who require them (adults are assessed by the Integrated Autism Service). Figure 6.1 shows the number of referrals to the Cardiff and Vale Neurodevelopmental team since March 2020 (referrals prior to this date were in the range of 43 – 183 per month). Of note, is the increasing waiting list in terms of volume, but also the duration of waiting list from 58 weeks in March 2020, to 129 weeks in September 2021 (83).

Young people with learning difficulties across Wales have reported difficulties with the short health care appointment length, stating that they would like more time in order to understand the discussion (81).

Some specialist health services have been difficult to access by young disabled people, such as sexual health. In addition, Welsh Government report that despite being more likely to have additional healthcare needs such as poor mental health, they are unable to access services until the situation is more severe, such as at crisis point (81).

Post-diagnostic support
The Neurodevelopment team provide support through different mechanisms including referrals to Primary Mental Health; CAMHS; the Emotional Wellbeing Service; or to Families First and Cardiff Family Advice & Support. The Integrated Autism Service (IAS) does not work directly with children, instead working with their parents or carers to indirectly support the child. During 2020/21, 15 parents or carers were supported by IAS. Of the 585 new referrals received, 22 were from people aged 16-17, and 173 by those aged 18-25 (note that referrals are for a range of services and not just assessment) (83). Support provided by the IAS includes: advice on managing sleep difficulties; assessments and strategies to manage triggers of behaviour that challenges; support transitions to adult services; training and support groups. In addition, services can be provided in conjunction with CAMHS or the learning disabilities team (83).

Transition of care from children’s to adult services
The aim of transition is to promote independence in a safe and supported manner – for both the young person, and their parent or primary carer, who may struggle with the change in relationship, according to Welsh Government (81). A consultation in Cardiff and Vale for the regional joint commissioning strategy for adults with learning disabilities identified transition from child to adult services as a priority; and anticipated that between 2018/19 and 2020/21, approximately 19 people with learning disability would transition year in Cardiff, and 9 in the Vale of Glamorgan (84). In the Vale of Glamorgan for the
years 2016 and 2017 combined, 24 young people were assessed in the year they turned 18, of whom 22 had eligible care and support needs requiring input from the Adult Learning Disability Team. In 2020, 12 were assessed and 9 eligible for input from the Adult Learning Disability Team (29). In Cardiff, in 2020/21, of the 36 young people known to the Child Health and Disability Team, 33 transitioned to the Adult Learning Disability Team. In 2018/19, the figures were 25 and 20 respectively.

However, transition remains a challenge for many in Wales, citing lack of awareness of sources of support, inadequate signposting, and barriers to access. The role of parents as carers also changes as young people gain their independence, which can add stress to the relationship (81). Members of a professional workshop held in Cardiff and the Vale UHB stated families are often in limbo whilst they are transferring between services and transitioning to adult services (85).

The Multi Agency Transition Review Interface Group is a forum to discuss the needs, outcomes and resources required for young people in the 15-18 year old age group who have, or may have a need for care and support into adulthood. This forum runs in both Local Authorities and informs both individual and strategic planning (86).

Both Cardiff and the Vale have developed a support planning service, which comprises a person-centred assessment with people known to the teams to consider options for day opportunities. The specialist service focuses on opportunities to gain skills, enhance networks and inclusion within local communities. Both councils also have employment support for those who are interested in paid work. As with all service areas, this has been impacted by the COVID-19 pandemic but work is restarting to widen access to community options (29) (30).

The Multi Agency Transition Review Interface Group is a forum to discuss the needs,
outcomes and resources required for young people in the 15-18 year old age group who
have, or may have a need for care and support into adulthood. This forum runs in both Local
Authorities and informs both individual and strategic planning (86).
Both Cardiff and the Vale have developed a support planning service, which comprises a
person-centred assessment with people known to the teams to consider options for day
opportunities. The specialist service focuses on opportunities to gain skills, enhance
networks and inclusion within local communities. Both councils also have employment
support for those who are interested in paid work. As with all service areas, this has been
impacted by the COVID-19 pandemic but work is restarting to widen access to community
options (29) (30).

Wider determinants of health

Deprivation
No local data are available relating to children and young people with complex needs. A reduction in Direct Payments has been experienced by recipients in Wales; therefore decreasing access to finance and increasing isolation with reduced well-being (81). In contrast, Disabled Students’ Allowance has improved equity of access to higher education (81).

Support provided by the IAS includes guidance on benefits and employment. The Code of Practice on the Delivery of Autism Services asks employers to promote inclusion of autistic people (82). Increasing awareness of inclusive recruitment will enable more autistic people to gain higher quality jobs.

Education and employment
Data from the Pupil Level Annual School Census demonstrate that the proportion of pupils aged 5-15 years with special educational needs is lower in the Vale of Glamorgan, and higher in Cardiff, than the Wales average. In Cardiff, 2.7% of pupils aged 5-15 years have a Statement of Special Educational Needs, compared to 0.6% in the Vale of Glamorgan, an2% in Wales (26). In Cardiff, there were 9,446 pupils with special educational needs in 2020/21, of whom 2,143 had a Statement (1639 in 2016/17). In the Vale of Glamorgan, there were 3,213 pupils with special educational needs, of which 439 pupils have a
Statement of Special Educational Needs (378 in 2016/17) (87).

Welsh Government reports that many people still incorrectly assume that young disabled people are unable or unwilling to learn (81). This report calls for those in Education services to inspire young disabled people and aim for aspirational goals. They state that children with hearing or sight loss should be supported to feel confident traveling to and around school. Mainstreaming children with disabilities from an early age was proposed to increase acceptance, and could be supported by the establishment of inclusivity league tables (81). Welsh parents reported physical barriers affecting school experience (e.g., steps in classrooms), and were concerned regarding the transition from primary to secondary school. Bullying is reported as a serious concern in both mainstream and additional learning needs schools, and further action is needed to address this in many schools in Wales (81). Three primary schools in Cardiff and the Vale of Glamorgan have undertaken Learning with Autism training between 2017 and 2018 (corresponding to 127 staff members), which helps staff adapt their communications and the learning environment to the needs of the child (88).

Supporting progression into employment or further education is beneficial for establishing and developing social relationships, supporting well-being (81). Welsh Government report that young disabled people want to access work, and should help co-produce pathways to employment. Those leaving education should therefore be signposted to specialist disability employment support (81).

Housing
The Cardiff Local Housing Strategy identified that demand outstripped availability for accessible homes of which many applicants had children with disabilities within the household (89). Children and young people with physical disabilities have experienced difficulties finding housing that meets their needs, and this is especially so in the private rented sector in Wales (81). Similarly, in the Vale, demand outstrips supply for accessible homes. During the last two years the Vale’s Council Housing New Build programme has increased the supply of purpose built adapted bungalows and flats. Within the Vale of Glamorgan Housing Strategy, there is a requirement for at least two adapted homes on new social housing grant funded developments. An Accessible Housing Panel was introduced in Autumn 2020 in the Vale of Glamorgan, which considers each property on its suitability for the individual applicant, and conducts any necessary adaptations (29).

Some children require residential and specialist care, however, a priority should be prevention of the need for unnecessarily high levels of care, as such placements are more difficult to find, and are more likely out of area. Improving local health team resources to support positive behaviours and provide family-centred support would work towards this aim.

Social Care Wales report data on the number of placements and type for young people with learning disability. The total number of placements in Wales has decreased between 2015 and 2019 (2,842 to 2,342), but has increased in both the Vale of Glamorgan (68 to 108) and Cardiff (227 to 236). Most placements are in the community with their parents or family, with a minority placed in foster homes (6 in Vale of Glamorgan, 9 in Cardiff in 2019) (90).

In Cardiff and Vale of Glamorgan, some children and young people have experienced family placement breakdown due to needs arising from their neurodevelopmental disorder. This presents a challenge for local authorities who need to arrange placement at short notice, and may result in out of area placement. Early intervention can help reduce this risk (91).

Unmet needs
Engagement work identified the following as gaps in care and support:

• Children and young people without a diagnosis are missing out on care and support
  services
• Service provision: a lack of joined up care causes distress as children young people (and their parents or guardians) are moved between services; this is in part due to different IT systems and different uses of language between different services. In addition, difficulties were encountered with long durations until a diagnosis is reached; and a need for increased mental health support and opportunities for multidisciplinary appointments
• Support: a need for more peer support, and that this could be met by being mentored by another family to share lived experience. Support for the whole family was also identified
• More specialist sports opportunities and youth service provision Gaps in our knowledge and understanding were identified as follows:
• The number and needs of children and young people who have care and support needs but do not fit an established pathway
• The number and needs of young people transitioning to adult services
• Socio-economic characteristics and Welsh language profile of children and young people undergoing neurodevelopmental assessment

What are the range and level of services needed?

Prevention and asset
Early help

Early Help and Enhanced Support are a key pillar of the Together for Children and Young People 2 (T4CYP 2) programme (68). This stipulates a whole system approach. Early support for mental health concerns may help to avoid a crisis. Early Help services have recently experienced high levels of demand. Cardiff Family Gateway managed 12,359 calls and emails between November 2019 and November 2020; and supported 8,696 people. Cardiff Parenting received 686 referrals during the same time period, with 265 one-to-one psychology led parenting interventions (85). The Families First Advice Line in the Vale of
Glamorgan provide Early Help, and received 1626 calls during the same time period (1013 were from professionals and 582 from parents or carers) (29). Of the total calls, the Families First Advice Line referred 340 to the Vale Parenting Service (29).

In Cardiff and Vale of Glamorgan, early identification and management of behaviours of concern could prevent ongoing difficulties into adulthood, which may reduce the risk of other complications such as contact with the criminal justice system, substance misuse, or mental health issues (92). Early intervention can additionally prevent placement breakdown, as well as being less costly. Regional mechanisms by which to provide this early intervention include development of life skills, parental support, and improving transitions of care (91).

Assets to support well-being
Professional workshops as part of the development of the integrated model for emotional health and wellbeing identified information provision for families, as well as services and programmes such as Flying Start, Family Gateway, Families First, Cardiff Parenting, Cardiff Family Advice & Support as supportive to the well-being of children, young people, and their families and carers. Parents of children with cerebral palsy identified third sector organisations such as Cerebral Palsy Cymru and Shine Charity as assets, for their in-depth knowledge and advice. In addition, groups and coffee mornings with other parents of children with complex needs, to share lived experiences were helpful. Social services and social workers were also valued.

Other sources of support include Autism Wales, who provide resources for parents and carers,
information on a wide range of topics including banks and dentists. Both Cardiff and the Vale of Glamorgan have outreach teams to support children in school. Both areas have a voluntary Index which offers support for children and young
people and their families and carers.

Community services

Inclusive services considerate of the individual in their own context Services need to be inclusive, accounting for the child or young person’s communication needs (for example, use of Augmented and Alternative Communication (AAC) or language preferences), as well as access (85).
Services should include care and support tailored to the needs of children and young people as well as the family and carers, so that they can then care for the child or young person “…without [Cerebral Palsy Cymru] being there we would feel really lost” – parent of a child with complex needs, focus group
“…one [social worker] in particular has been superb” – parent of a child with complex needs, focus group
(85). Inclusivity of parents and carers should be a focus also, as men are underrepresented.

This includes respite for families and carers, which is accessible and available in a timely manner, and provision of “wrap around” support in line with ‘No Wrong Door’ and NEST (85). Care and support services must be timely, and considerate of the notion that some children and young people may need multiple sources of care and support, each with their own waiting list. Change in demand should be anticipated and services planned to meet this. Services close to home, including accommodation
Services must be provided close to home. The Welsh Government White Paper ‘Rebalancing Care and Support’ notes that children are often placed far from home, which is more costly and increases strain and stress on families as well as children and young people (93).

Sufficient accommodation should be available locally for children and young people; this should include a range of options to appropriately meet the needs of the individual.

Partnership approach

Integrated, whole system approach
Service providers (including third sector) should be aware of other services available and how to access them, in order to build resilience within the system, and improve signposting (85). This is championed by the No Wrong Door report (32) (93). This approach should streamline access and improve communication between providers, so information is not lost between services, and families do not need to repeat themselves. Variation in referral mechanisms and documentation used between services should additionally be streamlined with better collaborative working (85). The Complex Needs Service is trialling delivering a fully joined up health and social care service for children and young people with complex
needs (91).

Engagement work identified that parents wanted a central point for information, for example, through a care coordinator: parents of children and young people with complex needs have experienced long waits for appointments, and a need to be proactive in order to arrange annual reviews. A “road map” of support available, and upcoming appointments may help with this.

Transition of care from children’s to adult services
‘No Wrong Door’ reports that children and young people with learning disability experience a stressful period of transition to adult services (32). The T4CYP 2 programme includes transitions as a core component within its Early Help and Enhanced Support work stream (68). Care and support provision should continue seamlessly through this period of transition, and focus on what matters to the individual. Cardiff and Vale RPB is developing a regional protocol for transition of young people with learning disabilities.

What is likely to happen in the future?

Population projections from Social Care Wales suggest that the numbers of children with moderate, profound and multiple, or severe learning disabilities are likely to remain fairly similar over the next 20 years (94). In Cardiff, the number of children with learning disability is predicted to decrease from 3,027 in 2020 to 2,907 in 2040; in the Vale of Glamorgan a slight increase from 1,124 to 1,149 is predicted (94), likely reflective of the decrease in under 18 population predicted in Cardiff between 2018 and 2040 (95). Social Care Wales have predicted relatively stable numbers of children and young people with autism between 2020 and 2040 (1,370 to 1,316 in Cardiff; 509 to 520 in Vale of Glamorgan) (94). However, these figures are based on prevalence data. Neurodevelopmental services are currently recording increased referrals, waiting list times, and numbers of diagnoses of autism and anticipate this may lead to increased numbers of autistic children and young people in future (83).

In line with wider demographic changes, the population of people with learning disability is ageing. In addition, people with learning disability have increased likelihood of development of other comorbidities such as dementia (84) (96). There is work ongoing for the development of an integrated Infant, Children & Young People’s Emotional Wellbeing & Mental Health Needs model for the Cardiff & Vale Regional
Partnership Board. The model aims to bring together examples of best practice and make use of local assets to provide universal, targeted and specialist services in an accessible and equitable way (85).

The Additional Learning Needs code will introduce some changes, for example, that some services may continue until age 25 (97).

Recommendations

Cardiff and Vale University Health Board, Cardiff and the Vale of Glamorgan Local Authorities, education providers, and third sector to:

• Promote universal and targeted early intervention and preventative services including parental support
• Undertake training to increase awareness and promote services accessible and comfortable for children and young people with neurodevelopmental disorders
• Work to ensure the T4CYP 2 programme is fully embedded Cardiff and Vale University Health Board and Cardiff and the Vale of Glamorgan Local Authorities to:
  • Share good practice and learning
  • Address data gaps
  • Address gaps in service provision
  • Promote early help and preventative approaches in line with T4CYP 2
  • Embed the NEST framework and No Wrong Door approach
  • Address the increasing waiting list for assessment
    Regional Partnership Board to:
  • Lead on development and implementation of an integrated model for children and young people’s emotional health and wellbeing

Children Looked After

This chapter should be read in conjunction with the following chapters: Children and Young People; Children and Young People with Complex Needs; Healthy Lifestyles and Long Term Conditions; VAWDASV; Asylum Seekers and Refugees; Substance Misuse; Secure Estate

Recommendations
Cardiff and Vale University Health Board and Cardiff and the Vale of Glamorgan Local Authorities to:

• Continue to foster a culture whereby children looked after feel valued and listened to; are informed of choices available to them; and can influence decisions about their care
• Promote a preventative approach to prevent needs arising or escalating
• Ensure that children looked after have timely access to health and education services that they need, in order to meet statutory education requirements, close the inequalities gap, and promote their well-being (98)
• Develop of an integrated working model to promote seamless transition between services, including actions to be taken when children go missing from care, and interaction with the criminal justice system (98)
  Cardiff and the Vale of Glamorgan Local Authorities to:
• Develop additional placements close to home for children and young people
• Orientate services to be person-centred, building trust and rapport with children and young people, promoting a sense of value through co-production

Overview
Looked after children are children who are in the care of their local authority, or in recei
of accommodation from social services. They form part of the wider umbrella of children
receiving care and support, which also includes child protection cases, and children or
parents receiving support due to the child’s illness or disability (99). Although looked after
children (LAC) is the statutory term, the acronym in particular has been noted to invoke
connotations of the child “lacking”, therefore often the term “children looked after” (CLA) is
used (99).

In 2021, there were 990 CLA in Cardiff, and 285 in the Vale of Glamorgan (7,265 in Wales)
(100). For both local authorities and across Wales, more boys were looked after than girls,
and the highest proportion were aged 10-15 years (100).
53
Data from 2018 identifies the following parental factors amongst CLA: mental ill-health
(37%); substance misuse (36% of CLA); domestic abuse (29%); physical ill-health (12%) (101).
See also chapter 18 (substance misuse). The Cardiff Youth Justice Health Needs Assessment
identifies that CLA are overrepresented in the youth justice system (102) (see also chapter
19: Secure Estate).
Information for this chapter is taken from various data sources, including a focus group with
three children looked after. Twenty-three respondents to the provider survey worked with
children looked after and 21 worked with care leavers aged under 24. These findings are not
representative of all children looked after.

What has changed since 2017?

Pre-COVID-19
The Integrated Care Fund made significant funding available for children at risk of being looked after, in care, or adopted in 2018/19 and 2019/20 (32). Cardiff published their Multi Agency Corporate Parenting Strategy 2021-2024 to describe how the council will fulfil their parenting responsibilities when the child or young person enters the local authority’s care (103). The Vale of Glamorgan have published their corporate strategy for children who need care and support 2019-2023, which has early partnership working with families as a core component, to support families to stay together, amongst other objectives (104).

Both Cardiff and the Vale of Glamorgan have experienced large increases with 305 (+47%) and 75 (+41%) additional CLA respectively, compared to Wales with 1,560 additional CLA (+28%) between 2015 and 2020 (100). The number of children on the child protection register has decreased in the Vale of Glamorgan (95 in 2016/17; 65 in 2018/19) and decreased in Cardiff (190 and 185 respectively) (105). The majority of children in Cardiff in 2018/19 were on the child protection register for emotional abuse (46%), followed by neglect (30%), physical abuse (22%), and sexual abuse (3%). This follows the same pattern as
the total for Wales. In the Vale of Glamorgan, the highest proportion of children were on the register for neglect (46%), followed by emotional abuse (38%) (105). Nationally, abuse and neglect cases have increased but this is thought to be due to better reporting (53).

COVID-19
Due to COVID-19 restrictions, young people in the focus group reported feeling isolated and needing to support each other. They were unable to see grandparents; contacts were cancelled; and one “stayed in [their] room for the whole time”. One moved from the Vale of Glamorgan to Cardiff and didn’t know anybody, which they felt impacted their confidence and mental health.

What are the care and support needs?

Individual
Autonomy
All focus group participants agreed with the National Outcomes Framework statement: “I speak for myself and contribute to the decisions that affect my life, or have someone who can do it for me”. However, later, one participant stated they “[don’t] feel relevant – just another number in the system”. Young people want to feel valued and supported by services, however, focus group discussions included “no one cares”; “was told I would be helped and guided, not seen anyone since 19 and now 22”.

A review by the Wales Centre for Public Policy identified that better outcomes of CLA are linked to the focus on reunification of families; the involvement of children and families in care decisions; placements available; and how “joined-up” local services are (106).

Language and communication
Data on Welsh or other language skills amongst children looked after is not routinely collected. Between 2014 and 2018, Care Inspectorate Wales report an increase in the number of residential child care managers and workers who speak some Welsh or are fluent (33% of managers and 38% of workers speak some Welsh or are fluent) (98). Half of children in contact with the Cardiff youth justice service are known to children’s services (103). Between 8-25% of children undergoing assessments through the Cardiff
Youth Justice Service have speech and language needs (102)

Community

Youth Justice
CLA are subject to disproportionate inequities, and are overrepresented within the youth justice system. The Cardiff youth justice health needs assessment recommends that providers of care and support for young people in youth justice systems, should additionally have links with services providing for CLA, as well as health and physical health professionals. The assessment notes that there is not yet a specific approach recommended as to the delivery of health services to this population group (102)

Wider determinants of health

Inequalities
Children in foster care in the focus group were aware of children’s disadvantages and wide inequalities between those in care and those not.

Deprivation
Wales has a higher CLA rate per 10,000 children and young people than England; and the biggest difference in rates between most and least deprived communities in the UK (53). A 2017 study identified that a child in the most deprived decile in Wales was 12 times more likely to be a CLA than a child in the least deprived decile, throughout the study period 2008-2014 (107).

Education and employment
In Cardiff, 95% of CLA attend primary school (103). Nearly two-thirds (62%) of CLA at key stage 4 have special educational needs (103), and three-quarters of CLA in school have a Personal Education Plan (103). In 2018/19, 54% of care leavers were in education, employment, or training at 1 year in Cardiff (103).
In October 2021, all CLA aged 5 – 16 years in the Vale of Glamorgan had a Personal Education Plan in place. Most (89%) were in mainstream schools, and 40% had special educational needs. Most CLA in the Vale of Glamorgan after the age of 16 are in education, employment, or training: 95% of year 12; 92% for year 13, and 72% of year 14 aged young people. Since 2019, the Vale of Glamorgan has a designated member of the Vulnerable Groups Team who works in partnership with social workers from the 15+ Team, Careers Wales, carers and post-16 education providers to ensure the school leavers access their post
16 destinations for education or training and support to ensure the young people looked after are on the right course. This has improved the numbers of looked after children accessing education employment or training post-16 (29).

Housing
Local Authorities have a responsibility to provide accommodation suitable for looked after children; and support families to stay together where possible with the aim of preventing the need for a child to be taken into care. Increasing placements are required to meet the increasing numbers of children looked after. Notably in the Vale of Glamorgan, is the increase in those placed for adoption, residential settings, and placed with parents/person with parental responsibility. There is a similar position in Cardiff, with an additional increase in foster placements, and a reduction in those living independently (108). A 2020 review in Wales found an 84% increase in children and young people placed with new parents over the preceding 5 years (99). Across Wales, although most (66%) of children are placed in their local authority, increasing numbers of children are being placed outside of Wales (255 in 2016, 365 in 2020), suggesting there may be difficulties finding suitable local placements (106). The average age in months of CLA
being adopted is 35 in the Vale of Glamorgan; 42 in Cardiff, and 37 in Wales (109). This is corroborated by a 2019 Care Inspectorate Wales review, in particular as the needs of children are becoming more complex. Some children had experienced multiple placement breakdowns, negatively impacting their well-being and relationship forming (98).

Changes of placement can be disruptive to children’s lives; in Cardiff in 2019/20, 8% of CLA had 3 or more changes of placement (103). In the Vale of Glamorgan, this figure was 12% (29). Supporting a child or young person when they leave care is a critical part of the process. Nationally, in 2018/19, 12% of 16-18 year olds leaving care experienced homelessness; compared to 21% in Cardiff in 2019/20 (103).
Despite these aims, young people in foster care in the focus group reported some negative experiences, feeling isolated as they are moved far from their families.

Unmet Needs

All three focus group participants disagreed with the NOF statement “I get the right care and support, as early as possible”. Reasons for this include feeling as though services arent open, honest, or transparent; and feeling as though services “do what they can to tick a box” rather than address need and work together with families. Children want to be “cared for and nurtured”, and “knowing their roots is also important…shouldn’t always have to be a fight for support and contact”. Young people felt as though they have “little opportunity”. Young people wanted support officers to receive more training. They wanted foster parents to “prove they are good parents”. Tension exists between the rights to a family life, and the duty to protect the child from harm, both of which are enshrined by the UN Convention on the Rights of the Child (110).

One focus group participant reported that the family who loves and wants him were only allowed to contact him 12 times a year. Another stated he had “4 foster families by 15…[my] grandparents wanted to foster [but this] wasn’t allowed”. Gaps in knowledge and understanding include the profile of Welsh and other languages amongst children looked after and children at the edge of care; and understanding of
factors leading to placement breakdown, in order to better provide appropriate placements.

What are the range and level of services needed?

Prevention and assets
The Integrated Family Support Team (IFST) is a partnership between the Vale of Glamorgan Council, Cardiff Council and Cardiff and Vale University Health Board. In conjunction with Flying Start and Families First, these programmes provide preventative and supportive approaches for families who need it. Successful working of these programmes acts to reduce harm to children and reduce escalation of care and support needs. The IFST intervenes where a child is described as being at “the edge of care”, and is able to liaise with other local teams (such as the Early Intervention Team) to support children and their
families through, for example, substance misuse intervention, or traumatic stress (111). Half of children known to the Youth Justice Service in Cardiff receive input from Children’s Services; and 15% are Children Looked After (103). Of cases known to the Vale of Glamorgan Youth Offending Service in 2021, 19% have a child protection plan, 28% have been in care, and 24% are a Child in Need. Only 16% have experienced no ACEs, and 45% have experienced 4 or more (112). Services should be aware of the association between ACEs and future interaction with the criminal justice system. Protective factors should be considered
as a preventative mechanism. Recommendations from the 2021 Cardiff Youth Justice health needs assessment are being progressed through partnerships including the Cardiff Youth Justice Service, the Cardiff Youth Justice Board, Children’s Services, and South Wales Police (102). Recommendations
include expanding the offer of well-being activities; increased involvement of families; and supporting crucial points of transition, for example, between secure estate and the community, and from children’s into adult health, social care, and justice services (102).

Focus group participants stated neighbours and
the local community were assets. Third sector
organisations such as Grandparents Raising Grandchildren were named as supportive,
including during periods of lockdown where
mutual support was provided through telephone
or online platforms.
Participants did describe negative experiences of
being in foster care which undermine sources of
support. They were unable to see their families,
and said they had “no support or places to go”.

Community Services

Transparent services
Services provided must be transparent and accountable, as young people report broken promises: “[I] was promised if I’m good can go home and visit family – never happened. It’s not fair and services shouldn’t be allowed to lie to children.” Young people perceive services to “make it up as they go along”, for example, when they believe judge’s decisions do not match the evidence provided. Processes within the system need to be clear, so that young children can understand.

Partnership Approach

Joined up services
The number of looked after children continues to increase year on year, despite policy supporting children to remain with their families and out of care, including prevention and early intervention schemes. Also too often children are placed far from home at great expense, removing them from their families and sourcing appropriate, regulated placements is often difficult. Alongside this the secure accommodation system often is unable to meet young people’s needs and there continues to be a lack of investment in expanding residential care for looked after children with complex needs, to support them to
remain close to home and transition to independent living (93).

Co-production
Co-production is central to any service. Focus
group participants were appreciative of the
opportunity to be listened to. One suggestion
to achieve this was through “creating a
befriending advocacy service – giving the
child a voice, care about their welfare, and
nurture them”.

What is likely to happen in the future?

Welsh Government have prioritised reducing the number of children looked after by local authorities (25); and identify the importance of preventing the child from needing local authority care (93). However, numbers of children looked after have increased despite this, and the impact of COVID-19 and the challenges that children and young people in vulnerable situations faced during lockdown and restrictions is yet to be fully realised.

Recommendations

Cardiff and Vale University Health Board and Cardiff and the Vale of Glamorgan Local
Authorities to:

• Continue to foster a culture whereby children looked after feel valued and listened to; are informed of choices available to them; and can influence decisions about their care
• Promote a preventative approach to prevent needs arising or escalating
• Ensure that children looked after have timely access to health and education services that they need, in order to meet statutory education requirements, close the inequalities gap, and promote their well-being (98)
• Develop of an integrated working model to promote seamless transition between services, including actions to be taken when children go missing from care, and interaction with the criminal justice system (98)
• Cardiff and the Vale of Glamorgan Local Authorities to:
• Develop additional placements close to home for children and young people
• Orientate services to be person-centred, building trust and rapport with children and young people, promoting a sense of value through co-production