Dr Silver is a clinical psychologist who has been involved in mental health services for children for more than two decades. She has managed and developed services in the NHS and social care sectors, specialising in children with complex needs including those with neurodevelopmental conditions, and those who are living outside of their family of origin, including those in residential care, supported accommodation, foster care, with special guardians or connected people, or in adoptive families, as well as those known to social care services or on the edge of care. In 2005 she led a national working group on outcomes for children in care, which recognised that it was hard for carers and social care staff to identify the mental health needs of this group, and they were often referred to Child and Adolescent Mental Health Services (CAMHS) when in crisis. They often presented with a mixture of mental health needs, attachment difficulties, normal responses to traumatic life experiences, and the fact that their placements were at risk or had broken down. The people concerned about the child or young person often didn't speak the language of CAMHS and made referrals that (despite showing genuine need) didn't meet the criteria of the service. This meant that they were turned away, and research showed that the majority of children with complex psychological needs did not access any specialist mental health services. Dr Silver felt that this was unfair. It was compounding injustice that the children with the greatest needs were finding it hardest to access the right help. She decided it was time to try something new, and set about designing a measure that would help to map these needs in a way that would allow people to address them better, and CAMH services to be able to prioritise referrals and suggest alternative sources of support for the issues they didn't cover.
The starting point for the new questionnaire was a series of focus groups in which Dr Silver asked people involved with children living outside of their birth family, what the issues were that might lead them to seek the input of someone like her or might lead to a referral to CAMHS. She also asked what factors about the child's needs or presenting issues influenced or determined the types of placements or services that were required by a child, the issues that placed placements at risk or made carers feel there were needs they were unable to meet. One focus group concentrated on children in residential care and contained residential care workers, children's home managers, social workers responsible for a child in residential care, the nurse responsible for medicals of children in a local residential home, the liaison clinician from CAMHS, and a service manager who was responsible for Local Authority placements in the area. The second group focused on children in foster care and included foster carers, link Social Workers who support foster carers, social workers for children placed in foster care, a nurse responsible for medicals for fostered children, the liaison clinician from CAMHS, and a service manager who was responsible for Local Authority placements in the area. Dr Silver recorded all of their suggestions on flipchart sheets. She then sorted these into themes, and discovered that they overlapped significantly between the two groups, and that the best way to understand the concerns was with five themes: Behaviour, Emotional wellbeing, Risk (to self and others), Relationships/attachment and Indicators of specific neurodevelopmental or mental health conditions (eg learning disability, autism, OCD, psychosis).
We then converted this information into a questionnaire that we piloted with a large range of users, including a lot of clinical psychologists with an interest in children in care and adopted children. That gave us feedback about usability, and the need to incorporate a checklist of life events that might influence the scores given. We used a system in which we score both the frequency of particular issues and the level of difficulty they present, as Dr Silver's prior research about challenging behaviour showed that this is the best model of how great a challenge a person presents to carers or services. This makes intuitive sense - a person who is aggressive every day is more difficult to manage than someone who is aggressive once a month. Yet there can be a range of aggressive behaviours from getting into someone's personal space in a threatening way, to pushing, to more serious physical assault. It is the combination of behaviours being more severe and occurring more often that is the most challenging to services. And the level of challenge presented by meeting all of a child's needs is best measured by the total requirements from all the different issues they present, so the total scores allow us to compare the needs of different children or to see how a particular child changes over time. The pattern of these issues can help to identify where interventions are required.
We subsequently sought feedback from care leavers and other experts by experience, before refining BERRI and building our online tools around it. We have then trained a large number of users to use the system. Once BERRI was working well with services for children in care we looked at how we could make it accessible to wider groups of children and young people with complex needs. We still continue to improve the system based on user-feedback, and to develop new features. As we gain more research data we continue to refine the tools to make them even more useful.
