Obesity: A Plan for Action?

Oct

‘16 The Quar terly Newslet ter of The British Association for Communit y Child Health

Childhood Obesity:

A Plan for Action?

BACCHCHAIR INFOMATICS BACCHTRAINEES OBESITYSPECIAL

Page 7

BACCHSPECIAL BACCHNEWS

BACCHNEWS

Contents and Contacts Table of Contents 2

CONTENTS and CONTACTS

3

FROM THE EDITOR

4

FROM THE CHAIR

4-5

FROM THE CONVENOR

5-6

BACCH TRAINEES

6

OBESITY SPECIAL

13-21

BACCH SPECIAL

21-22

INFOMATICS

22 @$

BACCH welcomes new members! The benefits of your BACCH membership include the following: 1 2 3 4 5 6 7

FROM THE REGIONS

7-13

BACCH is an organisation representing professionals working in paediatrics and child health in the community. It is a specialty group of the Royal College of Paediatrics and Child Health.

Advocacy on behalf of children everywhere Contributing to the development of community child health in the UK Stimulation of research/evidence-based health care Networking – regional, national, international and online with website Training and CME events Quarterly BACCH News newsletter Substantially reduced subscription to Child: Care, Health and Development the official journal of BACCH

ISABELLE ROBINSON EXECUTIVE OFFICER Tel: 020 7092 6082 E-mail: [email protected] or [email protected]

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BACD UPDATE

BACCH is an incorporated company (6738129) limited by guarantee and a registered charity29758) in England and Wales

MORE ONLINE AT www.bacch.org.uk BACCH Newsletter Contact Information BACCH EC Officers/Members www.bacch.org.uk/about/ec.php Chair Treasurer Convenor Assistant Convenor Newsletter Editor Academic Convenor Deputy Academic Convenor SAS rep

Gabrielle Laing Pauline Shute Ben Ko David Vickers Anu Raykundalia Sita Jayakumar Gabriel Whitlingum Yinka Fadahunsi-

[email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected]

Specialty Training Trainee Reps

Oluwole Elaine Lewis Briony Arrowsmith

[email protected] [email protected]

PMHA BAPA BACD BACAPH CPSIG

Sarah Mills Max Davie Kathleen Coats Karen Horridge Simon Lenton Shade Alu

[email protected] [email protected] [email protected] [email protected] [email protected]

BACCH Regional Coordinators www.bacch.org.uk/about/regional.php East Anglia Mersey Northern North West N Ireland NE Thames NW Thames SE Thames SW Thames Oxford South West Trent Wales Wessex W Mids Yorkshire Scotland

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Venkat Reddy Jackie Gregg vacant Sheila Reilly Gerry Mackin Corina O’Neill vacant Georgina Siggers Paul Wright Adeola Vaughan Melanie Parker Jehan Labatia Nia John Kathy Padoa Shiv Rajdev Vacant Christine Niven

[email protected] [email protected] [email protected] [email protected] Corina.O’[email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected]

Editor Anu Raykundalia E-mail: [email protected] (Please send your submission to Anu Raykundalia before the next Editorial deadline date.)

Design and Print Wyndeham Group Ray Bushall E-mail: [email protected]

Editorial deadline 15 November ‘16 15 February ‘17 15 May ‘17 15 August ‘17

Publication date 15 Dec ‘16 15 March ‘17 15 June ‘17 15 Sept ‘17

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All enquiries to the BACCH office: [email protected] All enquiries to the Editor The opinions expressed in BACCH News are those of individual contributors, and not necessarily of the Editor or BACCH. Publishing 2016/17

October 2016

BACCHEDITORIAL FROM THE EDITOR

CONFERENCE DIARY Date

It’s with very mixed emotion that I find myself writing my last editorial for BACCH News after three years as Editor. Relief that my workload has now lessened considerably but sadness also as I have become so fond of this publication and have really enjoyed the part I have played in producing it. This edition has a “Reader's Choice” theme. There was no clear winner but several suggestions ….. Changing Times, The Child Crossing the Seas, Looking after Refugees, The Bigger Picture in an Ever Changing World, The Curtain Falls and Collaborative Working. I hope that this issue has captured them all but as this is my last edition and my personal interest in refugee health I have gone for a mixed safeguarding theme – from obesity to unaccompanied asylum seekers. We have, thanks to Simon Lenton a response to the newly published Obesity Strategy and an article from my colleague in the Kent UASC Health Project Dr. Ana Draper on Early Intervention for UASCs. I am very grateful to Clare Shortall from Doctors of the World, who is now en route to work in Lebanon for her piece on the camps in Greece and to Michael Mchugh for highlighting the plight of children and young people in the ‘Calais Jungle’. As you will read residents in the ‘Jungle’ are about to be evicted with, from what we can tell, no clear plan for the resident children (around 1000). As the camp is unofficial there appears to be no legal obligation for the French Government to provide safeguarding. It is hard to imagine a similar situation in the UK. It would be impossible to think of no social care or health response to the unprecedented number of arrivals of UAScs that we had in Kent last year. The response has at times felt inadequate but is pole apart from what we see happening across the water. Many of you with a Looked after Children interest will now have heard from me with an update to the National Transfer Scheme that the Home Office put into place on 1st July this year. I am hoping to set up a national network for those who have an interest in UASC health so if that applies to you, please get in touch. We have now launched our website www.uaschealth.org which I hope will be of help to any staff working with this vulnerable group. Do take a look. It has been an immense privilege to have held the Newsletter Editor role. Thank you to you all for your support and feedback over the past three years. I shall miss the BACCH exec meetings, and miss the luxury of deciding on themes and articles. But I’m really looking forward to reading BACCH News without knowing the content. This role has left me very well developed punctuation spotting skills. I hope that I will be able to enjoy future issues without feeling the need to be constantly checking for exclamation mark abuse. I wish Anu all the very best in her new role. Goodbye!

Georgie [email protected]

October 2016

Organisation

Event

October 2016 13 Health Safeguarding 14

BACCH

20

CoramBAAF

November 2016 4 RCPCH

7

Health Safeguarding

8

Health Safeguarding

8

Health Safeguarding

11

DSMIG

January 2017 16 HC-UK

16

HC-UK

23

HC-UK

26

BAPA

6-27

PMHA

30

HC-UK

Location

Child Protection Update Bradford http://www.healthsafeguarding.com/conference. php?name=child_protection_update_ october_2016__bradford South West Regional Meeting ‘Anxiety in Taunton children and young people: a current epidemic?’ http://www.bacch.org.uk/about/SouthWest.htm Ensuring good transitions into adoption – London preparing and supporting children, their foster carers and prospective adopters http://corambaaf.org.uk/node/8145 How to Manage: Child Mental Health in General Paediatrics http://www.rcpch.ac.uk/courses/how-managechild-mental-health-general-paediatrics Court Skills - The Basics: Demystifying the process of giving evidence http://www.healthsafeguarding.com/ conference.php?name=court_skills_the_basics_ demystifying_the_process_of_giving_evidence Update for Named and Designated Professionals http://www.healthsafeguarding.com/conference. php?name=update_for_named_and_ designated_professionals Serious Case Reviews http://www.healthsafeguarding.com/conference. php?name=serious_case_reviews Annual Winter Meeting https://www.eventbrite.co.uk/e/dsmig-uk-andireland-one-day-symposium-and-membersmeeting-friday-11th-november-2016registration-27112063913 Safeguarding Children & Young Adults: Level 3 Mandatory Safeguarding Training in Accordance with the Intercollegiate Guidelines http://www.healthcareconferencesuk.co.uk/ safeguarding-children-and-young-adults-level3-safeguarding-training Eating Disorders Summit: Rapid Early Intervention & Developing a Gold Standard Service http://www.healthcareconferencesuk.co.uk/ eating-disorders Meeting the National Reporting Requirements for FGM http://www.healthcareconferencesuk.co.uk/ female-genital-mutilation Annual Conference - save the date http://www.bapa.uk.com/conferences Annual Winter Meeting http://pmha-uk.org/ Transforming Mental Health Services for Children & Young Adults http://www.healthcareconferencesuk.co.uk/ mental-health-services

London

London

London

London London

London

London

London

London Northampton London

March 2017 16

BACD

Annual Scientific Meeting: Updates in Neurodisability https://www.participant.co.uk/BACD2017

Manchester

24

SACCH

Annual Conference and AGM http://www.bacch.org.uk/about/Scotland.htm

Glasgow

See also the BACCH website conference directory: http://www.bacch.org.uk/conferences/conferences.php

BACCH NEWS NEEDS YOU!

For the rest of this year BACCH News has the following themes: December: ASM Christmas Special You will note that December has been allocated as ‘ASM Christmas Special’, so please let us have ideas and articles related to the event. Also, please keep sending in your ideas, thoughts, comments and feedback. It is much appreciated… Anu Raykundalia [email protected]

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BACCHCHAIR I write this on a beautiful sunny day in mid-August, knowing that by the time this issue is published autumn will be fast approaching. It’s a long time since I was in Newcastle so I am very much looking forward to spending a few days in the City, taking a short trip up the coast, catching up with many of you as well as being educated and entertained. I wrote my last column only a few weeks after retiring; three months have rapidly passed by. I spent several weeks travelling without having to rush back and I love the luxury of being able to decide what I want to do from one week to the next. I was very sad to hear about the death of Dr Simon Newell, RCPCH vice-president who contributed so much to the College and who I understand was only a few weeks from his retirement. I know that many BACCH members will have shared their condolences. Have you activated your Paediatric Care On-line account? If not, it is worth checking out this resource. All RCPCH members are able to access ‘free of charge’ but this resource is aimed as much at primary care and other health professionals so if you think this would be useful in your area it’s worth knowing that institutional licenses are also available. As topics continue to be developed, input from community paediatricians is of great value. Comments can be fed back to the RCPCH team but please get in touch with me if you have suggestions for additional topics that should be included. The resource would benefit from being broadened to cover more of the types of problems that we see from day to day and the team are open to suggestions. One of the agenda items at the last Speciality Board was about the milk sponsorship. Following this, and a meeting of RCPCH Council, it was decided to consult with the whole College membership making use of the new arrangements approved by the Privy Council which allow both on-line and postal voting. Voting closed on September 6th but I hope that you participated in the vote and that the opinion of a majority of RCPCH members will be obtained. We will watch out for the result but it is unlikely that BACCH will change their current position in not accepting support from companies that market breast milk substitutes. At the AGM in September we will be saying goodbye to a number of members of the Executive team. Dr Ben Ko has been a member of EC for several years, has initiated, lead and made a big contribution to many areas of our work; Dr Pauline Shute (BACCH treasurer), has kept our finances in excellent shape and Dr Georgie Siggers as newsletter editor has done an amazing job, producing a whole series of very high quality newsletters. I would like to offer my personal thanks as well as the thanks of BACCH members for all their hard work and dedication. Dr Anu Raykundalia who has been the deputy editor will become newsletter editor whilst Dr David Vickers, current assistant convenor, becomes convenor. Dr Paul Wright who has been the SW Thames regional co-ordinator for a number of years has now taken on the role of treasurer and over the last few months has been getting to grips with BACCH finances. We also welcome Professor Alastair Sutcliffe as Assistant Convenor. I welcome everyone to their new roles and look forward to working together. The Executive team and Council are always on the lookout for paediatricians who can contribute to the work of the organisation. At our next Executive Committee meeting on October 5th we will be agreeing a revised work plan for the year ahead and I will cover details in the next newsletter. The workforce project was undertaken in response to requests from BACCH members and has been a

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BACCHCONVENER significant piece of work over the last 12 months. Now is your chance to influence next year’s agenda. Suggestions and comments please to [email protected] Dr Gabrielle Laing [email protected]

FROM THE CONVENER Four years of fun with BACCH Times flies, when you are having fun. I joined BACCH Executive Committee in the spring of 2012, as Assistant Convenor. I couldn’t have had a more inspiring Convenor to assist, in the form of one Fawzia Rahman. At that particular moment, the Health and Social Care Act had just become law, and we were all wondering what that might bring. Before long, a plethora of unconventional providers had successfully secured contracts for Community Child Health Services. We suddenly found that we were working to different protocols and under different cultures, and not necessarily working in the same organisation as therapists and community based nurses. In other word, not only were some of us lifted off to foreign places, we had lost our allies at the same time. Divide and conquer comes to mind… As if that was not enough, austerity measures came into place shortly after, and what a double whammy that was. NHS funding of course wasn’t spared, so commissioners and managers got creative in transformational initiatives. We heard of managers in the name of increasing productivity impose a maximum of 30 minutes per appointment upon some Community Paediatric colleagues, regardless of the complexity of the cases. As the ultimate champion for threatened community child health services, Fawzia got busy, and I tagged behind and assisted away. And what fun we had! In the following two years, we put out a number of BACCH policy documents on service design and standards, in the hope that our colleagues can use them as national standards when negotiating with commissioners and managers. The ‘BACCH Prospectus’ with an associated workforce calculator, ‘BEST’ Quality Standards and ‘Service Review Template’ were amongst these documents. In particular, the Prospectus is now widely referred to, and RCPCH has been using the ‘Prospectus calculator’ regularly in their invited service reviews. All these are available to download for free for BACCH members. Meanwhile, Simon Lenton the then BACCH chair finalised the ‘Family Friendly Framework’, adding to the repertoire of guidance for Community Child Health Services. Fawzia left BACCH Executive Committee, and retired in 2014, and I took over as BACCH Convenor. ‘What am I going to do without Fawzia?’ I asked myself. I was so pleased that an old ally of BACCH, David Vickers, came forward and stood as Assistant Convenor. Meanwhile, another piece of government legislation came along in 2014, and kept me busy for the following two years. The Children and Families’ Act of 2014, with Part 3 specifically written for Special Educational Needs and Disability, became law in the autumn of 2014. And for me, the fun continues. To begin with, BACCH collaborated with BACD and put out three reference documents very quickly, including a model job description for Designated Medical

October 2016

BACCHTRAINEES Officer for SEND. I have been busy writing articles for the BACCH Newsletter on the subject, and putting relevant links on the BACCH Website for members. This year, I ran the third workshop on SEND at the BACCH ASM. It is still early days and we are still finding our way through this new piece of legislation. I hope that BACCH will continue to support members in implementing the SEND reforms, especially a programme of joint Ofsted and CQC inspections for SEND had commenced in May this year.

During our time we set up the facebook group which has almost 70 members and is a good forum to discuss experiences and what people are looking for and there may be things you feel you want to pick up and go with.

Fawzia will be pleased to know that we have continued with her good work on service design and quality standards. Under the leadership of Gabrielle Laing, current BACCH Chair, and supported by Cliona Ni Bhrolchain, who was Community Paediatrics CSAC Chair and had done an enormous amount of work on Community Paediatric workforce planning, we joined forces with RCPCH and the ‘Community Workforce Project’ was launched in 2014. This is a funded project, supported by a dedicated project manager. We collected examples of good practice up and down the country. We surveyed in detail the workload, workforce resource and service models of over 80 services nationally. And all these are correlated with published evidence from a literature search. The project will be concluded by the end of 2016. We envisage the output from this project will include an evidence based guide for Community Child Health service design, workforce planning, a new workforce calculator and examples of good practice.

We extended the role of trainee reps to a regional level where trainees can assist the BAACH regional coordinator in organising study says and also have the opportunity that tend the BACCH council meetings as observers. Speak to your regional coordinator if you are interested in taking up this role of no-one else has done so already.

So my term as BACCH Convenor has come to an end. Having served on a number of national bodies and committees over the years, I can whole-heartedly say that working for BACCH has been the most enjoyable and rewarding experience. Although those of us on the Executive Committee may have different views and approaches, we are in complete unison when it comes to what we are working towards – the best possible health service for vulnerable and disadvantaged children.

Sarah and Briony are already busy organising the next Trainees’ Day which will take place in on 26 May 2017. Their terms as Trainee Reps are due to come to an end and their replacements are being sought. Please look at the BACCH website for further information or contact them. They are both happy to explain the roles. Thank you to them both for all their hard work, especially in organising some very successful trainee days.

I shall miss working for BACCH. I am confident that you are in very good hands as David Vickers takes over as the Convenor, and I wish the Excecutive Committee well in their future pursuits.

Thank you to Gemma for contributing the following on one aspect of her training.

Ben Ko [email protected]

FROM OUR TRAINEES Our time as trainee reps for BACCH is coming to an end, we have had a great few years and look forward to handing the reins over to a new team! To give you an idea of what it entails we have done a job spec of sorts: As the trainee reps our fundamental role is to represent the views of trainees to the BACCH committee. So in order to do this you need to attend the executive committee meetings every quarter. They last a couple of hours and you will usually need to take them as study leave. The other major part of the role is planning and running the BACCH trainees’ day. Started in 2013 these have really gone from strength to strength…during our time we have focussed on competencies and this has seemed quite popular. Apart from those things the role is very flexible to allow you to pursue areas of BACCH exec committee work that interests you.

October 2016

We also regularly contributed to BACCH News and have started a ‘cases you have learnt from’ section to help all trainees get things published!

All in all it’s been great fun, a good learning experience and presents loads of opportunities to get involved with around your interest. Thanks to everyone who has supported us in our role and loads of luck to those of you applying to taking over from us! Briony and Sarah [email protected]

My CAMHS Placement - a reflection Last year I was fortunate enough to have the opportunity to spend six months of my Community Child Health training with the local Child and Adolescent Mental Health Team (CAMHS team). I wanted to share my experiences in the hope that this may become more commonplace in our training. I had had limited involvement with CAMHS prior to this placement and therefore did not really know what to expect but decided my main objective, which was not particularly ‘SMART’ was to gain a greater understanding of what CAMHS did, in the hope that I could use this knowledge to help patients I came across in the Community that might benefit from their input. The six months was full of many more opportunities and experiences than I anticipated. I envisaged observing a lot of ADOS assessments, which I did, but it was the over five age group (I only had experience of children under the age of five). I was struck at how it had taken until adolescence for these teenagers to be identified as being on the autistic spectrum, many because they had presented with mental health problems and wondered how things may be different had the diagnosis been

Continues overleaf

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BACCHTRAINEES made earlier. I am now far more appreciative of the overlap between mental health and autistic spectrum disorders. I also participated in ADHD assessments and follow up clinics, learnt more about the various types of medications and gained confidence in starting and changing medications. I saw new referrals, mainly depression and anxiety jointly with members of the CAMHS team and, as a consequence, became much more confident and able to take a competent psychiatric history. I was surprised how open patients and their families were when I took a psychiatric history and wondered whether this was because they were being seen by the psychiatric team so thought they had to share intimate information, or whether I had become more confident in asking more personal questions, perhaps it was a bit of both. As a consequence, I felt I knew my patients and their families well and hope this continues in my paediatric practice. I discovered what is available in the voluntary sector for children with mental health problems that may not reach the threshold for CAMHS, which made me realise there are a lot of resources out there that may not be well ‘advertised’ to Paediatricians. I certainly didn’t expect to be on the ‘overdose rota’; seeing the patients on the paediatric wards who had taken overdoses and were medically fit for discharge. This really improved my suicidal intent history taking and assessment and I found, when on my acute paediatric oncalls that I spent more time exploring this with patients, rather than just taking a very brief history, prescribing the n-acetyl cysteine and admitting them to the ward for ‘CAMHS assessment in the morning’.

FROMTHEREGIONS BACCH Trent Educational Meeting 27th June 2016 Barnsley Hospital, South Yorkshire, was the host location for the above meeting. Chaired by Dr. Shobha Sivaramakrishnan, this event was well attended by paediatricians from around the region. It was an excellent opportunity for networking as some trainees in attendance are exploring a career in community child health and others were on the GRID programme or nearing CCT. There was a chance for discussion with Consultant colleagues in CCH during breaks and also during the question and answer session on the CCH Grid training programme. The theme of the day was ‘behaviour’ and we were fortunate to hear from Vicky Dawson, the founder of Yorkshire and the Humber’s Children’s Sleep Charity. This is the only charity available to support parents in getting a good night’s sleep using cognitive and behavioural methods. She shared her personal experiences which led her to becoming a sleep practitioner. It was interesting to note that up to 86% of children with additional needs have sleep issues which are likely to be behaviour based. Through sleep success workshops and working alongside Sheffield Children’s Hospital, there is now a support programme in place for parents who are experiencing the consequences of sleep deprivation which impact every area of family life, mental health and emotional wellbeing.

I counselled patients about commencing anti-depressant medication (obviously under supervision of the Consultant) and monitored the patient’s progress with regular reviews. I sat in on CBT sessions with the nurse therapists and was encouraged and supported to work with a girl with social phobia. It was really rewarding when she took the train by herself! In addition to the clinical work I was able to take away some ideas about how CAMHS work that may help my future practice in Community Paediatrics. I found the weekly team meeting where patients were discussed and ideas and suggestions for management were explored amongst the team was really beneficial to my learning. My clinical supervisor’s practice was to meet trainees on a weekly basis to discuss patients or research etc. On reflection I think these two meetings made me feel very supported in an alien environment and is something I would be keen to implement when I reach Consultant level to facilitate a supportive team environment. Some other things I experienced included; attending school meetings regarding a patient with school phobia, liaising with patient’s teachers, social and support workers. I also jointly assessed a child with hallucinations who ultimately received a diagnosis of epilepsy in the joint neurology and psychiatry clinic. Overall this placement vastly exceeded my expectations. My experiences were invaluable to my clinical and non-clinical learning. I realised how important it is to have good links with the CAMHS service and this should start at a trainee level. Perhaps it should be a compulsory part of the curriculum? Ultimately and most importantly I feel that this placement has made me a better Community Paediatrician.

Gemma Trays ST8 Community Paediatric Trainee [email protected]

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We were privileged to hear from Dr Max Davies about behaviour difficulties in children and the challenges and responsibilities faced by community paediatricians. We discussed which services were appropriate for children with behavioural problems and considered a bio-psycho-social approach to the individual child. During a workshop (see image) we discussed this further; exploring the predisposing, precipitating, perpetuating and protective factors underlying challenging behaviour. Using such a technique can help parents understand the root of the behaviour. The afternoon sessions discussed local service development and improvement within individual hospitals in the region. There was a mix of trainee presentations and an educational session on the investigations of children with sensorineural hearing impairment; those to be performed on all children and those required only in specific conditions. This led to a discussion about Connexin testing and regional variations in services. Overall an educational day which was well organised, attended and gave plenty of food for thought for paediatricians of all grades with an interest in CCH. Dr. Fiona Blyth ST5 Paediatric Trainee Yorkshire and the Humber

October 2016

CHILDHOODOBESITY

Childhood Obesity: A Plan for Action. Big, brave and bold or Weak, wan and weedy? How should we respond?

On his re-election in May 2015 David Cameron rightly made tackling the childhood obesity epidemic a flagship issue, putting number 10 in charge, rather than the Department of Health, in order to tackle the wider non-NHS issues. Draconian action in a ‘game changing moment’ was promised by Jeremy Hunt to tackle obesity, which currently costs the NHS at least £4 billion annually and may eventually bankrupt the NHS if action is not taken now. Then on 13 July Theresa May, in her inaugural speech, promised that her government will do everything to give back people control over their lives and not merely attend to the interests of the powerful in society. Professional expectations for the obesity strategy were high. The back story, prior to the obesity plan, is interesting. Public Health England published ‘Sugar Reduction Responding to the Challenge’ in 2014 and ‘Sugar Reduction the Evidence Base’ in 2015. The Health Select Committee then produced a publication entitled ‘Childhood Obesity - Brave and Bold Action’ which endorsed the majority of the PHE conclusions.

October 2016

A summary of the key points are reproduced below:

• Strong controls on price promotions of unhealthy food and drink. • Tougher controls on marketing and advertising of unhealthy food and drink. • Extending current restrictions on advertising to apply across all other forms of broadcast media, social media and advertising. • Limiting the techniques that can be used to engage with children, including plugging the ‘loopholes’ that currently exist around the use of unlicensed but commonly recognised cartoon characters and celebrity endorsement within children’s advertising. • Tightening the current nutrient profiling model that governs what can be advertised. • Limiting brand advertising of well recognised less healthy products including restrictions on sponsorship on e.g. sporting events. • A centrally led reformulation programme to reduce sugar in food and drink. • A sugar drinks tax with all proceeds targeted to help those children at greatest risk of obesity. • Labelling of single portions of products with added sugar to show sugar content in teaspoons. • Improved education and information about diet. • Universal school food standards. • Greater powers for local authorities to tackle the environmental issues leading to obesity. Early intervention offered to help families of children affected by obesity. • Further research into the most effective interventions.

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CHILDHOODOBESITY

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The report concluded that there is no single solution equally applicable to all areas and that we should experiment with solutions rather than working for perfect proof of what works, especially where the risks of the intervention are low. Neither the Public Health England nor the Health Select Committee reports were mandated by government or supported by resources as these were expected to be contained within the childhood obesity plan. The Spring budget 2016 saw the introduction of a soft drinks sugar tax to be introduced in 2018, which will be a levy on producers and importers rather than on consumers. There will be two bands: one for total sugar content above 5g per 100ml with the second higher band for drinks with more than 8g per 100ml. Pure fruit juices and milk-based drinks will be excluded. Then August 2016 saw the long awaited launch of the ‘Childhood Obesity - a Plan for Action’. Spot the missing components below! It is primarily a strategy to prevent the occurrence of overweight and obese children, not a plan to address the management of overweight families, although many actions may be common to both.

The recommendations included:

• Introducing a soft drinks industry levy, with revenues being invested in programmes to encourage physical activity and balanced diets for school age children. • Taking out 20% of sugar in products. Sugar reductions should be accompanied by reductions in calories and should not be compensated for by increases in saturated fat, with progress being reported by PHE every six months. • Supporting innovation to help businesses to make their products healthier. • Every food and drink being assigned a ‘nutrient profile’ based on much sugar, fat, salt, fruit, vegetables and nuts, fibre and protein it contains. • Developing a new framework by updating the nutrient profile model. • Making healthy options available in the public sector. The public sector in England spends about £1 billion on food and ingredients and will comply with the Government Buying Standards for Food and Catering Services (GBSF). • Continuing to provide support with the cost of healthy food for those who need it most. The Healthy Start scheme provided an estimated £60 million worth of vouchers to families on low income across England in 2015/16 will continue to support an average of 480,000 children in low income families each month. • Helping all children to enjoy an hour of physical activity every

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day. Every primary school child will receive at least 30 minutes of exercise delivered in a school setting every day. A further 30 minutes will be encouraged outside of school time. OFSTED will measure the impact on outcomes for pupils. Improving the co-ordination of quality sport and physical activity programmes for schools. The Sport England Strategy ‘Towards an Active Nation’ (2016) has already set out new opportunities for families and children to get active and play sport together, supported by £40 million investment and a further £300 million will be invested in support for cycling and walking. Creating a new healthy rating scheme for primary schools. From September 2017, we will introduce a new voluntary healthy rating scheme for primary schools to eat better and move more and this will be included in OFSTED inspection criteria. Making school food healthier. The School Food Plan, came in to force from January 2015 and this will be updated by the Department for Education (DfE), supported by PHE. Clearer food labelling. Ensure we are using the most effective ways to communicate information to families. This might include clearer visual labelling, such as teaspoons of sugar, to show the sugar content in packaged food and drink. Supporting early years settings. PHE have commissioned the Children’s Food Trust to develop revised menus for early years settings by December 2016 which will be incorporated into voluntary guidelines for early years settings. Harnessing the best new technology. We will therefore work with PHE, Innovate UK, the third sector and commercial players to investigate opportunities to bring forward a suite of applications that enable consumers to make the best use of technology and data to inform eating decisions. Enabling health professionals to support families. Health Education England (HEE) and PHE have launched a suite of resources aimed at supporting the health workforce to ‘Make Every Contact Count’ and further targeted training for Health Visitors and School Nurses will be developed.

The plan concludes by saying that this ‘represents the start of a conversation, rather than the final word’ and that ‘long-term, sustainable change will only be achieved through the active engagement of schools, communities, families and individuals’.

The recommendations of the two publications are contrasted in the table below. Proposed interventions Controls on price promotions Controls on marketing and advertising Restrict advertising on all forms of media Limit celebrity endorsement Tightening nutrients that can be advertised Limit brand advertising Limit sporting sponsorship deals Reformulation programme to reduce sugar content Sugar drinks tax Labelling sugar in single portions Improved education about diet Universal school food standards Greater powers for LAs to tackle environmental issues Early intervention for these families Further research into effective interventions Innovation support for businesses Healthy options in the public sector Food vouchers for low income families 30 minutes of physical exercise in school Sport and physical activity programs for schools Healthy schools rating program by OFSTED School food plan/Children’s Food Trust Harnessing new technology Training for health professionals

Brave and bold / / / / / / / / / / / / / / / / x x x x x x x x

Obesity plan x x x x x x x / / x / / x / x / / / / / / / / /

October 2016

CHILDHOODOBESITY Responses to be Obesity Plan.

The plan has been greeted with virtually universal condemnation, from ex-ministers, through professional alliances and concerned celebrities. ‘This is certainly not the ‘game changing’ plan for reducing childhood obesity that it had been built up to be. This policy has over-promised, but I fear that the reality will be under-delivery’ Dr Dan Poulter ex Conservative Minister for Health ‘The disappointing watering down of the childhood obesity strategy demonstrates the gap in joined-up evidence-based policy to improve health and wellbeing. Government must match the rhetoric on reducing health inequality with a resolve to take on big industry interests and will need to be prepared to go further if it is serious about achieving its stated aims.’ Dr. Sarah Wollaston, Conservative Chair of the Health Select Committee ‘Disappointingly short of what is needed’, with some anticipated measures ‘significantly watered down or removed entirely’. The Obesity Health Alliance ‘Where are the actions on the irresponsible advertising targeted at our children, and the restrictions on junk food promotions? With this disappointing and, frankly, underwhelming strategy, the health of our future generations remains at stake’ Jamie Oliver, Celebrity Chef

The concerns

The greatest concern was the lack of regulation for the food industry to improve the nutritional content of food and drinks and action to restrict advertising in all forms of media of unhealthy foods, particularly towards children and young people. Many of the proposed actions were merely reinforcing existing policy that had already been announced, for example, the sugar tax, the Healthy Start Scheme, the School Food Plan, the Government Buying Standards for Food and Catering Services, and food labelling reform.

The development of the diabesity epidemic parallels the Anthropocene, free rein of market forces (i.e. neo-libertarian economic policies), commercialisation of food production and sedentary lifestyles associated with the digital age. In essence the technological revolution is outstripping the ability of human evolution to adapt to new circumstances. This is not a problem that is going to go away with better food labelling, exercise in school and OFSTED inspections! This is a global problem and also an international equity issue since the numbers of people now overfed (approximately 2 billion) exceeds those underfed (approximately one billion), but in both scenarios it is poor people who suffer most from malnutrition associated with either excess or lack of calories. European evidence had shown a link between financial distress and obesity. People experiencing periods of financial hardship are at increased risk of obesity and these risks are greater with more severe and recurrent hardship. This Conservative government has demonstrated a lack of evidencebased, pan government departmental integrated policy and planning on this issue. Obesity ranks equally with terrorism, climate change and substance misuse in terms of global economic impact and personal misery for humanity as a whole. In an era when this Government claims to be a world leader in health representing the people it serves, this obesity plan for children now and the next generation should have been better. The current obesity plan risks that sugar will be replaced with artificial sweeteners (thereby maintaining the desire for sweetness) or sugar will be replaced by fats (which have a higher calorie content per gram). The focus on schools is unlikely to engage families in the general policy of ‘eating better and moving more’. Hopefully innovation at a local level will prove me wrong. Sugar also matters because of its impact on children’s dental health. 12% of 3 year olds now have tooth decay, rising to 28% of children by the time they turn 5 years. Dental caries are the most common reason for children aged between five and nine to be admitted to hospital—some 46,500 children and young people under 19 were admitted to hospital for tooth removal in 2013–14.

Tackling Obesity Plans from the 4 Nations The new actions focus on the school environment where young children spend approximately 50% of their annual days and less than 50% of their waking days, with OFSTED being given the responsibility of monitoring the impact of better food and exercise on school outcomes. It will be interesting to see how they manage that. Better food labelling is welcomed, but voluntary agreements to reduce sugar content by the commercial food sector have not, to date, proved effective as evidence-based policy strategies to change the eating and drinking habits of the nation. Interestingly the food industry would probably welcome compulsory regulation, rather than voluntary agreements, simply because it creates a level playing field between competing food producers. Mike Coupe, chief executive from Sainsbury’s summed up the situation well: ‘We need compulsory and measured targets for the reduction of sugar (and other nutrients such as saturated fat) across the whole of the food and drinks industry. Nothing less will work.’ Even the British retail Consortium agreed saying: ‘Only laws would achieve the 20% reduction in sugar demanded by the government plans’

October 2016

Each nation in the United Kingdom has their own childhood obesity plan or strategy. • Preventing Overweight and Obesity in Scotland • Turning the Curve on Childhood Obesity in Wales • A Fitter Future for All. A Framework for Preventing and Addressing Overweight and Obesity in Northern Ireland 20122022 • Childhood Obesity A Plan for Action (England) The same themes appear in each report. A recent systematic review of national obesity policies concluded that ‘the policies are often written in general terms and frequently identify sets of actions which could be pursued without making commitment to carrying them out. Interventions in schools and the workplace are the welldeveloped. Many countries have created active transport strategies to increase both cycling and walking. Apart from these, there are few specific proposals for tackling obesity. Those countries with obesity polices highlight the need to tackle the problem among socially disadvantaged people. Fiscal and legislative interventions are almost completely absent from policy documents. There is also little mention of funding for the range of proposed interventions’.

What should we do next?

When facing a global epidemic is often difficult to know where to start! I would suggest reviewing the problem from the perspective of multiple stakeholders as the first step, followed by understanding

Continues overleaf

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CHILDHOODOBESITY 2. Children of pre-school age who are capable of walking unaided should be physically active daily for at least 180 minutes (3 hours), spread throughout the day. 3. All under 5s should minimise the amount of time spent being sedentary (being restrained or sitting) for extended periods (except time spent sleeping).

public health approaches based on the life course pathways, reviewing ‘what works’ from an evidence-based perspective, and finally engaging with local obesity prevention plans, would be a reasonable way forward.

Understand the problem - read the key reports.

There are a plethora of reports relating to obesity prevention and obesity management from a wide range of organisations from the World Health Organisation, to independent charities, to European organisations, NICE and Public Health England. The perspectives of different organisations are very briefly reviewed here. 2007 Foresight Report. Tackling Obesities: Future Choices – Obesogenic Environments – Evidence Review. This report examined the research evidence on the impact of the physical and social environment on obesity and concluded there was a clear link between the broader environment with both quality of nutrition and physical activity. The report uses the term ‘obesogenic environment’ which refers to the role environmental factors play in determining both nutrition and physical activity. The conclusion was that while changes to the environment are unlikely on their own to solve the problem of obesity they need to be considered alongside complementary strategies to address the determinants of obesity. 2012 WHO Prioritizing areas for action in the field of population-based prevention of childhood obesity This report provides a set of tools to identify priority areas for action in the field of population-based prevention of childhood obesity. The tools can be used at a national or local level. The report provides a structured approach based on process, output, outcome, and impact to monitor the effect of interventions. 2014 PHE Everybody Active, Every Day: An evidence - based approach to physical activity This report complements the sugar reduction report above. We are 24% less active than in 1961. To deliver this vision requires action across four areas at national and local levels. • Active society: creating a social movement • Moving professionals: activating networks of expertise • Active lives: creating the right environments • Moving at scale: scaling up interventions that make us active The report reiterates the Chief Medical Officer’s Guidelines on Physical Activity as follows. For early years (under 5s) 1. Physical activity should be encouraged from birth, particularly through floor-based play and water-based activities in safe environments.

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For children and young people (5-18 years): 1. All children and young people should engage in moderate to vigorous intensity physical activity for at least 60 minutes and up to several hours every day. 2. Vigorous intensity activities, including those that strengthen muscle and bone, should be incorporated at least three days a week. 3. All children and young people should minimise the amount of time spent being sedentary (sitting) for extended periods. Further guidance on exercise is included in the 2009 NICE ‘Physical activity for children and young people’ (PH17) PHE Sugar Reduction The evidence for action and further resources This report provides the evidence behind ‘Brave and Bold’. Public Health England provide a useful list of resources on their websitehttps://www.noo.org.uk/Resources/Reviews 2014 EU Action Plan on Childhood Obesity 2014-2020 This report helpfully reviews childhood obesity in Europe and the various interventions being taken by different governments. No single, universal strategy can be recommended because tailored interventions will be needed for different geographical and socioeconomic groups since priorities will vary between nations, regions and individual communities. NICE Recommendations NICE has produced multiple evidence-based guidelines for professionals working in health and social care covering the prevention of obesity, management of obesity, evidence for the benefits of exercise for both adults children and young people. Their extensive recommendations will not be reproduced here as they are readily available on the NICE website. http://pathways.nice.org.uk/ pathways/obesity 2012 RCPCH Position statement Childhood obesity The RCPCH recommends action in four areas: • All health professionals should be trained in weight management issues, following NICE and SIGN guidance, alongside emphasising the importance of parenting style and parents’ lifestyles when their children’s weight is considered. • The extension of free school meals so that it is universal should be looked at and costed, while academies and free schools should be mandated to follow nutritional standards. • Local Authorities need to implement strategies to encourage active travel and play, by making the built environment more accessible for young pedestrians and cyclists. These plans can be implemented through joint partnership with Health and Wellbeing Boards. • Food manufacturers’ influence on younger children should be curtailed by implementing a ban on ‘junk’ food advertising before the 9pm watershed. • Increases in taxation on foods high in salt, sugar and fat in other countries should be independently evaluated, scoped and costed with a view to implementation across the UK.

Review the evidence - know what works.

It is important to recognise that the quality of evidence in the prevention of obesity field lags far behind the levels expected

October 2016

CHILDHOODOBESITY in randomised controlled trials, for obvious reasons. Most recommendations are based on observational studies supported by professional expertise. However there is an increasing consensus that the problem must be tackled by legislation and regulation, complemented by tackling the determinants of ill-health generally and then eating and exercise lifestyle specifically. All the evidence to date suggests that interventions to reduce access to high calorie foods is a more successful approach than attempting to educate individuals or groups in order to change lifestyles and eating habits. UK Health Forum for Public Health England 2014 provides a useful framework and recommendations are reproduced here. Produce Less This theme explores options to reduce sugar consumption through reductions in agricultural production and assessing the impact of other non-health policies on sugar consumption. Currently the equivalent of 13.3 million tons of white sugar is produced within the European Market, with over 90% used for human consumption. The complex sugar market in Europe is governed by a combination of agriculture production quotas (including subsidies), a minimum sugar beet price and trade mechanisms. • Review EU and UK sugar market for impact on consumption (including the Common Agriculture Policy – CAP) • Undertake Health Impact Assessments (HIA) on all policies that influence nutrition e.g. trade, investment. Use less This theme includes options to use less sugar through changes to food manufacturing. This theme focuses on how food providers including manufacturers and the food service sector may reformulate their products to contain less sugar or use non-calorific substitutes. Reformulation has led to an estimated 15-30% reduction in added salt in the British diet through successful Government-led initiatives. • Reformulation to reduce free sugar content • Substitution of sugar with non-calorific sweeteners Sell less This theme explores the potential options through which less sugar could be sold for human consumption. Off-shelf displays are frequently used to increase sales. Confectionery and snacks, for example, have become a mainstream feature of retail checkouts ranging from supermarkets, to news agents and petrol stations. A recent study found end-of-aisle displays increased the sales volumes of carbonated drinks by 52%. A variety of mechanisms to sell less sugar to the population are explored, ranging from taxes to environmental changes in the community and within retail stores. • Tax or duty on sugar or products high in sugars • Switch in-store retail promotions away from high sugar foods • Reduce portion sizes of high sugar foods • Diversification into other products • Public and private sector procurement standards and guidelines to restrict sugar and promote alternatives • Planning restraints on outlets selling food high in sugar Market less Food marketing is known to drive purchasing and consumption and this theme explores potential options through which the marketing of sugary products to the population could be reduced. The commercial sector is estimated to have spent £838 million promoting confectionery, snacks, fast food and sugary drinks in the UK in 2007. Options for action explored include marketing restrictions, removal of tax incentives and regulating health claims. • Controls on marketing of foods high in sugar, saturated fat and salt (HFSS). • Disallow marketing of sugary food as a tax-deductible expense for companies. • To agree a nutrient profile model e.g. for use in the EU health claims regulation.

October 2016

• Develop guidelines to rate food and beverage companies suitability for sponsorship (e.g. of local authority activities). Recommend less Implemented as part of a package of wider measures, the provision of information, communications and education all have important roles in supporting behaviour change through improved knowledge and skills, and changing social norms. Options for action explored range from public awareness and social marketing campaigns to professional and workforce education on sugar. • Review Food Based Dietary Guidelines (FBDGs) in light of new SACN sugar guidelines. • Public awareness & social marketing campaigns. • Professional education of health, social care and catering workforce. • Nutrition education in schools including practical cooking skills. Eat less Consumer research has identified the need for information which supports rapid judgements on the nutritional content of individual products, as well as comparisons between products ‘at a glance’ while shopping. This theme explores the provision of information on sugars to support consumers to eat less, through mechanisms which range from labels on food packaging to menus and displays in the out of home food service sector. • Implement UK FOP hybrid nutrition labels universally on all food products. • EFSA to review food labelling Reference Intake levels for total sugars. • Codex Alimentarius Commission (Codex) to set standards for front of pack labels. • Consider health warnings on products high in sugar. • Consider menu and display labels in out of home food service outlets.

Public health - the life course pathway approach Tackling obesity throughout childhood and adolescence will require substantially different approaches at different ages since the factors that influence diet and exercise are very different between infancy and teenage years. Basing national and local strategies to tackle obesity on a life course approach have been recommended from the World Health Organisation (WHO) to the National Institute for Health and Care Excellence (NICE). Indeed, the life course approach is proposed in the BACCH/BACAPH Family Friendly Framework for improving services. The life course approach recognises that the health of children requires protection from hazards (that can cause harm) throughout their life course simultaneously coupled with the promotion of assets (which create health). This twin protection/promotion approach can be applied to both lifestyles (factors largely within the control of families) and the wider determinants of health (generally outside the immediate control of families).

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CHILDHOODOBESITY Lifestyle assets

Determinant assets

Stable family

Stable communities

Good diet

Sustainable economy

Creative play Friendships

Affordable homes Lifestyle assets

Promotion

Infant

Child

Determinant assets

Small inequalities

Protection

the whole population (universal) or high risk individuals or groups (selective) and interventions to tackle the determinants of obesity. Interventions for obesity/diabetes prevention Note: although interventions are categorised individually it must be a recognised that the most effective programs combine individual interventions into a combined program. The particular program implemented locally must address the predominant local issues, seek engagement with multiple stakeholders, and innovation must be linked with evaluation to determine what works. Examples of child orientated interventions

Lifestyle hazards Poor diet

Lifestyle hazards

YP

Determinant hazards

Determinant hazards

Smoking

Poverty

Lack of exercise

Poor housing

Substance misuse

High crime

Antenatal Preschool

Figure x: Illustrating a life course pathway (vertical) in the centre, with assets and hazards relating to determinants and lifestyles as the factors to be addressed at different ages within the life course pathway. This general approach is illustrated in figure x. The intention would be to align public health interventions with service interventions, for example, protecting individuals from excess calories, promoting exercise as well as managing the diabesity and cardiovascular complications of obesity. Some of the key wider determinants for children include low income households, living in areas of deprivation, poor housing, little access to the natural environment and low educational attainment of mothers. This twin protection/ promotion approach is then coupled with public health programmes targeted specifically on individual conditions, for example, fluoride in water to prevent dental caries or folate in flour to prevent spina bifida or community based programs such as walking to school or safe cycle ways. Obesity prevention interventions are therefore orientated towards:

Diet (‘eat well’)

• Reducing exposure (protection) to known dietary hazards such as refined sugars, particularly in drinks, and excessive sugar and fats in processed food. • Increasing exposure (promotion) to a healthy diet rich in unprocessed nutrients especially fruit and vegetables.

Exercise (‘move more’)

• Increasing exposure (promotion) of healthy levels of exercise and activity. • Decreasing exposure (protection) from excessive inactivity particularly ‘screen time’. These interventions can be orientated directly towards children, their families or the communities in which they live, which in turn provides a framework for local action. Lifestyles

Determinants

Services

Child Family Community

Table x: a simple matrix for organising interventions at a local level. This simple matrix can be expanded to include more detail on the vertical axis and then lifestyles, determinants and services columns can be further divided by interventions to tackle hazards or promote assets. Public health/health service interventions include advocacy to promote national policy change, local advice and surveillance for either

12

Child

Inaccessible services

Lifestyles Promotion five a day balanced diet Breastfeeding and late weaning (>6/12)

walking to School aged school PHSE in school 60 mins. Exercise per day healthy foods at Young school person walking/cycling to school active leisure times

Determinants Protection Promotion unhealthy financial diets support for healthy eating high calorie breastfeeding foods places excessive Green play screen time space excessive screen time snacking between meals

safe routes to School access to active leisure facilities

Protection

Health Services Promotion Protection healthy eating weight monitoring

poverty advertising unhealthy foods

breastfeeding promotion

growth surveillance

poverty advertising unhealthy foods

Healthy schools

BMI surveillance

poverty fast food outlets near schools

PHSE programme content

BMI surveillance

Similar tables can be created for family –based and community based interventions for local implementation. Likewise the same approach can be used at a regional or national level.

Engage with local obesity prevention plans.

Paediatricians have wide experience seeing children and families where obesity is a problem and should positively engage with this agenda in order to improve the health of children and reduce the future burden on NHS services. Each clinical area should nominate a clinical lead both to contribute to the prevention agenda as well as to further improve service pathways for the management of obesity. Suggested actions could include: • Lobbying your local public health lead for children to implement the childhood obesity plan. • If need be, advocate for a local childhood obesity strategy with both the local authority and local clinical commissioning groups. • Offer to be part of the stakeholder group. • Be prepared to contribute - encourage the use of life course pathway approaches. • Review data on the distribution and prevalence of obesity locally. Consult the CHIMAT Obesity: Tools and data website http:// www.chimat.org.uk/obesity/tools or the Best Start materials http://www.chimat.org.uk/beststart • Examine the value of existing interventions. • Distil evidence base for interventions that complemented the existing local strategy. • Check to see whether your local parent or child health records contain appropriate BMI charts. • Prioritise and implement the new programs. • Make sure the prevention strategy is complemented by service pathways to manage obese children. • Review hospital food quality and procurement for both patients and staff. • Contribute to additional training/learning programs for health and education staff as appropriate. • Ensure that when innovations are proposed they are evaluated rigorously to determine what works. • Check that the impact of community and school-based proposals are monitored and evaluated. • Report innovations that work to BACCH to be highlighted to others.

October 2016

BACCHSPECIAL The Future

The current obesity prevention plans across all four nations are the beginnings of translating evidence into practice. Drawing comparisons with reducing smoking, the introduction of speed limits and safety belts is helpful in that both started with changes in lifestyles before later mandated legislative policies were introduced. Hopefully these more Draconian game changing interventions will be introduced sooner rather than later, in the meantime we must advocate for changes locally to improve nutrition and exercise opportunities for children in our local communities. We must also argue for improved evaluation of local initiatives or innovations, particularly those that have the potential to be rolled out extensively. Research must concentrate on both the evaluation of interventions and the implementation of successful interventions. Simon Lenton Consultant Community Paediatrician [email protected]

Obesity Quiz 1. Which is the largest global burden? • smoking • alcohol • obesity • armed violence 2. How much sugar as an average eight-year-old consume in a year? • 10 kg • 20 kg • 30 kg 3. What proportion of the world's population go to bed hungry? • 10% • 20% • 30% 4. What proportion of the world's population is overweight or obese? • 10% • 20% • 30% Answers on page 23 October 2016

BACCH SPECIAL Stranded – Shifting from in transit to static the safeguarding needs of refugee children in northern Greece The Humanitarian Crisis in Europe

Over the last year, the number of people moving from the Middle East to Europe has reached unprecedented levels; the like of which has not been seen since the Second World War. The number of people that have been forcibly displaced worldwide has now exceeds 60 million, including 20.2 million refugees fleeing war and persecution.1 By the end of 2015, 856,723 refugees had arrived in Greece and 3,780 were reported missing or presumed dead. From the beginning of 2016 till June when I arrived back from Greece, a further 157,801 arrived in Greece crossing the Aegean and 59% of whom were women and children2 and 376 are reporting missing or dead.3 According to the UNHCR 90% of the refugees in Greece come from the top 10 refugee producing countries in the world and with the closure of the Balkan route there are now 59,836 persons of concern stranded across Greece.4

EU – Turkey Agreement

On 18 March, the European Union and Turkey agreed that all new ‘irregular migrants’ crossing from Turkey to the Greek islands as of 20 March 2016 will be returned to Turkey and for every Syrian refugee returned another Syrian refugee will be resettled to the EU. So far, 484 people have been returned from Greece to Turkey under the Greece-Turkey Bilateral Readmission Agreement as of 28 August. The main nationalities included Pakistan, Afghanistan, Bangladesh, Iraq, India, Morocco, Egypt, Palestine and Algeria. 31 Syrian nationals have voluntarily returned to date.5

The Greek Asylum System and Relocation

For those arriving prior to the EU-Turkey agreement there are three options: apply for asylum in Greece, apply for family reunification or apply for the relocation programme. The biggest obstacle with these options is that at the time of my journey to Northern Greece in May 2016 they could only be applied for via a Skype appointment between 10-11am with the Greek Home Office. Many refugees reported difficulty not only accessing a good wifi connect to do the skype call but not being able to get through when they did. In September 2015, the Justice and Home Affairs Council agreed to relocate 160,000 asylum seekers from Italy and Greece, to assist these countries in dealing with the pressures of the refugee crisis. Under the emergency relocation scheme, asylum seekers who are felt to have a high chance of success (EU average recognition rate of over 75%) are relocated from Greece and Italy to other Member States to have their asylum applications processed. If these applications are successful, the applicants will be granted refugee status with the right to reside in that Member State. However, the number of actual relocations and scheduled departures remains low at 3,386. 5% of the 66,400 people who are supposed to be relocated from Greece by September 2017.

Host Country Factors

In contrast to other refugee camp settings this is a refugee response in the context of Europe with Greece ranking 29 out of 118 in Human Development Index.6 However, the economic crisis in Greece is well known with Greece owing its creditors more than €300bn - about 180% of the annual economic output of the country (GDP) exacerbated by 24.9% unemployment.7

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BACCHSPECIAL Access to the Greek healthcare system is via the local hospital and healthcare clinics. However, there is often an issue with lack of interpreters and transport to get there. There were only two ambulances available in the region I was based in in Northern Greece and there can be a large variation in time to arrive with some taking up to 40 minutes. In general, the Greek healthcare infrastructure is overstretched and needs additional resources to support its now significantly larger population. As only certain people were allowed to transport refugees there was real difficulties in getting to appointments.

Safeguarding and the impact of exposure to violence

As Healthcare professionals we are in a key position to be able to identify those with vulnerabilities and had a duty of care and are bound to try and safeguard duty children in these difficult situations. Yet, never have I found safeguarding so challenging both in terms of its nature and trying to prevent and respond. From practicing in the UK, with its emphasis on pro-active interventions to ensure all systems and policies minimise the risk of harm to children to a response more centred on child protection due to the immense challenges faced by actors to safeguard in such difficult living situation. The switch from a transit population to static has made early intervention possible and actors such as Save the Children and the Association for the Social Support of Youth (ARSIS) work tirelessly on this but the same factor also exacerbates the situation. As desperation escalates due to the situation and lack of financial recourse refugees of all ages were increasingly turning to smugglers and traffickers to travel on which has huge repercussions for their safety. More than 90% of refugees travelling to Europe have had to use intermediaries and these services are mostly provided by criminal groups.8 Population movement, uprooting and the breaking down of social hierarchies, increases the risk of Sexual and Gender-Based Violence (SGBV) in general.9 Amnesty International10 have reported that female refugees are at risk of SGBV at all stages of their journey, whether it be at the hands of security forces, smugglers or people they meet on the way.11 SGBV encompasses not only trafficking but other forms of sexual exploitation, physical assault, sexual exploitation, sexual abuse, forced marriage, sexual harassment, rape, trafficking and forced prostitution, female genital mutilation and violence related to exploitation.12 In all emergency settings a SGBV response is needed with a coordinated response and lead agencies responding to the difference components of Health/Medical, Legal/Justice, Safety/Security and Psychosocial Support and Child Protection. In addition to this high stress, uncertain futures, breakdown of family units and societal structure in a dense living situation can lead to higher levels of domestic abuse.

Unaccompanied Minors

Unaccompanied minors separated from social supports are particularly vulnerable. In 2015, 85,482 unaccompanied minors applied for asylum in the EU, which was three times the 2014 figure. Half of them were from Afghanistan, and 13% from Syria.13 Europol report that over 10,000 unaccompanied children have gone missing across Europe since the start of the crisis and this is likely a massive underestimate.14

Impact of Violence

Self-report from refugees indicate exposure to highly traumatic journeys often compounded with chronic trauma sustained during conflict. Even in the temporary host country there have been reports of Police brutality in Idomeni camp, a former unofficial camp on the Greek border with the Former Yugoslav Republic of Macedonia (FRYOM). At the beginning of April up to 300 people had to be

14

treated15 after the security forces used teargas, rubber bullets and stun grenades to push back the refugees who were attempting to cross the border. I frequently met families reporting feelings of hopelessness and of being trapped and frustrated. The poor living conditions, uncertainty about the future and lack of information regarding asylum processes, and difficult economic circumstances taking its toll on a population that demonstrate exceptional resilience. Repeated exposure to violent situations (physical, psychological and structural) for some can result in sequential traumatisation impacting on overall physical, psychological and social wellbeing. Manifestations of mental health issues reported by families included: sleep disturbance, depression, anxiety, Post-traumatic stress disorder (PTSD), risk taking behaviour and self-harming. Exposure both directly or indirectly to violence as a predisposing factor is certain however progression to mental health problems is not. There are many precipitating and perpetuating factors along the migration route such as lack of appropriate care, loss of protective factors e.g. social support and the high levels of stress and uncertainty associated with their current situation all of which can further increase the rate of mental health problems both for parents and children. Of the 311 Syrian refugee children attending a school in Islahiye refugee camp in southeast Turkey 79 % had experienced a death in the family; 60% had seen someone get kicked, shot at, or physically hurt; and 30% had themselves been kicked, shot at, or physically hurt. 45% displayed symptoms of PTSD, 10 times the global prevalence in children and 44% reported symptoms of depression.16 According to the German Chamber of Psychotherapists (BPtK)’s at least half of resettled refugees in Germany are experiencing psychological distress. Of these, 58% stated they had witnessed death, and 43% claimed to have been tortured. Among children, 40% have witnessed violence, and 26% have watched family members being attacked.17 A study of 100 Syrian refugee children in Germany showed that one in every five children were suffering from post-traumatic stress disorder.18 However, there are limitations to all these studies.

Case Study19

17-year-old Amala was originally from Syria living with her step mother after her father had left them to travel on to Germany. And her extended family unable to cross the border had ended up living in an informal camp at the boarder of Northern Greece. She had started a relationship with a boy in the camp and then became pregnant not wanting to continue the pregnancy she had asked for help. At first they had thought she had had a miscarried but when they realised she was too still pregnant she was 14 weeks and told in Greece this was too late to have a termination. Distraught she took a selection of tablets that she had accumulated from the various visiting NGOs included several paracetamol tablets. I was called to her tent after her friend figured out what she had done. She was distressed and refusing to leave the tent.

Responses

Psychological First Aid 20 – A framework for a humane and supportive response to a fellow human being who is suffering and who may need support. Medical Response – Called an ambulance to take her to hospital followed by Save the Children and an interpreter. Referral made in Greek to the receiving hospital highlighting the fact she was pregnant, had taken an overdose (with as much detail as was known) and was actively suicidal. Initial medical assessment was undertaken which indicated no obvious harm to mother or unborn child.

October 2016

BACCHSPECIAL Safeguarding – Already known to Save the Children who liaised with the Association for the Social Support of Youth (ARSIS). Who have the overall responsibility for safeguarding in Greece. Additional Options include the International Rescue Committee if this is a child who is a survivor of Sexual and Gender-Based Violence. Psychiatric – She was not discharged post medical clearance but assessed by a Greek Psychiatrist in the hospital who fed back to Save the Children.

Barriers and Challenges

The greatest challenge is meeting the needs of a population that was until recently transient in both body and mind. In the shift to a now static population health actors are challenged to meet the evolving needs of a now stranded refugee population still living in temporary shelter in a poorly resourced setting. Local Greek Health facilities are over-capacity, there is not enough staff, equipment, medicines or logistical support to meet the current needs of the local and refugee population. There is also a Lack of independent and medical-trained interpreters available in camp.

What Should you do working as a Doctor in Northern Greece?

• Be alert to potential indicators of abuse or neglect; • Be alert to the risks which individual abusers or potential abusers, may pose to children; • Be alert to the impact on the child of any concerns of abuse or maltreatment; • Be able to gather and analyse information as part of an assessment of the child’s needs.

Summary

With one in three refugees arriving in Greece now under 1821 the precariousness of their situation makes safeguarding incredible difficult. As a once mobile population becomes stranded the barriers to child safeguarding is leading to an escalation of the situation with significant morbidity and feasibly mortality. There is a great danger as the spotlight shifts of the tens of thousands now living in limbo in Greece that Europe will fail to safeguard both the refugees in our care and their right to health. Dr Clare Shortall, Doctors of the World [email protected] 1.

UN High Commissioner for Refugees (UNHCR). 2015 likely to break records for forced displacement – study. Available online at http://www.unhcr. org/5672c2576.html [Accessed 21 April 2016]. 2. UNHCR. Refugees/Migrants Emergency Response - Greece http://data. unhcr.org/mediterranean/country.php?id=83 3. IOM. Missing Migrants Project. http://missingmigrants.iom.int 4. UNHCR. Refugees/Migrants Emergency Response - Greece http://data. unhcr.org/mediterranean/country.php?id=83 5. UNHCR. Refugees/Migrants Emergency Response - Greece http://data. unhcr.org/mediterranean/country.php?id=83 6. UNDP. Human development index (HDI) http://hdr.undp.org/en/ indicators/137506 7. OECD. https://data.oecd.org/greece.htm 8. Europol. Migrant smuggling in the EU. February 2016. https://www.europol. europa.eu/content/migrant-smuggling-eu 9. Asgary R, Emery E, Wong M. Systematic review of prevention and management strategies for the consequences of gender-based violence in refugee settings. International health. 2013;5(2):85-91. 10. Amnesty International. Female refugees face physical assault, exploitation and sexual harassment on their journey through Europe. Available online at https:// www.amnesty.org/en/latest/news/2016/01/female-refugees-face-physicalassault-exploitation-and-sexual-harassment-on-their-journey-througheurope/ [Accessed 21 April 2016].

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BACCHSPECIAL 11. UNHCR. Sexual and Gender-Based Violence against Refugees, Returnees and Internally Displaced Persons. Guidelines for Prevention and Response. May 2003. 12. Asgary R, Emery E, Wong M. Systematic review of prevention and management strategies for the consequences of gender-based violence in refugee settings. International health. 2013;5(2):85-91. 13. Fate of 10,000 missing refugee children debated in Civil Liberties Committee. European Parliament News. 21st April 2016 http://www.europarl.europa. eu/news/en/news-room/20160419IPR23951/Fate-of-10000-missing-refugeechildren-debated-in-Civil-Liberties-Committee 14. http://www.europarl.europa.eu/news/en/news-room/20160419IPR23951/ Fate-of-10000-missing-refugee-children-debated-in-Civil-LibertiesCommittee 15. Medecins Sans Frontiers. MSF treats hundreds after Greek-FYROM border violence. Available online at http://www.msf.org/article/msf-treats-hundredsafter-greek-fyrom-border-violence [Accessed 21 April 2016]. 16. Özer, S., Şirin, S. & Oppedal, B. 2013. Bahçeşehir study of Syrian refugee children in Turkey. Available in www. fhi. no/dokumenter/c83Fb3a78c. pdf. 17. The Federal German Chamber of Psychotherapy (BPtK). “Mental Disorders among Refugees”. 18. Mall, V. The majority of Syrian refugee children are ill. Annual conference of the German Society for Pediatrics and Adolescent Saturday, September 5, 2015 https://www.tum.de/en/about-tum/news/press-releases/short/ article/32590/ 19. Some of the details of have been changed to maintain anonymity 20. WHO, War Trauma Foundation and World Vision International. Psychological first aid: Guide for field workers. 2011. Available at: http://apps. who.int/iris/bitstream/10665/44615/1/9789241548205_eng.pdf 21. WHO. Refugee Crisis situation update report 6 April 2016.

The Refugee Youth Service in Calais The coverage about the unofficial refugee camp within minutes from the town centre and port of Calais has been frequent over recent this past year. Much of the focus has been given on the minors within camp, in particular the unaccompanied minors. This has varied in terms of depth and has often focussed on the political discussions on this topic or touched on headline inducing incidents such as the deaths of minors attempting to seek routes to claim asylum in the UK, or when individuals deemed to be of note visit the camp. However those working here on the ground frequently note a lack of professional curiosity and evidence based research undertaken on the needs of these young people. In particular from UK based government agencies alongside those who are presently charged with their care in france and amongst those who will be charged with the care of those with a legal right to be reunified with families Asylum seekers and displaced children are often noted to be a particularly vulnerable group within most services from health care providers, local authority fostering services and educational facilities. They are often identified as cohorts of young people having additional needs due to their circumstances yet at present little work is being done to actively support meeting these needs here in the camp, nor to participate in proactively identifying needs in advance of their presentation to the UK or resettlement within france. Acknowledging that major organisations are being denied access to carry out their traditional roles in this crisis, or are being restricted by lack of donor funding to support work in developed countries where the state is believed to be capable of fulfilling their obligatory and statutory duties, RYS was founded to fulfil this role. RYS has also benefited from being able to meet the need for provision of assistance in a camp which is being not being recognised with official status as a refugee camp. As such the UNHCR and other agencies guidelines for best practice for camps are not enforced and often neglected. As is often the case  politics and issues of sensitivity can obstruct the provision of need. The desire not to get into conflict with governments, and the funding they can provide must

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also not be overlooked, and as a grassroots organisation founded and developed by skilled and dedicated individuals from across the professional spectrum this flexibility has proved to be invaluable and necessary for many of the thousand plus young people living in this limbo minutes from Europe's busiest port and 30 miles from the UK. The present border crisis is considered particularly complex due to high levels of mixed migration, with people of over 20 nationalities resident within the Calais camp. Even within these populations we have residents with unique minority needs, such as Bedouin youth, LGBTQ youth and deaf youth alongside a diverse multilingual, multi-faith and multicultural population. We acknowledge that some of our children, having fled persecution within their home country, now find themselves within a minority of a different type, amongst the over ten thousand strong population and thousand or so unaccompanied minors. Very sadly this figure is rising at an alarming rate with up to eight new unaccompanied minors arriving each day. Into a camp where any individual can freely enter, where no direct provision of youth orientated services exist for minors and the state and NGO’s make no provision for unaccompanied adolescent centred accommodation. At present a restriction on bringing building materials and/or caravans into the camp means at present we are unable to assist with the repair of damaged structures or enable children to be given waterproofed or locked homes. Vulnerable unaccompanied children including teenage girls often sleep within tents, on ground which frequently floods and that offers no insulation against cold nights. RYS started in November 2015 and was run out of a shelter space by three volunteers who recognised the lack of any provision for the young people within camp.  It’s main target group is unaccompanied minors aged between 10-18 years, due to the demographics of the camp it is numerically mostly males that engage in wider range of  services we offer. We do however  work closely with the unofficial women and children’s centre to provide educational and youth support services to of the young women in camp whose numbers are less. RYS was first set up to create a safe space for young people to be able to engage with their peers and trusted adults in an otherwise dangerous and uncertain environment. In December 2015 RYS fundraised to build a purpose built building for the growing numbers of young people that were engaging in the service, since then RYS has been actively supported by Help Refugees, L’Auberge des Migrants and Save the children in it’s work. After collaboration on cases over several months RYS and MSF agreed to move into a purpose built space together, with MSF building the existing cohort of young people using the service to offer legal psychological support whilst facilitating access to request official protection from the French state. RYS now has 10 long term volunteers covering areas of responsibility from child protection to community liaison and educational services and actively recruits team members who are current or former residents of the camp who are people who were without papers now claiming asylum within france. AS a team which contains a public health nurse, graduates in emergency response studies, youth workers, educationalists and people who have previously been displaced RYS knows that we cannot advocate effectively for children’s rights if we does not possess an in depth understanding of their needs. Through our participation in the monthly help refugees census, our dedicated outreach teams and the hosting of a dedicated educational facility and youth orientated safe space we are in contact every day with the young people and the communities they live within to

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BACCHSPECIAL provide a conduit to listen, learn and participate it the process of meeting many neglected needs..

Child Safety

In the Calais camp there are no official child protection measures. Whilst local services can respond to some of the referrals made to them there exists no registration of camp residents. Therefore the vast majority children in the camp are unknown to the state generating vast child protection and safeguarding risks. This further enables the neglect to assess and meet these risks. The majority of children aged over ten are unaccompanied, increasing the risk of harm dramatically as they do not have legal guardians to protect them. Disabled children’s needs go unmet, and unaccompanied females are at  risk, due to the frequency of sexual harassment and assault, of which both are regularly reported. A proportion of the children reject the protection that can be claimed within the state of France as they want to go the UK, often to be reunified with family there. They therefore remain here in dangerous conditions, absent of secure shelter and adequate support mechanisms whilst they make illegal attempts to cross the border.  Currently the French and British states do not support these wishes to request protection in the UK from here. Legal family reunification under the Dublin III regulations are slow with only almost sixty cases successfully processed by non government agencies and charities since October last year whilst 160+ young people with a legal claim wait in limbo. Most children with legal cases have little faith in the system and most have spent months attempting to cross over informally and as such illegally. Even amongst those with strong cases most risk life and limb due to a lack of information on processes being enacted on their part. Another proportion of the children attempt to claim protection within France but are turned down to a lack of space in this region and little  motivation or processes to effectively share this challenge with other regions. Children showing help seeking behaviours often become dejected by such attempts. Attempts to cross to the UK illegally are often dangerous, due to the methods used, the risks around people smuggling and trafficking. The actions of the French riot police in violently blocking these attempts see children injured or living in fear of the French state. Working to support accessing existing child protection procedures is hugely challenging when one is trying in part to protect children from harm being inflicted by the state. It is for this reason that the camp exists. Two deaths of minors attempting to make informal crossings with ongoing yet slow moving cases have occurred in the past year. Numerous more are injured and as yet unreported upon, including broken legs jumping from motor way overpasses, injuries incurred whilst hanging onto the axels of lorries and one child was mistakenly trapped in a shipping container bound for the Philippines until he texted a volunteer in camp for assistance. RYS provides a tracking and monitoring system in the Calais camp. This is done through running outreach in the camp six days a week. The outreach engages with young people directly within their community to make sure they are safe and to gauge what their needs are. We are the only service on camp that provide this form of monitoring on a large scale using census data to so. The tracking and monitoring system keeps a record of the young person's; name, age, nationality, phone number, who they live with and where, if they are accompanied or unaccompanied and what form of accommodation they live in. It also allows the youth service to gauge the vulnerability of the young people on a weekly basis. This system allows the service to know when the young person leaves to claim asylum in France, family reunification or if they are unaccounted for or missing.

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This system then supports our work in relation to child protection and safeguarding of the young people in camp. We have implemented a missing children’s system and have engaged with other direct work services on camp to highlight the serious need of reporting young people missing. RYS has also requested that if another service reports a young person missing that they inform RYS so we can keep a record of the amount of young people that go missing or are unaccounted for. RYS has implemented safeguarding measures in relation to recording any child protection concerns. Again this is to highlight the needs of the young people but also to make sure that the young people get the support that they need. RYS works to distribute phones to many young people, to ensure they have access to credit and their SIM cards and IMEI numbers are recorded with young people’s consent so that they can be relayed to relevant agencies if they go missing or become unaccounted for as sadly often happens in the absence of any registration processes for displaced minors here in Europe.

Child Development

Children often spend many months living in the camp before making it to the UK, deciding to claim protection in France if they can secure a place, or moving onto another country or camp. During these long periods of time (up to a year so far) children are missing out on a key parts of their education and essential opportunities for healthy social development. The psychological well-being and development of children is therefore compromised, and as the months spent in the camp draw on a visible deterioration of mental health commonly takes place, especially during the winter months. This deterioration in mental health displays itself in many different ways including the use of drugs and alcohol, self-harm, emotional and violent  outbursts, depression and nightmares. Whilst many of these things are the result of the experiences of children before they enter the camp, they are issues that are particularly difficult to resolve whilst they are resident in the camp and in what is essentially a state of limbo.

Health and  mental wellness

Health is often a poorly neglected area for these young people and RYS volunteers escort young people with health conditions, both chronic and acute, to medical services on site. However many of these conditions are aggravated if not caused by their unacceptable conditions, including chicken pox, scabies, skin conditions. RYS this week has also been supporting a young person living in a damp tent with a young man with TB like symptoms awaiting diagnosis. Dental services, sexual health services, optical services are not readily accessible to the young people here and as such core aspects of care and screening frequently recognised as essential for adolescent health are not delivered. RYS is working with professionals with NHS backgrounds volunteering to  develop health promotion programmes, dental screening tools and continue to advocate for the needs of these future citizens. Those of us who work in community and public health understand the economic benefits of investment of time and energy in delivering early interventions. The lack of desire by governments on either side of the water to proactively address the needs of young people now rather than wait till they present with more serious  and costly complaints at a later dates appears short sighted and sadly a conscious omission impacting upon children's development and well being today. As mentioned previously poor mental health and the impact of cramped conditions, police violence and a chaotic living environment manifest in many ways. RYS works with a group of practitioners from the Calais resilience collective who are themselves NHS workers to provide trauma mapping groups and a safe space to talk alongside collaborating with MSF’s psychological services. We also host Art therapy groups, boxing, music and sports sessions

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BACCHSPECIAL along with other means for non verbal expression and therapeutic release. Weekly trips for young people out of camp to bowling alleys, beeches and other facilities see a respite from the grimness and danger of the camp. The value of problem free time within a youth orientated space with peers and trusted adults should also not be overlooked. The drop in service provided by the Youth centre allows vulnerable people to engage on their own terms when they would like to spend time as a young person rather than be defined by their status as a child without papers.

The future.

Recent weeks have seen posturing from politicians on both sides of the water with declarations about the rights of nations to control their borders, suggestions to build a wall and that an eviction of the camp will be imminent. RYS alongside other agencies has deep concerns about the wellbeing of young people living here, at present no source of age and language appropriate information for young people exists with relation to their rights and options for asylum and protection. The previous eviction of the southern portion of the camp in february saw 120+ children become unaccounted for as those listed on the first census were no longer on the subsequent census post event. At present all attempts by RYS to develop its services are tempered by the looming prospect of a potential dispersal of hundreds and hundreds of children who will be reluctant to take up the offers of protection from the state whose officers they remember demolishing their homes and communities a few months ago. Whilst we do not know where these children will go in the interim period, however we do know that protection in either France, the UK or other countries in Europe will be the final destination for most. The prospect of further deaths, permanent disability or risk of trafficking, exploitation and abuse for many others as this camp is dispersed is sadly one which we and many other agencies fear. The fact that little knowledge or academic research is being or has been done either here or in Greece, the Balkans or Italy where other such camps exist on the needs of these future citizens of respective nations yet still children presently in our borders is a missed opportunity. This is something which all community health and child protection practitioners should lament as we work to support the tens of thousands of unaccompanied child refugees here in Europe as we speak when they enter our services in whichever country and region we work. Michael Mchugh, Refugee Youth Service, Calais [email protected]

An Emotional Health and Wellbeing Specialist Early Intervention Framework. In July 2016, A Parliamentary Select Committee report entitled Children in Crisis: Unaccompanied Migrant Children in the EU makes the statement: ‘All we can know for certainty is that the number of unaccompanied children in the EU runs to many tens of thousands and has grown significantly in recent years’. From this uncertainty a very specific figure of 3,043 asylum applications from unaccompanied minors were made in the UK, an increase of 56% from 2014. Most of these children have arrived in Kent and passed through reception centres in the county before being rapidly dispersed either into foster care or supported living arrangements. It is from the experience of working therapeutically with these children that the recommendations in this paper are being made. What is outlined here is a model of the early interventions that the Unaccompanied Asylum Seeking Children (UASC) project in Kent recommends as necessary in order to create a resilience model that provide crucial foundations for the long term wellbeing of children

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to Post Traumatic Stress Disorder (PTSD), depression and anxiety. The long term effects of such early intervention are vast in scope from the rescuing and humanising of individuals who have already had significant loss and trauma in their lives to providing a shield against future radicalisation and the nurturing of people who are assets to the UK. Embedded in the philosophy of this early intervention framework is also the creation of a culture of welcome to these children within the structures of bureaucratic disorientation in which they find themselves. This last point is especially pertinent given the observation in the Parliamentary report, that UASCs are faced with a pervasive ‘culture of disbelief’ and suspicion in the EU countries in which they arrive, including from ‘border force and immigration officials, law enforcement and social services’. A contributor to the report stated ‘ we received a wealth of evidence on these symptoms of the prevailing disbelief, most of it relating to the UK’. In a post Brexit Britain where it seems that a certain (ill-founded) legitimacy has been given to the voice of hostility and racism, it is essential that those who are hosting UASCs whether in reception centres or postdispersal, are equipped to provide, not just friendship and welcome, but the tools by which UASCs can find both their feet and their hope. The importance of early intervention in enabling resilience is well documented and it is important to recognise the reality of a situation where, because of the programme of dispersal, there can be limited time in which to affect therapeutic measures. However, we stress that the interventions recommended here are likely to have huge beneficial effects beyond the relatively short term nature of their implementation. From the work in dispersal and reception centres in Kent we think that there needs to be a change in emphasis on the way in which the ‘trauma’ that UASCs have suffered from is approached and regarded. Since much existing research and evidence has been focussed on symptoms of PTSD, PTSD itself has perhaps become an assured and expected outcome. By this we mean that it is often taken for granted by health professionals and support workers that all UASCs will be suffering PTSD. There is evidence that this may be the case for a proportion, and yet not a majority of cases. However, we argue that such an assumption potentially becomes a ‘catch all’ compartmentalising diagnosis. The irony then is that the very assumption of PTSD, which itself should lead to specific treatment and interventions, becomes a function of, if not ignoring, then at least ‘putting aside’ the problem. By assuming that PTSD is present, there is a concomitant assumption that the only cure is the ‘magic’ of specialist professionals who have a scarcity in availability and therefore there is a wait for anything to be done. The experience of relating to and talking with the UASCs in Kent reception centres shows that the children have incredibly traumatic experiences in their lives. In fact, these are so far off the scale sometimes that the diagnosis that they suffer PTSD is almost inadequate. It would be easy to assume that all these children are traumatised and will most probably require specialist interventions over time. However, symptoms that present themselves at the time of the child’s arrival in the UK system can be regarded in a more contextual manner that can be addressed simply and immediately and thereby provide the foundations of wellbeing and resilience from which the deeper traumas can be dealt with over time. The ethos should be of ‘caring vigilance’ whereby carers and professionals watch, wait and see what presents over both the short and long terms. Many young people, particularly if they have had strong, healthy attachments in their lives and good early years are extremely resilient. Each child has his/ her own history and resilience potential and the provision of early intervention steps will enable those with strong resilience potential to begin to rebuild their lives and potentially thrive, whilst those who are more vulnerable will become identifiable and therefore suitably cared for.

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BACCHSPECIAL The suggestion that a short term history should be dealt with first is backed up, if obliquely, by another witness to the Parliamentary report: ‘Some unaccompanied children have pointed out that on their journey they have been focused entirely on survival, the journey and arrival, and when they get to their destination country they are entirely depleted, but then of course they have to face a whole new set of challenges, so we have to be mindful of all they have gone through.’ When a child arrives in the reception centres in Kent, they are often in the midst of an extraordinary journey (because of dispersal and the asylum process, we cannot say the journey is over), one which may have involved being trafficked, hunted, starved, sleep deprived, witnessing death and close escapes with death for the child themselves. This is the immediate experience in the child’s life that they bring to the UK. The proximity of the experience requires a hyper vigilance to the effects of that experience. Therefore the disrupted and non-existence sleep patterns that many children exhibit, for example, may derive from the fact they have spent many months living an essentially nocturnal existence as they attempt to cross through Europe at night, in their ‘focus on immediate survival’. Similarly, the apparent ‘eating disorders’ and digestive problems the UASCs exhibit may be a result of the fact that during the journey of survival, the child has been malnourished or semi starved. The following are some of the issues that affect USAC: • • • • • • • • • • • • • • •

Poor sleep (a lack of sleep or disturbed sleep) Vivid flashbacks Intrusive thoughts & images Nightmares or sleep terrors Lack of concentration Hyper vigilance Poor emotional regulation   Poor understanding of nutrition Deliberate self-harm Irritable and aggressive behaviour   Issues with cultural acclimatisation   Intense distress at symbolic or real reminders of trauma Physical manifestations: trembling, sweating, pain and nausea Self-destructive behaviours or recklessness Disordered eating and related re-feeding symptoms

All of these symptomatic behaviours can be usefully regarded in their first presentation as being normal responses to the most recent, trying and exhausting experiences in the lives of the child. They should be seen as contextual and not abnormal responses and they should also been seen holistically as interconnecting with each other. If a child experiences nightmares, this can be regarded as a normal and in fact positive sign that some normal processes are happening towards the resolving of the trauma. This traumatised child can be supported in the short term with regards sleep patterns/nutrition so that a certain stability is attained as quickly as possible whilst understanding that longer term PTSD may manifest at a later date. The short term work advocated here will allow for more effective interventions on any deeper issues that may appear by equipping the child with a stable place from which to work. Four areas of early intervention we believe need to be addressed: 1. 2. 3. 4.

Sleep Nutrition and re-feeding Trauma and bilateral movement Hope and aspiration

Sleep

In the Kent reception centres, observations of the sleep patterns of UASCs showed that the majority of them would sleep during the day and were unable to sleep at night. This created problems at the very simple level of the routines that the reception centres were

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trying to establish, but one may not wonder that a child who has not slept at all during the night, is unable to turn up for skills training at 9 am. Thus a very simple negative patter is established whereby the lack of sleep leads directly to the child missing out on some vital elements of being able to function in their new environment. The GP who provides a service to young people in reception centres reported that 100% of the UASC he sees, report disordered sleep patterns in the consultations with him. In 2013, Israel Bronstein and Paul Montgomery examined the sleeping patterns of Afghan UASCs in which they state: “Within this group of children, sleep problems should not only be considered as symptoms of possible PTSD but as problems themselves, given they can lead to a range of daily functional impairments in memory, concentration, attention, motor performance, academic performance, and behaviour. In children specifically, sleep problems may influence cognitive and behavioural functions and lead to increased fatigue, sleepiness and slower reaction times” All of this is also exhibited amidst the population of the Kent reception centres where staff also reported that many young people would sleep in groups with the light on, having learned to do this to protect each other. In order to attempt to reset the sleeping patterns of the young people, sleeping hygiene education and packs have been developed, as well as a formulation to reset the circadian rhythms. When UASC were asked if the sleep packs had helped one week after using them at a reception centre, they stood up, clapping and cheering to demonstrate the difference this intervention had made. When clinicians have used this as part of a therapeutic formulation and intervention, the feedback is positive, with young people stating often a marked difference in the scoring from 0 to 10 in their ability to sleep. That said, there is a need to undertake further research into this intervention into disordered sleeping with UASC.

Nutrition and Feeding

The problems surrounding UASCs and nutrition are interlinked with the issues of broken sleep patterns - and are not dissimilar to an intense form of jet lag including symptoms of indigestion, constipation, diarrhoea, nausea, lack of appetite, anxiety, disorientation, irritability and memory problems. On top of this reception staff have reported that many young people ate very little and struggled to manage food. Many exhibit the physical symptoms of semi-starvation such as gastro-intestinal discomfort, dizziness, oedema, reduced strength, headaches, hyper-sensitivity to noise and light. Some of these children would also exhibit behaviours such as binge -eating and purging, self-harm, a loss of interest in the future, depression and an abnormal fascination with food which are indicative of eating disorders. Again, semi-starvation is linked to the experience of the arduous journey the UASCs have just undergone and there is a requirement to support their emotional health and wellbeing during the re-feeding phase of their recovery. The GP who sees children in the reception centre also stated that gastric discomfort in a variety of forms is also reported by most of the UASC in the consultations he gives. It is important that a general practitioner supports children experiencing gastric distress as part of the re-feeding process who can support with medication that deal with physical symptoms such as gastric reflux and constipation. On the main, most UASC are underweight and an initial weight that can be monitored is also good practice and will support an aspect of understanding in respect of the re-feeding process. A re-feeding diet of small meals every 2/3 hours is also important to support the digestion process and also the body’s ability to

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BACCHSPECIAL reacclimatise to being fed on a regular basis. A healthy diet needs to be followed that avoids foods that rapidly increase the blood sugar such as sweets and cakes, as hypoglycaemia is a likely by-product of such foods.

Ana: So she wanted to protect you? J: Yes; she wanted me to have a good life.

There is also a need to support a UASC’s understanding of their body, the re-feeding process and the emotional dysregulation that is likely to take place. It is also important that carers are aware and can support the young person during this difficult transition.

J: To learn, to have a job, to be safe.

Trauma and Bilateral Movement

Ana: So today, how can you make hope real? You know in the choices you have now?

There is a body of literature that shows that sport and physical activity triggers chemicals in the brain that make you feel happier and more relaxed. It also supports your brain to process information, thus learning therefore is enhanced. Physical activity is a distraction from daily stresses and reduces the level of stress hormones secreted and stimulates the production of endorphins, keeping stress and depression at bay. It has been shown to improve the quality of sleep which also has an impact on mood and general outlook. As per the symptoms described above, many of the UASC would benefit, after an initial period of recovery, in the early days of arrival and assimilation into the UK from sports related activity to reduce the symptoms which can escalate into long term and chronic mental health concerns. Many of the symptoms are suggestive of trauma experiences, which given the right support can be naturally processed by the brain. There is a volume of evidence that shows that bi-lateral movement helps the brain to process and desensitise from traumatic experiences. To enhance the body’s natural ability to process, there is a need to access sport that is bilateral in movement as a regular activity that a young person can undertake. It is an early intervention strategy that acknowledges that trauma is likely to be present and put protectors in place that enhance not only the body’s natural ability to process and desensitize, but enhances on multiple levels a sense of emotional wellbeing. A trial is being undertaken in Kent with UASC in supported living and once those results have been reviewed, it is hoped that further research will take place to assess the outcomes of such a formulation.

Hope and Aspirations

What is hope to a UASC, how can we enhance hope stories in a way that these young people can thrive wherever their paths take them? These young people live with constant uncertainty which can heighten a sense of permanent loss and trauma. Hope can be hidden or clouded, it’s not until we un-ravel the young person’s story that we get the full narrative and are able to identify their needs and aspirations. In supporting reception staff and social workers to connect these young people into hopeful narratives; we are tapping into the resources they have from past relationships into present connections linked to the choices they are making about how to go on and live their life in the UK. An example of this is shown in the transcript of a conversation that took place with a UASC. Ana: What were you running away from? J: From the army, as I didn’t want to become a soldier. Ana: Who else in your family agreed with you? J: My Mum arranged for me to leave, my brother died and she didn’t want the same thing for me.

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Ana: What does a good life look like?

Ana: So you hope to learn new things, to get a job and to be safe? J: Yes.

J: I can learn English? Ana: What would your Mum say if she knew that you are learning English? J: Good, good, she would be very happy. Ana: So hope is yours and hers every time you say something in English? This transcript shows the link to the continuing bonds they have with positive relationships which can be drivers towards making the right steps to things that are likely to shape their success and assimilation. As already stated previous healthy attachments are a known protector to a child’s resilience and linking them through continuing bonds into the present with those attachments is likely to enhance and motivate wellness behavioural patterns. Early intervention in these four areas as outlined here could have beneficial effects into the long term emotional health and wellbeing of each UASC entering the UK. The recommendations here have evolved out of Action Research which is a step by step methodology, in which the researcher(s) plan, act, observe and reflect. It is humanistic as it looks to work with and collaborates with those involved and affected to explore the emergent meaning and understanding under observation. In observing the effect of our actions at each stage of the cycle from which change emerges, we have been building a scaffolding of knowledge which allowed us to continuously incorporate findings into subsequent stages of the investigation. The project team, staff at reception centres, social workers and UASC are all within the observations and actions taking place. Therefore, all those involved, affected and connected are an active part of the research team and relational in nature. Bjorn (1996) and Shotter (1998) refer to participatory action research as multidimensional, dialogical and a fluid form of self-development. These interventions are key things that we have found are required to best help these children, some who have arrived here in some of the most unimaginably tragic circumstances and who may require additional psychological support in the future. The early intervention steps require further investigation and yet are already showing signs that they will help to reduce the negative impact of the things they have tried to escape from, the journey they have made and the need to wait, watch and see should there be any trauma that needs to be addressed in the future. The early interventions happen within a wider socio-political environment that is laden with misapprehensions, fear and prejudice. A child is not a terrorist (and there is no link between UASCs and terrorism as acknowledged in the Parliamentary report cited earlier). However, if a child who has seen his family murdered by the Taliban and who has subsequently undergone a journey of escape which he has survived against the odds (and we must remember the thousands of children who do not make it here and whose fate is death, sex exploitation, slavery), if that child arrives in

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BACCHQUALITY a disinterested and hostile UK that makes no attempt to meet any of their basic human needs, is not desperate political radicalisation more of a possibility? We must think of these children as assets to the nation, they are, after all, by and large brave and extremely capable as they have proved by being able to get here in the first place. The UK needs, ethically and humanely to show these children a face of welcome and the least we can do is meet them at the point of arrival with a supportive plan to help the ongoing asylum passage they will need to make. Ana Draper

BACCHQUALITY Following on from our last article, a piece from Dr Fawzia Rahman – BACCH lead for the Snowmed child protection terminology project. I dreamt of a brave new world in child protection – first steps towards an agreed national quality dashboard The Doctor on call

••She receives a call from a social worker requesting a Non Accidental Injury (NAI) examination. ••She agrees a date and time. The social worker informs the GP, who allows electronic access to the primary care record. ••She has one each of the service 3 tablets dedicated to child protection work, portable digital cameras and printers (total hardware cost under £2000) ••The tablet is linked to the NHS demographic spine and to the local GP network (happens with OOH GPs) ••She logs in and sees relevant information from GP record e.g. parental risk factors (paternal alcohol substance misuse, family history of FGM) ••She records the history and examination on a preloaded proforma based on the RCPCH child protection companion which is part of the electronic health record ••She marks bruises etc. with a stylus on a body map based on Professor Kemp’s work; this lights up as red, amber or green according to predetermined software. ••She takes photos on the digital camera. These will be loaded up securely to the EHR. ••She enters nationally agreed codes for her conclusions e.g. accidental or inflicted or other pathology ••She fills in an immediate conclusion form on the tablet; she sends this electronically to social care and GP, prints out one with the linked portable printer and hands it over to the attending social worker. ••She dictates the report and the system records the date the final report is sent. ••Within a month the doctor attends peer review where she can share the photos and diagrams ••Her conclusions are discussed and agreed or not and other actions e.g. amend report, order more investigations also recorded on an iPad by the designated lead/chair

The named/designated doctor

Knows from the automated reports ••How many children were seen over a specified period ••What the findings were e.g. 75% had no visible injury because there only was a history of being hit but service accepts all cases regardless of whether anyone can see a mark ••The peer review attendance for the whole service and for each doctor

October 2016

••The % peer review agreement level say 92% for the whole service This is the best measure of doctor competence i.e. technical effectiveness and one of two markers of quality defined by Sir Ian Kennedy i.e. the professional should be pleased with her work. ••The % of cases with good quality photographs •• ••The % of cases where the report was sent within 5 working days

Other stakeholders e.g. CYP/ parent/ social worker/ general practitioner

Receives an electronic questionnaire on the multi agency process (not the diagnosis), such as the MPOC (measure of processes of care) used in Canada for disability teams and fills it in This gives the other Kennedy measure, patient satisfaction, the patient & family should be pleased with the care received i.e. interpersonal effectiveness

Long Term Outcomes

At specified intervals thereafter e.g. after one month, a year and five years, social services or education administer a questionnaire such as SDQ or paeds QL to assess child well being. This is then linked to the health and social care records, as well as educational results.

Commissioners and inspecting bodies Can compare services on a like for like basis

Researchers & Public health Bodies

Have standardised longitudinal data, possibly internationally How do we make the dream reality? Get in contact with us and help in setting up a national dashboard:

The Safeguarding quality dashboard Mark I (August 2016) i. number and % of cases seen for suspected physical abuse within 24 hrs ii. number and % of cases seen for suspected sexual abuse within forensic time requirements iii. number and % of cases peer reviewed within 2 calendar months of examination iv. number and % percentage of cases where agreement was reached at peer review v. number and % of cases where report was sent out within 5 working days vi. number and % of stakeholders satisfied with service process vii. number and % of doctors on safeguarding rota attending 50% or more of peer review sessions.

Is this achievable?

If yes, why are we not doing it? Is this desirable? Why not? Is this sufficient? Definitely not, but it is a start. Some services in the country are already doing this, in some cases they have been doing so for a decade. Does anyone have anything better to suggest? I would love to hear about it. Fawzia Rahman

Continues overleaf 21

BACCHQUALITY The 2016 BACCH ASM informatics workshop updated delegates on the latest development in informatics in the field  of child protection. Topics covered include the child protection information sharing systems and the development of a new coding system for safeguarding using SNOMED CT. As previously reported this is due to replace both ICD and Read by 2020. There were also updates on the latest developments in Digital Child Health - Healthy Children : A Forward view for Child Health Information. If you attended or have an interest in these areas please do make contact and send your thoughts as we will probably use pilot sites to ‘sense check’ the safeguarding codes. “  

BOOK Reviews

This approach to practice obviously sets in a shift in the problem solving logic behind practices we apply everyday when caring for children. The sky is the limit to knowledge, particularly if one has to excel, however, if one is aiming to pass an examination in the first instance, such as membership examination of the Royal College of Paediatrics and Child Health knowing the Syllabus for membership examination is obviously the fundamental for candidates preparing for it. The Science of Paediatrics delivers exactly that. From the point of view of research in medicine for children through Epidemiology, Quality improvement, Ethics, Statistics the book covers the various areas adequately and succinctly, giving easy access to guidance for the user. A question and answer approach, at the outset of each chapter makes the learning points more clear to the reader. Coloured illustrations, cartoons, tables and charts break the monotony of continuous texts and serve the purpose of conveying the message more effectively.

The Science of Paediatrics MRCPCH Mastercourse

The Expert Consult eBooks give the reader the flexibility of access. One can enhance the images, share the notes. Beauty is that one can access the facilities both on and off line.

ELSEVIER ISBN: 978-0-7-20-6313-8

The book is most desirable tool for the candidates preparing for examinations and interviews.

Drs Tom Lissauer and Will Carroll have produced a very much wanted text , by putting together what committed professionals need to know .This compilation is different from text books , as explained by the editors . It high-lights the fact that mere knowledge about diseases based on the background knowledge of physiology , disturbed biochemistry and , pathology does not

Neel Kamal Convener, George Still Forum

The Boy Who Was Raised as a Dog Bruce D. Perry, Maia Szalavitz ISBN: 978-0465056538 As someone interested in child development and how the early years of life help to shape the trajectory of a person’s life, The Boy Who Was Raised as a Dog was an interesting and inspiring look at a number of children encountered by the author, a child psychiatrist. It is a fascinating perspective on children with emotional and behavioural difficulties, and incorporates psychology and neurology in explaining why these children behave as they do. These are stories of trauma, but also of compassion and hope. Because each chapter describes a new patient, it is easy to dip in and out of it, so is good if you have limited reading time. This book would be useful for healthcare professionals but is written in a very accessible way, such that it would also be helpful for parents and carers of children who have experienced trauma or a difficult upbringing.

actually make a difference to the outcomes . It is the science behind the implementation and delivery of the practices in the form of efficient service which forms the important difference to the outcome .

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Anna Taylor Year 4 Medical student

October 2016

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Available with your BACCH Membership See the journal online at: www.interscience.wiley.com/journal/cch

The multidisciplinary journal - incorporating Ambulatory Child Health Official journal of BACCH, Swiss Paediatric Society and ESSOP Edited by: Stuart Logan ISI Impact Factor 2008: 1.154

Developmental Paediatrics 5-day module

23-27 January 2017 • University of Brighton Falmer Campus Enhance your knowledge of clinical approaches to developmental paediatrics conditions, safeguarding, vulnerable children and child public health.

Child: care, health and development is an international, peer-reviewed journal which publishes papers dealing with all aspects of the health and development of children and young people. We aim to attract quantitative and qualitative research papers relevant to people from all disciplines working in child health. We welcome studies which examine the effects of social and environmental factors on health and development as well as those dealing with clinical issues, the organization of services and health policy. We particularly encourage the submission of studies related to those who are disadvantaged by physical, developmental, emotional and social problems. The journal also aims to collate important research findings and to provide a forum for discussion of global child health issues.

Learn how to apply specialised problem-solving skills to complex cases. Teaching with an emphasis on integrated service design and delivery develops your skillset to allow you to bring transformational change to your practice. Contact: 01273 644768 or [email protected]

October 2016

For more information or to view online content visit

www.interscience.wiley.com/journal/cch

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BACCHNEWSEXTRA BACDUPDATE

Paediatric Disability Quality Standards If you are involved in delivering, commissioning or receiving services for disabled children and young people, which includes all with special educational needs, this document should be of interest to you.

Please read it and reflect across agencies in your locality as to how your services compare and make action plans for continuous improvement. www.bacdis.org.uk/policy/documents/QualityPrinciples.pdf

Annual Scientific Meeting 2017 Updates in Neurodisability

Thursday 16 March 2017, Manchester The 2017 Annual Scientific Meeting will focus on Updates in Neurodisability. Confirmed lectures are: Paul Polani Lecture: Early Intervention in Autism - Prof Helen McConachie NICE cerebral palsy guidelines - Dr Charlie Fairhurst SDR: where are we now in the UK - Mr Kristian Aquilina Changing landscape of disability - Richard Newton Science of DCD - Prof Mark Mon-Williams Registration is now open. To register and pay by debit/credit card visit www.participant.co.uk/BACD2017. To register and pay by cheque or to request an invoice, please email [email protected]. The very early bird deadline is Sunday 4 December 2016. The £250 Mac Keith Poster Prize is awarded to the best poster presentation that reports innovative multi-disciplinary working for children with neurodisability and their families. Submission Deadline: 8 January 2017 Visit www.bacdis.org.uk/conferences/ abstracts.htm to download the abstract submission form.

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Neurodisability Research Opportunities

BACD-Castang Funding Award BACD and The Castang Foundation support UK research that includes children with neurodisability and their families, and are working together to invite research applications to improve the evidence around what treatments and interventions are effective, or not effective for children and families. The aim of the award will be to gather pilot and feasibility data that leads to an application for a large definitive National Institute for Health Research, Medical Research Council, Wellcome Trust, or Charity funded study into treatments or interventions for children with any type of neurodisability. A key impact of the research will be that the research had the potential to make a real difference to the lives of children with neurodisability and their families within 3-5 years of the definitive application. The topic for this research call, influenced by the BACD James Lind Alliance process, is: What health delivered strategies are effective in promoting participation for children and/or young people with neurodisability? There is a two-step application process: An Expression of Interest (EoI) form should be completed and submitted by email by 5pm, Friday 28 October 2016 Shortlisted applicants will be contacted in November 2016 and invited to submit full applications by early January 2017 Visit www.bacdis.org.uk/awards/index.htm for more information and to download the EoI form.

October 2016