Thematic review of 60 vulnerable children (23 girls, 37 boys) aged between 10 and 17-years-old. Review instigated after five children died between July-December 2017 from stabbing (three), ingestion of drugs and a road accident. All 60 children were known to Croydon Children's Services; 44 were known to Youth Offending Services. Review seeks to establish: who are the children; where they lived; what their home-life was like; what school was like; what happened in their lives; who worked with these families; what they said about services. Highlights themes experienced by cohort including: poverty; housing; parental issues; domestic abuse; children's services; looked after children. Black boys of Caribbean heritage and White girls of British heritage are the two largest groups in the cohort. Learning includes: a holistic approach to the child and family is needed, complemented by an integrated multi-agency response; making a difference to children's outcomes cannot be achieved by professional intervention alone and there is a need to understand and embrace family, kinship and communities; schools should be equipped to respond to challenges presented by children with high risk behaviour and placed at the heart of multi-agency service provision. Recommendations include: consider how awareness raising about the impact of adverse childhood experienced (ACEs) will be built upon to include professionals, families and the community; establish a data set about the most vulnerable children in Croydon to inform risk management strategies and service provision; consider how the involvement of professionals, families and the local community might be achieved, to explore how to address disproportionality.
      
 Title:  Vulnerable adolescents thematic review. LSCB: Croydon Safeguarding Children Board Author: Charlie Spencer, Bridget Griffin and Maureen Floyd Date of publication: 2019  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                 CROYDON SAFEGUARDING CHILDREN BOARD  Vulnerable Adolescents Thematic Review   February 2019                                          Charlie Spencer, Bridget Griffin & Maureen Floyd    1 | P a g e    This review would not have been possible without the contribution of the children and families who are the subject of this report.  We are extremely grateful for their courage in coming forward to share their experiences so that other children and families may benefit from the lessons learnt by this review.    We offer our sincere condolences to the families, friends and kinship at the untimely and tragic loss of their child.     2 | P a g e                                Subject Page no. Chapter 1. Introduction and Review Design 3  Terms of reference 4  Process and scope 5  The Review Panel 6  Methodological comment & limitations 7 Chapter 2 Summary 8 Chapter 3 The Children – Basic facts 10 Chapter 4 Local and National landscapes 22 Chapter 5 The Children – Child development, experiences, service provision and key learning 29  Where were you when I was six?  Child development 30  Where were you when I was twelve?  Child development 32  Where were you when I was sixteen?  Child development 34  Where were you when I was six? Experiences, service provision and key learning 37  Where were you when I was twelve?  Experiences, service provision and key learning 39  Where were you when I was sixteen? Experiences, service provision and  Key learning 44  Additional Learning 51 Chapter 6 Children, parents, carers and Multi agency practitioner views 52 Chapter 7 Findings and Recommendations  59 Chapter 8  Conclusion 63 Appendix  One  Summary and analysis of Multi-Agency Data   65 Appendix  Two References 98 3 | P a g e   Chapter 1 - Introduction & Review design  The London Borough of Croydon is the southernmost borough of London. Approximately 93,435 children under the age of 18 years live in Croydon. This is 25% of the total population in the area, with approximately 23% of children living in low-income families. Children from minority ethnic groups account for 58% of all children, compared with 21% in the country as a whole. The largest minority ethnic groups of children in the area are African and Caribbean. 10,261 people in Croydon live in areas considered to be within the 10% most deprived in the country. Thematic Review design During a period of four weeks in the summer of 2017, three Croydon teenage boys died. One 16-year-old looked after child was riding a moped with two others on board, and crashed and died as a result of his injuries. A 15-year-old, subject to a child protection plan, died from multiple stab wounds in a gang related incident. The 17-year-old died after ingesting a highly toxic drug. All 3 children had been known to Children’s Social Care by the age of 2.  These deaths were brought to the Croydon Safeguarding Children Board (CSCB) Serious Case Review (SCR) Sub-group and two Serious Case Reviews (SCRs) were agreed on the 15-year-old and 16-year-old.  It was agreed that the 17-year-old would be included in a Thematic Review to be undertaken into a group of vulnerable adolescents, with either poor outcomes or of considerable concern.  Police, Youth Offending, Children’s Services and MASE1 panel, were each asked to identify their own list of young people. Some of the children were mentioned in more than one list. A list of 56 children was initially identified.  Two further children were subsequently added, a 17-year-old male, who was stabbed to death in central Croydon, plus a 15-year-old female following presentation of her case to the January SCR sub-group due to grave concerns about child sexual exploitation and frequent missing incidents.  The Thematic Review has considered 60 children in total, 58 from the identified list plus the two children who were the subject of the SCRs. In light of the fact that children were identified with poor outcomes or were children who agencies had considerable concern about, all agencies were requested to reassure themselves that the children identified were safe and adequate risk management arrangements were in place. Sadly, another                                                              1 MASE – Multi Agency Sexual Exploitation Panel 4 | P a g e   child who had been included in the cohort of 60 children, was stabbed and killed within weeks of this Thematic Review commencing.  Five children were identified in the cohort because tragically they had lost their lives prematurely.  Purpose  The purpose of this Thematic Review was to determine whether there were any patterns in the children’s experiences, which could inform and improve future planning.  These were thought likely to be wide ranging including where they lived and went to school, their experiences of family care and the multi-agency services that were provided or offered.  Independent Chair, Lead Reviewer & Project Manager    Bridget Griffin, Independent Consultant was appointed as Independent Chair of the Vulnerable Adolescents Thematic Review Panel. Bridget has wide-ranging experience in statutory safeguarding work with specialist knowledge in being a Chair and Author in Serious Case Reviews. Bridget’s ethnicity is White British, she is of English heritage.   Charlie Spencer, Independent Consultant was appointed as the Lead Reviewer. Charlie has extensive experience as a Head of Youth Offending Service and Children’s Services senior manager responsible for the delivery of services to children and young people and has led and participated in multi-disciplinary peer reviews, on behalf of the Home Office, in ending gangs and serious youth violence. Charlie’s ethnicity is Black British, he is of African Caribbean heritage.  Maureen Floyd is the Manager of the Croydon Safeguarding Children Board.   Maureen has extensive experience of statutory safeguarding work within Children’s Social Care, from Social Worker to Head of Service, with a consistent specialism in child protection. Maureen is an experienced project manager of Serious Case Reviews and Learning Reviews. Maureen’s ethnicity is White British, she is of English heritage.  Terms of Reference  The following terms of reference were agreed by CSCB at the start of this review:   To gain an understanding of the factors that might be present in a child’s life that would make them vulnerable to such life-changing, or life-ending results. 5 | P a g e    To gain an understanding of what services or provision has been made to these children and their families in order to inform what might work for others in the future to prevent the same outcomes.   To influence commissioning of timely and appropriate services to address these issues. Process and scope  The review was initiated and commissioned by Croydon Safeguarding Children Board (CSCB). It has had the full support of senior leaders from all agencies represented on the CSCB who agreed that the review would seek the involvement of children, parents, front line practitioners and the community. The review methodology was made up as follows;  • Detailed analysis and findings from the two SCRs on individual children.  • Individual Agency Reports: Agencies were asked to examine their records for each of the 60 children and summarise their findings and identify any relevant learning for their agency. • Family Involvement: Communications were sent to the parents and carers to invite them to take part in the review, with the purpose of eliciting their views about services provided to their family. In addition, the views of family members involved in the SCRs for Child Y and Child Q are included in this review.  • Children’s involvement: The Lead Reviewer and Independent Review Chair sought the views of the children directly and interviewed five serving prisoners (of eight planned prisoner interviews) and one, a pupil in a pupil referral unit (PRU). A larger group of PRU children had planned to take part, but eventually decided against doing so. A further 40 children and young people in the community were also engaged via Croydon’s Big Youth Forum Day and a Youth Congress in summer 2018. • Four one-day Practitioner Learning Events (PLEs) were held for those staff involved from a wide range of statutory and voluntary services, with the aim of capturing multi-agency views about the services provided to children in the cohort and to stimulate constructive debate about how these children’s needs might be best met.  • Community involvement: The Lead Reviewer and Independent Review Chair, met with the Croydon BME Forum (Black & Minority Ethnic) to discuss the review. • An in-depth case analysis of 15 children’s social care case files  6 | P a g e   • Draft findings were shared with the CSCB and Croydon’s Local Strategic Partnership who were invited to offer comments and feedback. Review Panel A review panel was established to contribute to the review, provide data, information, their agency perspective, insight and experience and to make themselves available for constructive professional challenge.  The panel met on five occasions and included representatives from statutory and non-statutory services including:  • Croydon Clinical Commissioning Group (CCG) which includes Croydon GPs • Croydon Health Services (CHS) which includes Croydon University Hospital (CUH), Midwifery, Health Visitors and School Nurses and Family Nurse Partnership • South London and Maudsley NHS Foundation Trust (SLaM), Adult Mental Health • Child & Adolescent Mental Health Service (CAMHS) • Metropolitan Police Service (MPS), Croydon  • National Probation Service (NPS) • London Community Rehabilitation Company (CRC) • London Ambulance Service (LAS) • Croydon Children’s Social Care (including Youth Offending & Early Help Services) • Croydon Adult Social Care • Integrated Adult Mental Health Service • Croydon Housing • Croydon Education  • Safer London • Off the Record • Ment4 • Redthread • Young Carers • Croydon Recovery Network  7 | P a g e   Methodological comment & limitations  This review is limited to a specific cohort of children who were identified subjectively as being of concern by Children’s Social Care, the Youth Offending Service, the Police and children known to the MASE panel. No other agencies were invited to identify children. Consideration was given to the identification of a control group of Croydon children but this would have added to the complexity of the review and detracted from the focus on understanding the experiences of vulnerable adolescents well known to statutory services and about whom there was considerable concern.  Rather than using a control group, the outcomes for these 60 children are compared and contrasted against the general outcomes for Croydon children of the same age. Some of this comparative information is provided in Appendix One – Summary and analysis of Multi-Agency Data. The data gathering and work involved in this review was extensive and frequently required difficult decisions to be made about proportionality. This thematic review is built upon the direct experience of children and their families derived from agencies case notes, records and management information systems.  In the main, the data requested was not readily available to all agencies, so they were required to undertake a more resource intensive piece of work to interrogate their management information system or paper case files to support this review. Other agencies had dedicated personnel to undertake data collection and collation. Data quality was therefore variable.  All parents and carers of the identified children were invited to respond to a written questionnaire to the review or, if they chose, could meet personally with the review team. It was disappointing that only four written submissions were returned, complimented by four one to one meetings with parents, plus family members who participated in the serious case reviews for Child Y and Child Q.  This made a total of 17 family members who contributed to the review.  The reasons for the small response are not known although it is entirely possible that the finding of this review in relation to issues of trust in the system may have a bearing on this outcome. This was an issue highlighted by parents we spoke with, who stated they were reluctant to be involved given their own experiences of the system. We acknowledge that as a result of the small number of parents and family members who took part, we are only able to reflect their views. Those views remain pertinent and provide important insight into the family’s experiences and perceptions of the services provided. 8 | P a g e   The review team audited 15 cases files from Children’s Services (8 boys and 7 girls) which were representative of the cohort, reviewing referrals, interventions, assessments and unmet needs to test emerging findings against the wider cohort of 60 children. The case examples provided in this report are based on the experiences of children in the cohort. This review recognises that some of the crimes committed by children in the cohort were extremely serious and caused untold suffering, and grief to children, parents, extended family and the community. This review is not intended to review or comment on these offences, or the enforcement options or sentences the children received for their crimes. In addition, the review team appreciates emerging initiatives to address serious violence with the introduction of ‘a public health approach‘2 supported by the introduction of violent crime units, that are consistent with the Glasgow model.  This review seeks to inform how services can improve outcomes for children in the cohort, or other children who may be exhibiting similar characteristics. Chapter 2.  Summary The review has identified several factors that were prevalent in the children’s lives, and the service response to the concerns noted. Children were known about early with over half of the children in the cohort being known to Children’s Services before the age of 5 years and nearly three quarters of the children known by the age of 12 years old. The service response appeared to address the initial concern via short term intervention, with little appreciation of underlying trauma or the plethora of their adverse childhood experiences (ACEs).3 Some children were placed on child protection plans (CPP) and others were brought into the care of the local authority due to concerns of actual, or risk of, significant harm. Throughout their childhood, children continued to come to the notice of Children’s Services; some were placed on new CPPs, and at age 14 there was a peak of children in the cohort coming into care, suggesting that the children’s situations had deteriorated and interventions to that point had been unsuccessful.   Throughout primary education, some of the children’s aggressive and disruptive behaviour in school was of concern. Primary schools attempted to address the behaviour identified without                                                              2Public health approach to violence. It seeks to establish the causes of violent conduct and to identify and pioneer new approaches to preventing it, often by promoting co-operation between the police, education system and health service. 3 The term Adverse Childhood Experiences (ACEs) is used to describe a wide range of stressful or traumatic experiences that children can be exposed to whilst growing up. There are 10 recognised ACES; examples of ACE’s include physical abuse, parental substance misuse, parental criminal activity, neglect, parental mental health 9 | P a g e   success, leading to 19 children receiving fixed term exclusions in primary school. As they got older, all 19 of those children subsequently received criminal convictions. The primary schools had limited interventions available to them to address such behaviour and referred on to other agencies. It is not clear if they were aware of any potential causal factors that could explain the children’s behaviour to inform the interventions that were put in place.  There was a range of parental factors, such as absent parents, substance misuse, mental health problems, parental criminality and domestic abuse, but parental interventions and interventions for children were not joined up in a coherent whole family plan. Adult services and children’s services did not work together, and the needs of the children remained unmet.  Overall, there were poor transitions between primary and secondary school, behaviour deteriorated throughout secondary education with over half of the children being made subject to fixed term exclusions, managed moves, and placements in pupil referral units (PRU) or alternative education provision (AP).  Some families and professionals referred children to services for assistance, but the children often did not meet the thresholds, it seemed that their behaviour had to get worse to be able to access those services. There was a need for targeted support, but there was little evidence found to suggest this was provided. The children’s behaviour continued to escalate; they were involved in offending, substance misuse, were victims of child sexual exploitation (CSE) or child criminal exploitation (CCE), over half were thought to be in, or affiliated to gangs, suspected of running county lines and were both victims and perpetrators of knife crime. The review identified a significant over-representation of black boys of Caribbean heritage who disproportionally achieved poor outcomes.  The multi-agency response was reactive, and sometimes could be described as crisis management. As the risks and vulnerability grew, behaviour was more serious, more violent and more frequent; agencies struggled to meet their needs and to effectively engage families to keep children safe. The child protection framework and criminal justice enforcement and interventions were applied. However, these interventions were ineffective as agencies continued to primarily address the presenting crisis and issues. Engagement of the children dwindled, and they seemed to lack the motivation to change.   10 | P a g e   Over three quarters of the children were reported missing, this included 100% of the girls, the youngest being at age 7.  The average number of missing episodes being 16 times each, totalling over 1000 reported missing episodes among the cohort. The frequency of these missing episodes meant that the ability to effectively intervene was crucially undermined. The initial concerns were in the home, but as children got older the risks extended to school and into the community. This was recognised by professionals who did not have a framework in place to address risks in the community. Children were beyond parental control and appeared to be more and more influenced by their peers. Had early intervention services been available from a young age, or targeted support been provided earlier, complemented by a holistic family plan, it is reasonable to conclude that children might have achieved better outcomes. Children and parents who were spoken to as part of the review were unhappy with the multi-agency response and questioned if the boys had been white, would more have been done to assist them? Those children in the cohort who were spoken to appeared resigned to their situation, the issues of domestic abuse, bereavement and related trauma were never addressed and as indicated in research, the impact of these traumas became entrenched. Family difficulties often remained, and the children subsequently sought a sense of belonging, purpose and safety from their peers. Chapter 3. The Children – Basic facts This review is informed by an analysis of the children’s experiences. This report will use the term children, not young people, in recognition of their legal status and their vulnerabilities and to reflect that they all came to notice of services as children. The review team were particularly interested to understand: Who are the children? Where did they live? What was life like at home? How was their health? What was school like? What happened in their lives? Who knew and worked with these families? What would they say about services? What would they want us to know? What can we learn from their experiences? Where are they now? These themes are further explored throughout the report, complemented by Appendix 1: CSCB Summary and Analysis of Multi-Agency Data.    11 | P a g e   The five children who tragically died unexpectedly during July to Dec 2017 are included in this review.  Ethnicity and gender There were 23 girls and 37 boys identified and these children are the subject of this review. 71.67% of the children were classed as being from BAME backgrounds.  Black boys of Caribbean heritage and White girls of British heritage are the two largest groups in the cohort. Black boys (Caribbean) are significantly over-represented with four times (36.66%) as many children in the cohort in comparison to the ethnicity make up of 10 to 17 years olds in Croydon (9.66%). Whilst White British girls are the largest proportion of girls, this representation is similar to that of the Croydon population. Black girls and Mixed White and Black Caribbean girls are also over-represented with double the proportion compared to the Croydon census data. (Within this cohort, they represent 30.43% of the cohort, but make up only 15.42% of 10-17 year olds in Croydon.)    1021311414721860510152025White BritishAny other White backgroundTraveller of Irish HeritageWhite & Black CaribbeanWhite & AsianAny other mixed backgroundAny other Asian BackgroundCaribbeanAfricanAny other Black backgroundA1 A3 A4 B1 B3 B4 C4 D1D2D3Ethnicity & Gender of the VA 60 cohortFemaleMaleDate of Death Age Gender Ethnicity Cause /reason for death  July 2017 17 Male White British Ingestion of highly toxic drug  July 2017 16 Male Caribbean Head & spine injuries as a result of a  moped crash  August 2017 15 Male Caribbean Stab wounds  October 2017 17 Male Caribbean Stab wounds   December 2017 17 Male White &  Black Caribbean Stab wounds 12 | P a g e   Deprivation We sought to identify if there was any link with deprivation, i.e. is poverty one of the factors in their experiences?  The children’s Croydon home addresses were mapped against the map of indices of deprivation and this established that 32 children (53%) lived in the 20% most deprived areas in the country. The vast majority of the children lived in the most densely populated areas of Croydon and closest to those geographical areas of deprivation.  Entitlement to free school meals is regarded as an important proxy indicator of poverty, and of the level of income in households. From the data gathered, a minimum of 37% of the children included in this review were in receipt of free school meals at some period during their time at school, this is almost double the Croydon average of 18% and the national average of 14%.  These figures suggest that a significant number of the families could have been affected by living in poverty. Housing It is important to appreciate that where the children lived, the type, quality and stability of housing provided a further indication of poverty and deprivation. The provision of a secure nurturing environment for children to develop is essential, and where this is not in place, it can impact on their quality of life. Their bond with family and kinship can also be affected, especially when children are subject to frequent moves which will impact on their relationships with friends and peers.  82% (49/60) of the families were known to Croydon Housing, with 55% (33/60) currently living in social or housing association properties. This compares to 17.9% of the general Croydon population living in social housing, (2011 census data). 17 (28%) families were known to have resided in temporary accommodation leading to multiple moves of residence for the families of which 7 (12%) families have been evicted from council property. An illustration of 3 families housing experience with 14 moves of residence between them can be seen in Appendix 1. Parental issues Children reach their potential when they grow up in households where they feel safe and secure, and benefit from a close attachment with their parents or primary carers who are able to respond to their needs. A concerning pattern of issues was identified that had an important impact on the ability of parents and carers to provide a nurturing home environment for their child, to support 13 | P a g e   their development and keep them safe. The table below illustrates the multitude of issues that were known about parents of children in the cohort.   As can be seen, the percentage of paternal absence from the home was high. This review has found that whilst fathers were not at home, for some they continued to have an influence in the child’s life. Case Example – paternal absence and influence   Child A and his 2 younger sisters lived with their parents until he was 7 when they separated and father moved to live with a new partner. Father had a history of offending, which included a period of imprisonment during Child A’s early years.   Child A was deeply distressed at the departure of his father and mother struggled to manage his behaviour at home, he blamed his mother for father’s departure. He started to act out at school and would often get into fights with other pupils. Child A was always keen to see his father, who tried to see the children on a fairly regular basis.   When he was 9, mother’s partner moved into the family home and a new baby was born when Child A was 10 yrs. Soon after starting secondary school, his father received a second custodial sentence, which further impacted upon Child A.    2%5%13%15%17%17%22%23%27%27%28%37%42%72%0%20%40%60%80%Medical issues - fatherMental health - fatherMedical issues - motherAlcohol misuse - fatherDeath of a parentDrug misuse - fatherMental health - motherAlcohol misuse - motherDrug misuse - motherParental Absence - motherHomelesssnessParent or sibling known to policeDomestic AbuseParental Absence - fatherParental Issues of the VAR 60 cohort14 | P a g e   Mother’s partner took a greater role in seeking to control Child A, but Child A’s behaviour did not improve. Support was provided to the family, but at 12 yrs. he was excluded from school; it was noted that he was smoking cannabis, associating with known gang members and was the victim of physical assault and intimidation by these peers.   Child A was 13yrs when his father was released from prison and father spent more time with Child A. Child A’s behaviour was noted to improve over this time but rapidly deteriorated after his father was again imprisoned.  From aged 14yrs – 16yrs. Child A committed numerous gang related offences including; serious physical assaults and robbery, he was the victim of a stabbing, was involved in serious knife crime and often went missing. Many attempts were made by professionals to keep him safe; he was taken into care with his mother’s agreement and lived in multiple foster placements, but frequently went missing. He served a sentence in a Young Offenders Institute, and on release returned to his family.  This was short-lived, as he immediately returned to his gang activities and, like his father, Child A is now serving a prison sentence.   Domestic abuse Research confirms that exposure to domestic abuse as a child can have a lifelong impact on a child’s development; on their ability to learn, to form relationships with adults and peers, on their behaviour and on their emotional wellbeing.  Children who witness violence in the home, combined with some of the other experiences described (such as : parental mental ill- health, parental criminality or substance misuse) are at greater risk  of developing a range of social, mental and physical health problems and behaviour, which can result in physical violence and incarceration.4 38% (23/60) of children came to the notice of police due to reports of domestic abuse (primarily from aged 1 year to 12 years old - 13 were boys and 10 girls). See Appendix 1 Children’s Services  All 60 children in the cohort were known to Croydon Children’s Services. The graph below illustrates the age at which children first became known to Children’s Services.                                                              4 Bellis, M.A et al. (2013). Adverse childhood experiences: retrospective study to determine their impact on adult health behaviours and health outcomes in a UK population. Journal of Public Health, Volume 36, Issue 1, 1 March 2014, Pages 81–91. 15 | P a g e     This data establishes that children were known to Children’s Services early; over one quarter before age one, half by age five, almost three quarters by the age of eleven, and the remaining quarter came to notice for the first time after their twelfth birthday.  Effective early intervention had the potential to improve short and long-term outcomes for these children, and to possibly avoid the need for further statutory intervention throughout their childhood, but this review has found that early intervention was rarely provided. The graph below highlights the correlation between the age children were first known to Children’s Services, when they were first made subject of a Child Protection Plan (CPP), and when they first became a Looked After Child (LAC).   1615131627%25%21%27%024681012141618before the age of onebetween 1 and  5between 6  and 11from 12 plusNo of children in the 60 cohortAge range in years Age of Child when first known to Croydon Children's Social CarePlease note that some children were known to social care in other Boroughs at a younger age prior to becoming known in Croydon  16 | P a g e     This graph demonstrates that the peak of when children first became known to Children’s Services is pre-birth up to aged one year, however the peak of children being made subject to a Child Protection Plan (CPP) is age fourteen, which is consistent with the peak age for children in the cohort who became Looked After by the Local Authority. Analysis of the case records shows that in their early years, children were placed on child protection plans as a result of safeguarding concerns at home. As they got older, risk- taking behaviour outside the home became the greater concern.  8 children (25%) were subject to more than one CP Plan, 6 boys and 2 girls. Of those 8 children, 7 went on to become Looked After by Croydon Council, 6 boys and 1 girl (87.5%). The evidence suggested that services often invoked the correct procedures, in an attempt to safeguard the children, but the established mechanisms seemed to provide little added protection.    Case Example – contextual safeguarding  Child B’s mother suffered from serious health difficulties. When aged 2 months, Child B was removed from his mother’s care as she was unable to look after him. For the next 2 years he lived with his grandparents until mother recovered enough for him to be returned to her care. When he was 2 ½ yrs. he was again removed from mother as a result of very serious concerns about her health.   02468101214No. of children Age of child Social Care engagement type by age First contact to Croydon Social CareFirst CP PlanFirst Looked After17 | P a g e   Child B remained in the care of his grandparents, and mother would come and visit occasionally.  At primary school Child B was noted to have good attendance and there were no concerns about his progress.  Child B went to after school activities and enjoyed wide family support and contact.   At the start of secondary school there were no concerns about Child B, he seemed to be progressing well. His grandmother died when he was 13 years old. At 14yrs. Child B was reported as missing from home for the first time, his behaviour in school had started to deteriorate and he was spending increasing amounts of time with peers in the neighbourhood. At home, grandfather was struggling to control his grandson’s behaviour – he was frustrated about the problems at school and Child B was refusing to adhere to the boundaries he set.   During the next 2 years, Child B was excluded from school. He was often missing from home, known to the police for carrying knives and was suspected of robberies. Professionals were worried about his affiliation with gangs and his escalating risky behaviour. Tensions at home mounted and grandfather resorted to ‘physical chastisement’, Child B would spend more time out of the home, the frequency and seriousness of his offending increased. In grandfather’s view, despite a large number of professionals being involved, this was not providing Child B with safety; grandfather felt totally undermined by professionals, he was unable to control his grandson’s behaviour, his own health was deteriorating, and he was angry.   Child B spent more time on the streets with peers, who were known to be gang members - the risks to Child B outside the home were increasing.  Just before his 18th birthday he was seriously assaulted by rival gang members and suffered life-threatening injuries.  He is currently in prison.    Children’s Services – Looked After Children (LAC) Looked After Children are some of our most vulnerable children in society. They are separated from their families for the most part because they have experienced abuse in their own families or because parents and family are unable to provide them with safe care. Teenagers who become ‘looked after’ often experience placement breakdown and moves of carer.   A pattern of coming in and out of care and changes of placement can adversely impact upon a child and have long term implications for a child’s future relationships, their feelings of worth, their aspirations and future outcomes.  Without the structure and consistency that a strong family unit can provide, children become more susceptible to exploitation and risks in the community. Only 6 of the 45 (13%) had one placement, which is an indicator of the multiple moves the children experienced coming into local authority care. 18 | P a g e    75% (45/60) children were looked after by the London Borough of Croydon at some stage in their childhood; 78% (29/37) of the boys and 70% (16/23) of the girls. The youngest child to be taken into care in the cohort was under 1 year old and the eldest was 17 years old.  Of those children who came into the care of the local authority, 80% were over the age of 12. The numbers increase at each age from 12 years old to a peak at 15 years old.  General Health Of the 60 children in the cohort; 59 had good physical health, with one child having a chronic health condition.  Child and Adolescent Mental Health  In 2015, Croydon was estimated to have 5,557 children aged 5-16 with a mental health disorder, equating to 9.3% of the child population.   The 2017 NHS survey ‘Mental Health of Young People in England’5 found that 12.8% of children aged 5 to 19 years old had at least one mental disorder when assessed. Of the children in the cohort, 21% (9/42) were diagnosed with a mental disorder.  The greatest percentage was that of either no clear diagnosis and/or behaviour problems, 71% (30/42).                                                               5 Mental Health of Children and Young People in England – summary of key findings. NHS November 2018 p6 012345678123456789101112131415161718No. of Children No of different LAC PlacementsNo. of LAC Placements per Child by gender Cohort 45/60 FemaleMale19 | P a g e   This indicated the likelihood of psychosocial factors being present and contributing to the children’s vulnerability, rather than the severity of mental health problems alone.  70% of children in the cohort were referred to CAMHS:  16/23 girls and 26/37 boys. There was a steady stream of referrals to CAMHS at all ages, with the peaks being at age 7 and at age 11. The youngest child to be referred was aged 4 and the oldest aged 17. Nevertheless, the treatment or therapy received did not seem to address the emotional or behavioural issues the children presented. The reasons for this are variable, they can be associated with the level of engagement by the child and parent in the services offered or can be associated with the treatment available. The evidence from this review suggests that treatment approaches, modalities and methods of engagement may need to be adjusted to meet the needs of these children.   Fixed term exclusion at school  19 of the cohort (31%) received a fixed term exclusion at primary school, 17 of those children went on to receive fixed term exclusions in secondary school.  14 of those 19 children were later placed in a secure unit or young offender’s institute. All 19 children (100%) who received a fixed term exclusion in primary school went on to receive a criminal conviction.   This evidence suggests that use of fixed term exclusions by primary schools was a key indicator of young children struggling to manage their behaviour and, that for a significant percentage of the cohort, behaviour issues continued  into secondary school and beyond without being  addressed effectively. 16 of these children were from BAME backgrounds and the remaining 3 were white, which continues to demonstrate that the outcomes for these children are disproportionate. The evidence shows that those who received a fixed term exclusion in primary school were at a high risk of achieving poor outcomes. The schools attempted to use the limited options they had available to curtail the persistent concerning behaviour the children displayed. This included persistent disruptive behaviour, verbal abuse, threatening behaviour and physical assault. Evidently there were underlying issues for each child that the schools may not have been aware of, and were not equipped to deal with, as this required the support from other agencies. The importance of schools in a child’s life is explored later in this report.  20 | P a g e   The tables below provide an insight into the frequency, type, and duration of fixed term exclusions.    Victims or Villains? The table below illustrates that the children in the cohort were vulnerable to exploitation and crime as victims &/or perpetrators and brings into question how services engaged with these children. Should they be treated as victims first, or perpetrators?  This is a complex question and one which is discussed further in the findings section of this report.    12142102033016232.560.252329.511279.5214.54115211210510152025303540YP6YP8YP9YP10YP12YP14YP15YP16YP18YP21YP22YP24YP25YP26YP28YP31YP49YP52YP54No of days Excluded by Reason Child ReferenceNo. of days and Reasons for Exclusion in Primary School  Cohort 19/42Physical AssaultPersistent disruptive behaviourVerbal abuse /Threatening BehaviourOther21 | P a g e                                                  23 Girls – Victims or Villains?  100% at risk of Child Sexual Exploitation 57% victims of Child Sexual Exploitation  52% victims of crime  48% suffered assaults including sexual assault & rape 35% self-harm & suicide attempt  22% bullied at school 52% noted as violent by Police  39% suspect of knife crime 22% subject to Stop & Search 17% caught for shoplifting  17% drug involvement & county lines.                                                 37 Boys - Victims or Villains?  3 were convicted of Murder 38% were victims of knife crime 70% were victims of crime 92% were stopped and searched by police *The age for Stop and Search ranged from ages 9 to 16 years 76% were in gangs or affiliated to gangs 81% convictions linked to drugs possession  84% were shown as a suspect in a knife-related crime  Case Example – victim or villain? Child C came to the attention of the police for the first time when she was 12.  A shop assistant called the police after witnessing her being hit and kicked by her mother and grandmother. Police found that Child C had abrasions on her body, she said her family hated her. The Local Authority were informed, and an investigation started. The family said they were finding the behaviour of Child C difficult to control, she was said to be rude and defiant. The family had fled domestic abuse and were anxious not to be discovered by the father. They were told they should not use physical abuse as a means of behavioural control, they agreed and they were said to have fully co-operated with all that was asked of them, although this was vehemently disputed by Child C.   When Child C was 13yrs, she collapsed at school and was taken to hospital. The paramedics noticed she had cuts to her neck – she said she had injured herself using a piece of glass. She was taken to hospital where she was abusive to staff and had to be stopped from harming herself – she said she wanted to die. She was referred to the child and adolescent mental health team (CAMHS), she went home but refused to see a therapist.    At 14 yrs., Child C was reported as missing and was found by the police. She was verbally abusive to officers, she said she had been hurt by her grandmother, but it was thought that her injuries were as a result of self-harm. This became a regular pattern of behaviour.  She got into fights regularly with other children at school and was regarded as a child who was not truthful. She was abusive to professionals who tried to support her.   22 | P a g e   Over the next year, Child C often went missing. She was placed in care, but moved to many foster placements in an attempt to keep her safe, but she frequently absconded and was often abusive to her carers. It was difficult to provide Child C with the care she needed, she perpetrated many acts of violence and professionals were concerned about her, but she was so often missing that attempts to stabilise her repeatedly failed. When she was seen, she was abusive, and staff struggled to get beyond her angry, aggressive behaviour to recognise her suffering - even when she said she wanted to die.  She is currently in a secure unit.  Chapter 4. Local and National Landscapes Gangs  In 2009, The Centre for Social Justice published the report ‘Dying to Belong’6 in which they estimated that 50,000 young people were involved in gangs7. In the new report: ‘It Can Be Stopped,’ (August 2018) an additional 20,000 young people were estimated to have joined gangs thus highlighting the increasing size of the task for government, services and society to turn young people away from this destructive activity in our communities. Our young people live in dangerous conditions, subject to the pressures of gang membership and exploitation.8  As highlighted in ‘victims and villains’ table on page 20, 76% of children in the cohort were suspected of being affiliated to gangs. The Government launched the Serious Violence Strategy9 (SVS) in April 2018 in which they proposed further action under three key themes; early intervention and prevention, supporting communities and local partnerships, and effective law enforcement and criminal justice response. In addition, further action is planned under the heading: county lines10 and misuse of drugs.                                                              6 Dying to Belong: An In-depth Review of Street Gangs in Britain. Centre for Social Justice (2009)  www.centreforsocialjustice.org.uk/library/dying-belong-depth. 7 Definition of gang: Dying to Belong: An In-depth Review of Street Gangs in Britain Centre for Social Justice (2009) www.centreforsocialjustice.org.uk/library/dying-belong-depth. 8 It Can Be Stopped (A proven blueprint to stop violence and tackle gang and related offending in London and beyond). Centre for Social Justice report August 2018 9 Serious Violence Strategy, April 2018. HM Government 10 County lines is a term used to describe gangs and organised criminal networks involved in exporting illegal drugs into one or more importing areas (in the UK) using dedicated mobile phone lines or other forms of ‘deal line’. They are likely 23 | P a g e   There is a local multi-agency serious youth violence strategy and action plan in operation in Croydon, within which sits a comprehensive training package. Weekly tasking and six-weekly Gangs Multi-Agency tasking arrangements are in place to bring all the relevant agencies together to discuss gang members, risk and diversion. All resources and interventions are planned around weekly updates produced by the gangs’ analyst and further enhanced by an annual in-depth review. These arrangements are well placed to further develop the local responses to vulnerable and risky adolescents and prevent serious youth violence. At present there are 5 active gangs in Croydon. The Gangs Team are currently working with 35 entrenched members and monitoring a further 46 (adults and children)11. In addition, the team deliver preventative work to approximately 40 individuals per annum, and deliver training and awareness raising workshops in schools and in the community. Summary of the Croydon Gangs Team activities during 2017/18:  33 gang members diverted   Work with 40 preventative cases.  Delivering preventive workshops in schools and the PRU’s.  Schools and community raising awareness training delivered. Knife crime In the five years from April 2012 to March 2017, Croydon was recorded as having the fourth highest percentage of non-domestic knife crime in London (5.1%).12  Black males up to age 25 years were believed to make up 35% of all suspects and 30% of all victims with the most prevalent age 15 to 19 year olds. According to Metropolitan Police report flagging, (See ‘victims and villains’ section of this report on page 21 which details number of children in the cohort who were victims or alleged perpetrators of knife crime). Child Sexual Exploitation (CSE)   The response locally and nationally to Child Sexual Exploitation (CSE) is well established, with local safeguarding boards across the country providing the governance across local partnerships                                                              to exploit children and vulnerable adults to move (and store) the drugs and money and they will often use coercion, intimidation, violence including sexual violence and weapons 11 Based on data provided by the Croydon Gangs team November 2018 12 This data has been drawn from a profile of knife crime in Croydon Borough over a five-year period: 01/04/2012 – 31/03/2017. MPS 24 | P a g e   to implement CSE strategies. In 2017, Government published: Tackling Child Sexual Exploitation Progress Report.13  This report notes that despite the best efforts of practitioners working with children and families some abuse and neglect, including child sexual abuse, continues to go undetected, however, reporting of CSE has risen significantly since 2012. The Government has three national strategic aims for the continued focus on CSE nationally, and to hold local authorities, and criminal justice agencies to account for their ongoing delivery of local CSE strategies, who are expected to work towards achieving the national strategic aims: 1. Tackling offending   2. Reducing vulnerability  3. Supporting victims and survivors14  In Croydon, recent research conducted by the Safer London Foundation15 found that the largest proportion of young people recorded to be most affected by Child Sexual Exploitation were aged between 14 – 16 years old. This research has also shown Black or Black British young people were known to be most affected (39%), followed by white or white British (30%) and then mixed heritage (26%).16        Child Criminal Exploitation (CCE) The term child criminal exploitation is relatively new, and recognises that children, particularly those involved in gangs or on the periphery of gangs, can be vulnerable to being criminally exploited by gangs or by ‘olders’ in the gang. The definition of CCE was defined by the Government in 2018;  ‘CCE occurs where an individual or group takes advantage of an imbalance in power to coerce, control, manipulate or deceive a child or young person under the age of 18 into any criminal activity (a) in exchange for something the victim wants or needs, and/or (b) for financial or other advantage of the perpetrator or facilitator and/ or (c) through violence or threat of                                                              13 Tackling Child Sexual Exploitation Progress Report. HM Government February 2017 14 London Borough of Croydon Opportunity and Fairness Plan 2016-2020 15 Work to support CSE Profile Mapping in the London Borough of Croydon   Final report by Safer London Foundation May 2015 16 London Borough of Croydon Opportunity and Fairness Plan 2016-2020 25 | P a g e   violence. The victim may be criminally exploited even if the activity appears to be consensual’.17  The level of criminal exploitation nationally or locally is not yet fully quantified. CAMHS – Child & Adolescent Mental Health Service  Key findings from the NHS suggest that the number of children who require support to address their mental health has increased from 9.7% in 1999 to 11.2% in 2017.18   The best evidence available, collated and presented by the Centre for Mental Health, identified a number of key and relevant facts to this review: - Young people in the youth justice system are 3 times more likely to experience a diagnosable mental health condition than children who don’t offend. (Mental Health Foundation, 2002)19 - Children from low-income families are 4 times more likely to experience mental health problems than children from higher-income families20(Morrison Gutman et al, 2015) - Severe and persistent behavioural problems starting before secondary school years which go unsupported, can have long term impact on children’s mental health and life chances. (Brown et al., 2012) 21 The Care Quality Commission (CQC) also identified that stigma can be a major barrier to accessing mental health services for children and young people from Black and Minority Ethnic communities.22   Education  In England, between 2006/7 and 2012/13, the number of permanent exclusions reduced by nearly half, but has since risen, with a 40% increase over the past three years.23As a result, more children are being educated in alternative provision.  According to the Institute for Public Policy Research (IPPR), some groups of children are more likely to be educated in alternative                                                              17 Serious Youth Violence Strategy HMG April 2018 p48 18 This is based on a cohort of 5-15-year olds. Mental Health of Children and Young People in England – summary of key findings – trends, NHS November 2018 p8 19 The Mental Health Needs of Young Offenders. London: Mental Health Foundation 2002 20 Morrison Gutman, L., Joshi, H., Parsonage, M. & Schoon, I. (2015) Children of the new century: mental health findings from the Millennium Cohort Study. London: Centre for Mental Health. 21. A Chance to Change: Delivering effective parenting programmes to transform lives. London: Brown, E.R., Khan, L. and Parsonage, M. Centre for Mental Health 2012 22 Review of children and young people’s mental health services: Phase one report, Care Quality Commission, 2017 23 , Making the Difference, Breaking the link between school exclusion and social exclusion, Institute for Public Policy Research (IPPR) October 2017, pp 12–13 26 | P a g e   provision, or excluded, than other children. Children in care, children in need, children with special educational needs and disabilities (SEND) and children in poverty24 are all more likely to be excluded than their peers.25Pupils with SEN support are almost seven times more likely to be permanently excluded than pupils with no SEN.26 Boys are more likely to be permanently excluded than girls; for every girl permanently excluded last year, over three boys were permanently excluded. Some ethnicities are disproportionately represented in alternative provision, including Black Caribbean, Irish Traveller heritage and Gypsy Roma heritage pupils, 27this is borne out by the findings of this review In July 2018, the Department for Education (DfE) released its most recent data set evidencing that permanent school exclusions continue to rise in state funded primary, secondary schools and special schools. There was an average of 40.6 permanent exclusions per day in 2016/17, up from an average of 35.2 per day in 2015/16.28  Data in respect of Fixed Term Exclusions in Croydon schools is noted in Appendix One. Multi-Agency Data Summary and Analysis.   Pressures on Multi-Agency Services  The challenge for local authorities and their partners to effectively prevent and intervene to keep children safe in light of the decrease in available resources, and the increase in the numbers of children requiring statutory intervention, has been evidenced in research.  In 2017,29 the ‘All Parliamentary Group for Children’ drew attention to the funding crisis in Children’s Services and called on the Government to take action and, in 2018,30 concluded that services continued to face increased demand and reduced resources, and that money is influencing decisions about whether to offer support:  ‘This inquiry presents further evidence that money is influencing decisions about whether to offer support to our most vulnerable children.’                                                               24 This refers to eligibility for free school meals, as in schools this is the standard poverty measure 25  Making the Difference, Breaking the link between school exclusion and social exclusion, Institute for Public Policy Research, October 2017, p 16 26, Permanent and fixed-period exclusions in England: 2015 to 2016, DfE July 2017, p 5. 27 Forgotten children: alternative provision and the scandal of ever-increasing exclusions . House of commons Education select committee, Fifth Report of Session 2017–19 28 Calculated by DFE, by dividing the total number of exclusions by 190 school days. 29 No Good Options: All Parliamentary Group for Children. NCB 2017  30 Storing up Trouble: All Parliamentary Group for Children. NCB 2018 p3 27 | P a g e   In June 2018, The Institute for Fiscal Studies recognised when the spending freeze on safeguarding children started: ‘Spending on early and preventative interventions, such as Sure Start and young people’s services, has been cut by around 60% in real terms between 2009–10 and 2016–17.’31 And in the same year, The Education Policy Institute concluded that: ‘Late intervention services have weathered the cuts so far, yet early intervention services have not, despite a solid evidence base for the effectiveness of prevention and early intervention in terms of improved outcomes and cost benefit.’32 The evidence signifies the dichotomy of struggling children’s services who are trying to balance increased and more complex demand against ever stretched resources. The London Context – Serious Youth Violence  In June 2017 the Mayor’s Office for Policing and Crime (MOPAC), launched the London Knife Crime Strategy33 and recognised that whilst there had been a decrease in the use of violence since the Ending Gangs and Youth Violence (EGYV) programme was launched in 2011, there had been a reported increase in violence across the country since 2014.  Analysis of Metropolitan Police crime data for 2016/17 indicates that 75% of victims of knife crime are male and frequently aged less than 25 years of age and almost half of all victims of knife crime were from BAME backgrounds. For offenders, almost 90% were male and of those, 62% were from BAME backgrounds. In September 2018, the Mayor of London announced plans to establish a new ‘Violence Reduction Unit’ (VRU) of specialists in health, police and local government to lead and deliver a long-term public health approach to tackle the causes of violent crime.34  The VRU plans to enhance and build on the public health approach already underway at City Hall with a new unit that has greater capacity to deliver early interventions to help prevent the spread of violence. The new unit will improve co-ordination between the Metropolitan Police, local authorities,                                                              31 Public Spending on Children in England: 2000 to 2020.  The Institute for Fiscal Studies 2018 p5 32 Vulnerable children and social care in England – a review of the evidence. Witney Crenna- Jennings 2018. The Education Policy Institute 2018 33 The London Knife Crime Strategy 2017, Mayor’s Office for Policing and Crime, Greater London Authority. June 2017 34 https://www.london.gov.uk/what-we-do/mayors-office-policing-and-crime-mopac/violence-reduction-unit 28 | P a g e   youth services, health services, criminal justice agencies and City Hall as part of the new enhanced partnership, backed up by the unit.  The Croydon Context – Young offenders  Croydon has a higher rate of first- time entrants into the youth justice system than the London and national average. Young offenders often present with other risk factors such as drug addiction, alcohol use and behavioural issues associated with mental health problems and special educational needs Overall, the proportion of young offenders from BAME backgrounds is reducing and is nearly in line with the ethnic make-up of Croydon’s population of young people. However, boys from Black and Black British backgrounds are over-represented with a higher percentage involved in serious youth violence, drug or theft offences and first-time entrants to the youth justice system, many of whom re-offend.35 Taking on board the knife crime trends as it relates to children as victims or offenders and the prevalence of children who are from BAME backgrounds, Croydon’s challenge is particularly acute. The Croydon Context:  Safeguarding Children Croydon’s most recent Ofsted inspection36 (June/July 2017) identified the size of the challenge facing services to protect children from serious harm and were clear that immediate steps needed to be taken to improve services.  Ofsted found that there were serious failures in the services provided to children and their families that left some children at risk of significant harm.  An Improvement Board was established in September 2017 to drive the substantial programme of work required to improve the quality of services for vulnerable children and young people, and an improvement plan was developed.  In its most recent monitoring visit, in October 2018, Ofsted recognised that ‘the local authority is making progress in improving services for its children and young people’. As part of service improvements, Children’s Services reorganised to create an Adolescent Service so that the Youth Offending Service, the Gangs’ Team, Children Exploited and Missing                                                              35 London Borough of Croydon Opportunity and Fairness Plan 2016-2020 36  Croydon Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the Local Safeguarding Children Board. Ofsted September 2017 29 | P a g e   Intelligence Team all sit under one Head of Service, along with two newly created Adolescent Support Teams.  Croydon have taken this important step in recognising that this specialist integrated service provides a greater opportunity to improve outcomes for vulnerable children. The Adolescent Support Teams include social workers and specialist adolescent workers to work with children where the risk is predominantly outside of the home. These risks have been identified as:  children who are missing, all forms of exploitation (Child Sexual Exploitation (CSE), Child Criminal Exploitation (CCE), County Lines, offending, serious youth violence (including knife crime), gangs (involved in or on the periphery of) familial risk and organised criminal gangs (OCGs). This Thematic Review will explore some of these key issues and consider the implications for the wider children’s safeguarding partnership to enable current practice developments to be built upon, and to inform the service response to safeguarding vulnerable adolescents in Croydon.  Chapter 5.  The Children: Development, experiences, service provision and key learning  The following sections of this report will reflect on what is known about child development at different stages of a child’s life:  6 (0 to 6 years), 12 (6 to 12 years), 16 (12 to 16+ years), explore the services provided and identify the relevant learning. The chapter starts with the question: ‘Where were you when I was six’. This was a question a child asked a social work manager shortly before he died. It was understood that his question indicated he believed his family needed the support of services when he was young. This child’s death was the subject of a serious case review (SCR Child Q) which concluded that there were missed opportunities to provide the services he needed.   This chapter will discuss child development and reflect on the multi-agency services provided to the children in the cohort.      30 | P a g e   Where were you when I was six? (0-6 years) Child Development – early years In the first 5 years, a child’s brain develops at a faster rate than at any other time. Research confirms the importance of the first 1000 days of a child life (pregnancy to 2nd Birthday) as a time that has more influence on a child than at any other time in their life.37 Children’s early experiences – their relationships and the things they see, hear, touch, smell and taste stimulate the brain, creating millions of connections. This is when the foundations for learning, health, how the child sees the world and behaves throughout life, are laid down. A plethora of books, research and policy papers have been published over many years stressing the importance of these early years on a child’s overall development.  The term Adverse Childhood Experiences (ACEs) is used to describe a wide range of stressful or traumatic experiences that children can be exposed to whilst growing up.  ACEs range from experiences that directly harm a child (such as suffering physical, verbal or sexual abuse, and physical or emotional neglect) to those that affect the environment in which a child grows up (including parental separation, domestic violence, mental illness, alcohol abuse, drug use or incarceration). Croydon’s latest Public Health Report puts the spotlight on the first 1,000 days of a child’s life to demonstrate the effect early experiences can have. It focuses on how Adverse Childhood Experiences can impact negatively on children as they grow up: ‘From preconception to age two, every aspect of a child’s world – including their parents’ and carers’ income, housing, neighbourhoods, social relationships, age and ethnic group – is already shaping their adult life’.38  Evidence now suggests that ACEs have a negative impact on all areas of health and development. ACEs are linked to involvement in violence, early unplanned pregnancy, incarceration, and unemployment and suggests a cyclical effect - where those with higher ACE counts have higher risks of exposing their own children to ACEs.39                                                              37 https://www.nct.org.uk/about-us/first-1000-days 38 We are Croydon: Early Experiences Last a Life time. The first 1000 days from conception to the age of 2: Director of Public Health Annual Report 2018– chapter one 39 Bellis, M.A et al. (2013). Adverse childhood experiences: retrospective study to determine their impact on adult health behaviours and health outcomes in a UK population. Journal of Public Health, Volume 36, Issue 1, 1 March 2014, Pages 81–91. 31 | P a g e   The Early Intervention Foundation review of literature on risk (completed in 2015 and 2018) found strongly predictive risk factors seen in children as young as seven, namely: ‘troublesome’ behaviour, offending, substance use, aggression, running away, truancy, having a disrupted family, and having friends who were frequently in trouble.40 In addition, this review found that primary schools often identify children early, but are unable to find appropriate early support and intervention when children’s needs did not meet the thresholds for Children’s Social Care or CAMHS.  In response, support was put in place for the child by the school, which often did not meet all their needs or failed to address underlying factors that were probably unknown to the school.  Case Example - Early help  A health visitor noted concerns about the relationship between a mother and her 2yr old child (Child D); mother seemed to be emotionally distant and she seemed to have a poor bond with her child. The health visitor tried to engage mother, but there was little change, a referral was made to Children’s Services. The needs in the family did not meet a threshold for involvement and so the information was noted on file.  At 8 years old, primary school, in agreement with mother, referred Child D to CAMHS. School were worried about Child D’s behaviour in school; she struggled to make relationships with her peers and was often isolated and would act out in class. CAMHS decided that Child D’s ‘behavioural problems’ did not meet the threshold for their intervention. One year later, mother and school were worried about Child D’s behaviour and a second referral was made to CAMHS. CAMHS again decided that Child D’s needs did not meet their threshold and so services were not provided.  At 13 yrs. Child D was referred to Children’s Services. School, YOS and police were very concerned about her; she had been excluded from school, there were difficulties in her relationships with family members, she was thought to be involved in gangs and was at risk of sexual exploitation.   Child D went on to be the victim of multiple physical and sexual assaults, she self-harmed, perpetrated multiple offences against others, was regularly missing and involved in county lines.  She has received criminal convictions and is currently in the family home.                                                               40 Intervening Early to Prevent Youth Violence – The Role of Primary schools. March 2018.  Early intervention Foundation.p10 32 | P a g e   Where were you when I was twelve? (6-12 years) Child Development – primary years Progression towards adolescence is a time of considerable change for children both physically and emotionally. This time coincides with wider societal and community expectations by adults, parents, carers, and teachers. It is a time of burgeoning independence and a time when peers have an important influence on their emotional well-being, behaviour and the decisions they make.   Moving from primary school to secondary school is a crucial transition point for children. They may travel unaccompanied using public transport, create new peer relationships and encounter other children who can have a positive or negative influence upon them. Secondary schools are much larger institutions and therefore will introduce children to a much larger, diverse and unknown group of children, staff and buildings. Structures and systems are very different, and this new environment can seem quite daunting for many children.   For some of those children who were already struggling in school this was challenge that they were not able to overcome successfully.   A crucial protective factor for these children is their relationships with family members and kinship. Evidence seen as part of this review suggests that these relationships may be undermined by issues such as substance misuse, domestic abuse or parental ill health and this can lead to difficulties in the relationship between a parent and their child. In these instances, it seems that children are more likely to seek relationships with role models in their communities or among their peers which can have a positive or negative impact. If negative, this can lead to exposure to gangs or pro-criminal peers.                                                       “It’s more about family”                 (Male 17 yrs., when speaking about what gang membership meant to him)  At age 10 years, children reach the age of criminal responsibility and are therefore regarded as being able to make informed decisions about the actions they take. They spend increasing amounts of time in their local community and the nature of this community can influence their behaviours and outlook on life, as well as their safety.  33 | P a g e   Evidence from research suggests that when childhood trauma occurs, and remains unresolved, it can lead to neurological damage and influence how a child naturally responds to situations. ‘The neurological damage caused by trauma suggests that survivors can be “primed” to respond to current situations that replicate the experience of loss of power, choice, control and safety in ways that may appear extreme, or even abnormal, when a history of past adverse events is not taken into account’ (Read et al. 2014).41  Cafcass were able to examine 22 case files and drew the following conclusion; ‘Without exception the 22 children in the cases reviewed experienced significant loss and trauma in their early childhood’.42 In a review of available literature, the Joseph Rowntree Foundation found that those who experience multiple bereavements, or bereavement alongside other difficulties, are statistically ‘at risk of experiencing negative outcomes (in areas such as education, depression, self-esteem and risk-taking behaviour) later in life: ‘There is also a case for paying particular attention to troubled young people who may have faced significant bereavement earlier in their lives, and to bereaved young people living in disadvantaged circumstances.43  In the cohort of children, 17% suffered the death of a parent. Furthermore, the children spoken to in custody highlighted their level of personal loss. “Lots of people close to me are being killed – it’s very upsetting” (Male 16) “I went to four funerals last year” (Male 17) Case Example – Bereavement   When Child E was 5 yrs.  Primary school were concerned about Child E’s behaviour, the attachment    between mother and Child E was noted to be poor, although no services were provided to seek to address this.  He was excluded on three occasions. When Child E was 9yrs. his father died suddenly following a car accident.                                                               41 Review: The traumagenic neurodevelopmental model of psychosis revisited, Read, J., Fosse, R., Moskowitz, A. and Perry, B. Neuropsychiatry, Vol. 4 No. 1, Future Science Group 2014 pp. 65-79 42 Cafcass Agency Summary Report to the VA Thematic Review 43 The impact of bereavement and loss on young people June 2005. Joseph Rowntree Foundation 34 | P a g e   One year later, Child E started to come to the attention of the police; he was often seen in the neighbourhood with older boys smoking cannabis. At 12 yrs., he was arrested for assault and theft.   At secondary school, concerns were raised about his affiliation with known gang members. His behaviour at school was of significant concern, he was often angry and aggressive to staff and pupils and spoke about killing himself. Over the next eighteen months Child E’s behaviour escalated; he was known to be involved in multiple offences including robbery, drug dealing, and physical assault and carrying an offensive weapon (knife).   When Child E was 15 yrs., he told his SW that things changed for him when his dad died - he felt ‘like a different person’. He recounted that although his parents had separated, he would spend time with his father who took him fishing and went to football matches with him.  By now, Child E was heavily involved in a gang and his criminal behaviour saw him convicted of multiple offences - much of his life was now spent in Youth Offending Institutions (YOI).    Where were you when I was sixteen?  (12 – 16+ years)  Child Development – secondary years The transition from childhood to adolescence and beyond is accepted as a time of considerable biological, psychological and social change. These changes invariably inform how the child, or teenager perceive themselves, developing their personal identity, their social identity and how they want to be seen by others. It is a time when positive role models are important for children, to provide encouragement and to be a consistent person in the child’s life, which in turn provides a sense of security and safety. At this time children need a sense of purpose, a sense of belonging, and when this is uncertain, they naturally seek it out elsewhere. Research evidence confirms how peer influences can have a detrimental impact on a child. The NSPCC briefing: ‘Teenagers at risk’, reviewed statistical information and UK-based research and established the following: ‘Peer influence is a major factor in the decisions made by young people to join groups or to offend (Young et al, 2007; Smith et al, 2001; Duffy et al, 2004).  Many young people in offending groups feel a profound need to develop secure relationships with peers.  For this reason, in much of the research conducted, young people spoke of the desire to impress and to gain the 35 | P a g e   respect of friends, and in some cases, this can serve as a catalyst for offending behaviour and the acquisition of weapons.’ (NCH, 2008)’.44   ‘Young people are also more likely to offend if their peers have offended on previous occasions: The Youth Lifestyles Survey in 199945 found that young men with friends who had previously been in trouble with the Police, were more than three times as likely to be involved with criminal offending.  Young women with delinquent friends were six times more likely to perpetrate crimes themselves (Flood-Page et al, 2000).  Young people living in densely populated urban areas are also less likely to avoid both positive and negative associations with neighbours and peers, so this effect will be increased (Smith and Bradshaw, 2005).’ 46 At this age, if there has not already been work undertaken to address emotional and behavioural difficulties these will become entrenched. Over time, the children who need this support, and do not receive it, adjust their sense of being or how they behave to compensate.  Croydon Health Service noted one child was identified for having anger and violent behaviour from the age of 4. There was evidence of short-term targeted intervention but it was unclear whether the interventions were effective. The records highlight that the angry and violent behaviour escalated throughout childhood and into the teenage years. The voice of the child is noted in the records following a violent outburst:   “I want help with my anger, I can’t stop myself”                       The young person became a victim and perpetrator of violent crimes.47  Mental health issues that remain unaddressed are likely to deteriorate and play a significant part in how the child behaves. Older children who have experienced domestic abuse, are likely to react in different ways depending on gender:                                                              44 Teenagers at risk: The safeguarding needs of young people in gangs and violent peer groups. NSPCC March 2009 45 The Youth Lifestyles Survey was commissioned by the Home Office to identify the relationship between offending with lifestyle and demographic factors.  It has been conducted twice in 1992/1993 & 1998/1999.  The 1999 sweep comprised a representative sample of 4,848 12-30-year olds.   46 Teenagers at risk. The safeguarding needs of young people in gangs and violent peer groups. NSPCC March 2009    47 Croydon Health Service Agency Summary Report for the VA Thematic Review 36 | P a g e   ‘Boys seem to express their distress much more outwardly, for example by becoming aggressive and disobedient. Sometimes, they start to use violence to try and solve problems and may copy the behaviour they see within the family. Older boys may play truant and start to use alcohol or drugs (both of which are a common way of trying to block out disturbing experiences and memories).’ 48  ‘Girls are more likely to keep their distress inside. They may become withdrawn from other people and become anxious or depressed. They may think badly of themselves and complain of vague physical symptoms. They are more likely to have an eating disorder, or to harm themselves by taking overdoses or cutting themselves. They are also more likely to choose an abusive partner themselves.’49 Children are fully aware of the greater expectations to be a responsible young adult, which many children embrace, and others rebel against. A natural part of a child’s transition to adulthood is experimentation, or risk-taking behaviours. For most children, this is a time of hope, and excitement as children become young adults and take more independent steps towards their life goals. For other children, dependent on their experiences to date, a sense of hopelessness can prevail, and this can impact on their perception of self, people around them and their perception of the world.   Where were you when I was six?  Experiences & service provision  Over half of the children in the cohort came to the notice of Children’s Services before the age of 5 years, this suggests that concerns were identified at an early age. However, as these children continued to come to the notice of multi-agency services throughout their childhood and adolescence, this suggests that the services provided did not have the desired effect on their long-term outcomes.                                                               48 https://www.rcpsych.ac.uk/mental-health/parents-and-young-people/information-for-parents-and-carers/domestic-violence-and-abuse-effects-on-children 49 https://www.rcpsych.ac.uk/mental-health/parents-and-young-people/information-for-parents-and-carers/domestic-violence-and-abuse-effects-on-children 37 | P a g e   Six children were made subject to child protection plans by the age of 5 years, and five children came into the care of the Local Authority. The trauma associated with significant harm, and broken attachments with primary care givers, should not be underestimated. The 31 children in this cohort were exposed to a number of adverse experiences throughout their early years which, research suggests, would have a negative impact on their development. Exposure to domestic abuse is an example of this: 10/60 children came to notice by the age of six, due to reports of domestic abuse. It is important to note that the evidence presented in this review refers only to children who were referred to the statutory agencies (Police and Children’s Services), it is likely this does not reflect the scale of the issues that were present for these children in these crucial early years.  Overall, service provision was characterised by short-term single agency responses to the presenting needs of the child and, separately, the adults. This response is not unusual, statutory services are neither equipped nor resourced to provide services to children and families over long periods of time, and a holistic approach that provides a unified adult and children service response to families often remains a gap in current service provision.   Where were you when I was six?   Key learning Evidence from the audit (15/60) showed that, in the most part, parents (mainly single mothers) were more open to the involvement of services during these early years than at any other time in the child’s life. It was the view of panel members that the benefits of providing non-stigmatising universally accessible services should be properly recognised and resourced. Health visitors and primary schools were considered to be well placed to support the relationship between a child and his or her care givers, and to provide advice and guidance to parents about child development and understanding the impact of ACEs.  38 | P a g e   Models such as Family Nurse Partnership, Perinatal Mental Health Teams50, Children’s Centres or other models designed to support parents in the early years of their child’s life, integrated with other local services, were regarded as critical. The evidence seen in this review suggests that primary schools were well placed to identify early patterns of behaviour that were of concern, even when the child’s history was unknown. The importance of primary schools in these early years is recognised by the Early Intervention Foundation:  ‘There is a clear opportunity to intervene earlier than we do currently on a key issue affecting outcomes for children, and primary schools have an important role to play here.’ 51  ‘The reality, starkly illustrated in this report, is that these opportunities are being missed. This is not a criticism of primary school teachers; whose voices are front and centre in this new report. Our analysis paints a picture of passionate, caring and committed professionals, deeply concerned about the risks facing their pupils but at a loss as to how best to support them, and feeling thwarted by the thresholds for social care or CAMHS involvement.’52 This report finding was illustrated when it was learnt that a child’s primary school had made an urgent referral to CAMHS highlighting the concerns of both the child’s mother and his primary school teacher:   “He is at risk, as he grows older, from peers/older children/gangs. Mum and school feel he will get involved in anti-social behaviour and/or physical difficulties, as a consequence of his attention seeking, interfering and, at times, own anger. This could have potentially disastrous consequences.”                          The child became a gang member and died at the age of 16 years.                                                                50 The family nurses in the team are drawn mainly from health visiting and midwifery and children’s and mental health nursing and have a wide variety of additional skills and experience 51 Intervening Early to Prevent Gangs and Serious Youth Violence. The Role of Primary Schools Foreword: Dr Jo Casebourne, Chief Executive, Early Intervention Foundation March 2018,  52  Foreword: Dr Jo Casebourne, Chief Executive, Early Intervention Foundation: Intervening Early to Prevent Gangs and Serious Youth Violence. The Role of Primary Schools, Stephanie Waddell and Naomi Jones 39 | P a g e   Where were you when I was twelve?  Experiences & service provision  The review has established a range of notable features that demonstrate the deterioration of the behaviours of children in the cohort as they progressed through secondary school and adolescence. There was evidence of increased vulnerability, increased risk and unmet needs. In school, the behaviour of a high percentage of the children was of increasing concern resulting in 41 of these 56 (73%) children receiving fixed term exclusions.53  This was made up of 18 girls (82% of the girls’ cohort of 22) and 23 boys (68% of the boys’ cohort of 34).54   53% of the children (32/60) needed extra support in school; being either classified to have special educational needs, subject of Education Health and Care (EHC) plans or supported at School Action or School Action Plus (under the old SEND Code of Practice or School Support under the current SEND Code of Practice). Despite the review only being able to access the attendance data for 25/60 children, a trend of poor attendance and absenteeism was clear. 72% (18/25) were classified as being persistent absentees. Of these 11 were boys (61%) and 7 were girls (39%). It is fair to conclude that this figure is likely to be higher, if all attendance records for the 60 children were available.   A consistent feature of the engagement with children, parents and carers was the perception of bullying and the response from schools. Parents said that when the bullying of their child persisted, and was not curtailed by the school, their child started to fight back and take matters into their own hands. They were said to become more involved in altercations with other pupils, which led to fixed term exclusions, managed moves, and a permanent exclusion. Practitioners and school teachers suspected some of the children in the cohort had possible conduct disorders, had suffered trauma without resolution, or were concerned about the                                                              53 Based on exclusion data in respect of 56/60 children 54 Croydon Council does not receive exclusion information from schools in other local authority areas therefore this number could be higher.  40 | P a g e   likelihood of depression. In the majority of cases there was no clear diagnosis, their behaviour problems indicated that psychosocial factors were contributing to the children’s vulnerability. It was clear that many of the children appeared to be increasingly influenced by their peers more than their families; they were spending increasing amounts of time out of the family home when their whereabouts were often unknown (although the audit findings suggest that they were often not reported as missing at this age). It seemed that drivers for some children in the cohort were difficulties in the relationships at home (Audit sample: 15/15).   A significant proportion of fathers were absent from the family home, which meant they had limited parental control or influence on their child’s behaviour, with the remaining parent finding it increasingly more difficult to curtail risky, or troublesome behaviours. Referrals were made to key agencies like Early Help, CAMHS or Children’s Services. On many occasions children did not meet the thresholds for services. When they did, professionals reported that they struggled to develop meaningful relationships with children or their parents due to poor engagement with services. Alternatively, some of the parents said that when they did engage, they received mixed messages from different professionals on actions they should take and were left uncertain how to best support their child. ‘The YOS worker told me to report child to the police if they went missing again, but the social worker told me if I keep calling the police to report child Q missing it would impact upon the trust you have with your child’. (Parent of deceased child). It was clear from the audit of children’s cases that the key age of the children’s behaviour escalating, and the risks increasing, was 12 yrs. old (15/15). This was a time when parents were struggling to place boundaries around the child’s behaviour, and the children were increasingly challenging parental control and influence.    The single agency response to the needs of children and adults seen in the 0-6 age range was equally seen in the services provided during this 6-12 age range. The two serious case reviews (Child Q and Child Y) and the case audits revealed that this lack of an integrated approach left the needs of the children and the adults unmet.      41 | P a g e   Case Example – a holistic family approach     At 9 years old, Child F, was taken to Children’s Services by her father. He said the family were unable to look after Child F as she was violent to the mother, who had a chronic health condition and disability. She had an older sister and younger brother at home. Father had another family in another part of the country and was not able to take her with him.  After a short period of intervention, the case was closed to Children’s Services and the family referred to Early Help for support, there had been no involvement by adult services.  One year later, Child F went missing from home and was seen with much older boys, she was later described as having suicidal thoughts. No support had been offered by Early Help and it was not known whether adult services were involved.    At 14 years, grave concerns were expressed about Child F; she was often missing from home, a victim of CSE & CCE, involved in gangs and county lines, carrying offensive weapons, suffering low mood. She was made the subject of a Child Protection plan at 15 yrs. and a decision was made to involve adult services. It was not known if services were provided as they were not involved in the plans made for Child F.   Child F is now living with foster carers   Where were you when I was twelve?  Key Learning Early intervention: It was apparent that there continued to be windows of opportunity to intervene in the children’s lives to prevent an escalation of harm, and to engage families with services. Some of the issues are transferable across the age range from 6 – 16 + and these will be covered in the next section. We learnt that schools are well placed to identify those children at risk and likely to achieve poorer outcomes.  Of particular importance in this age range was the need to provide early intervention/preventative services, to provide a whole family and whole system approach, and to fully utilise the engagement of family members/kinship.  Schools: Transition from primary to secondary school, meeting the emotional needs of children & exclusions were key identifiable features for children within the cohort. Some children had behavioural concerns, special educational needs, and/or underlying familial issues that were not fully communicated to the secondary school and specialist assessments were often not completed in a timely way to inform a tailored individual plan for the child. More often than not, the child’s 42 | P a g e   poor behaviour was responded to with sanctions   - their behaviour was not understood as a possible symptom of difficulties at home or trauma in their childhood. With that said, primary schools were sometimes unaware of important information known to other agencies that could have assisted them, and the new secondary school, to meet the child’s needs. This meant that, a lot of the time, schools worked hard to manage the child’s behaviour in school but as they were not fully aware of the children’s additional and/or complex needs or other multi-agency plans, the response of agencies was often fragmented and uncoordinated.  It appears that on occasion’s schools made decisions in direct response to the child’s behaviour in school, without appreciating what the implications of an exclusion might be for a child, who had experienced trauma or had other needs that could be exacerbated by the instability of education.  It is recognised that school have a duty of care to other pupils, therefore decisions are often taken in line with this duty of care to keep other children safe and ensure their education is not disrupted.  The children who were the subject of the SCRs, and the children who were seen as part of this review, spoke about the impact of exclusions, managed moves to other schools, and placement at Pupil Referral Units, on their hopes and aspirations. It was as if their dreams of a better future were lost, and a door seemed to be closed to any chance of exiting the gang lifestyle and criminal behaviour.  “PRU’s are for people who have given up, education in prison is better – they should do everything before PRU it should be a last resort” (Male 16) “Managed moves are a one –way street out of education” (Male 17) The provision of emotional health and well-being support to pupils in school was found to be inconsistent, or not available. In addition, the social and emotional learning that the children needed, defined as: ‘the process by which children acquire the knowledge, attitudes and skills to understand and manage their emotions, set and achieve positive goals, feel and show empathy for others, establish and maintain positive relationships, and make responsible decisions’ 55 was not routinely available to all pupils. There did not appear to be a focus on building emotional resilience                                                              55 EIF policy briefing Social & emotional learning: supporting children and young people’s mental health. Early intervention Foundation December 2017 43 | P a g e   and the absence of a CAMHS professional, who can tailor therapy for children delivered in schools, seemed to be gap in provision.  In addition, there was little evidence of coherent multi-agency working that included schools as key partners. Evidence provided by one pupil referral unit highlighted that 100% of the pupils had been referred by them to other agencies, but too often additional support was not forthcoming and when there was intervention, there was little partnership working.  This learning is consistent with the 12-16 years plus cohort. Throughout the SCRs, and the audit of the children’s cases, the importance of engaging fathers, involving and supporting extended family members and kinship, was highlighted. In the SCRs, it was found that the potential of this network in providing safety and support when the children were placed in their care was not realised. The audit of children’s cases showed that in 10 of the cases there were members of the family and kinship (outside the immediate family) who could have been engaged to find alternative placements for children, or who could have been involved in the plans that were made. In the most part it was clear, both from the SCRs and from the audit, that the children wanted this network to be involved in their lives.     Case Example – involving family members   A father contacted the police raising concerns about his two sons who were 9 (Child G) and 13 yrs.  He was worried that they were being neglected by their mother and physically abused by her husband. Mother and father were separated, father was seeing his children regularly and they often stayed at his home. Police visited the mother and step-fathers home and noticed it looked neglected, but the children did not disclose abuse. Over the next few years, father continued to raise concerns and sought to secure their care through the courts, which was unsuccessful.  During this time the children were reported as missing from mother & step-father’s  home, father reported concerns that his sons were at risk of exploitation and often asked Children’s Services to intervene.   Child G was 13 yrs. when agencies became very concerned about his welfare – he was regarded to be at risk and had been admitted to hospital a number of times as a result of consuming alcohol and taking drugs. Father often provided care but was concerned about his children’s safety when they returned to mother’s care. Both children increasingly came to the attention of agencies; they were often reported as missing, and were victims of multiple assaults. The children were made subject to a 44 | P a g e   child protection  plan when Child G was 14 yrs. Mother was hostile to professionals, father was not invited to engage with the plans that were made.   At 16 yrs. Child G was regarded to be at very serious risk, his behaviour had escalated and services were struggling to keep him safe. He was taken into care but continued to go missing, finally his father was contacted to engage and contribute to his care plan. Child G is currently living in independence   Where were you when I was sixteen?  Experiences and service provision  As described in the previous sections of this report, several characteristics were prevalent in the children’s lives throughout their childhood that were not effectively addressed. Although children came to notice of agencies early, their exposure to adverse experiences continued and behaviours deteriorated. Children became more vulnerable, were exposed to exploitation (child sexual exploitation and/or child criminal exploitation) and were both victims and perpetrators of crime. The risks the children presented, and were exposed to,  increased; with evident involvement in knife crime (as victims or perpetrators), affiliation to gangs, drug use or involved with drugs, frequent missing episodes, high risk and aggressive behaviour and being regularly stopped and searched by police suspected of crime. Many of the cases showed that risk could have been identified much earlier and a preventative service provided in an attempt to avoid the children entering a cycle of offending and exploitation (Audit data: 15/15). The data below suggests that despite some well-intentioned interventions, there was a devastating impact on the children of services not responding early enough or effectively enough to change the trajectory of these children’s lives.  Gang Affiliation 33(55%) of the cohort were shown having links to known gangs in the Croydon area or linked to associates from these groups. Child Sexual Exploitation & Child Criminal Exploitation (CSE & CCE)  • 22 (37%) of the cohort were exposed to CSE  45 | P a g e   • 16 (27%) of the cohort were exposed to CCE  • 4 (7%) were exposed to both CSE and CCE  Criminal Convictions/Offences  50/60 (83%) of the cohort had either cautions, criminal convictions or both.  The range of offences was varied including; street robbery, grievous bodily harm, kidnapping, causing a child to engage in sexual activity, attempted murder, possession of drugs with intent to supply, burglary, possession of points and blades (knives), and sexual assault.  12/23 (52%) of the girls were noted as violent by the Police. 44 (73%) were known to Youth Offending Service and 10 (16%) are now adults who are currently being supervised by the National Probation Service. Knife Crime • 14 (38%) of the boys, were victims of knife crime. • 39 (65%) of children in the cohort were suspect of committing knife crime (this is broken down by gender: 9 [39%] of the girls and 30 [81%] of the boys). Drugs • 14 (23%) of the children were known to Croydon Recovery Network’s Substance Misuse Team • The most common offence was drug possession; 45/60 of the cohort (75%) were suspected of possession of drugs or held a conviction.   • This increased to 81% convictions when linked to drugs possession and county lines • 17% girls: drug involvement & county lines • 100% (15/15) of the audit sample were known to be smoking cannabis    Stop & Search 63% (38/60) children were stopped and searched by police.  The average age of the first encounter of those searched was 14.3 years (this age is similar to the average for the first missing episode and a prominent age in relation to CSE/CCE).   46 | P a g e   Placements in Pupil Referral Units (PRU) 53% (32/60) children attended a secondary Pupil Referral Unit or Alternative Provision setting for part of their education. This was usually their final education placement after it was no longer possible to secure a mainstream school for the young person. Of the 32 Children, 21 were boys and 11 were girls. This represents 57% of the total boys’ cohort and 48% of the total girls’ cohort. 28 children attended the Croydon PRU (Saffron Valley Collegiate), which caters for children with challenging behaviour. The main points of entry into the PRU were in years 9 and 10, with 36% (10 children) joining in each of those years  Missing episodes 56/60 children were previously reported missing, the average age for the first time missing was 13.9 years. The average number of missing episodes was 16.8, three children were reported as missing on a total of 200 occasions. In total, 1010 missing episodes were reported in the cohort.    Ethnicity and gender Black boys in the cohort were disproportionally represented in relation to child criminal exploitation, often linked to gang involvement and sometimes county lines. For girls, the disproportion was related to child sexual exploitation, with 100% at risk of CSE and 57% had been the victim of CSE.   There were two types of provision in the Croydon PRU’s: one behavioural provision for those children excluded or at risk of exclusion, and one for those with mental health needs. In 2017/18, the proportion of white girls in the mental health PRU provision was disproportionate to the wider population as was the predominance of Black or Mixed ethnicity boys in the behavioural provision.  Emotional health and well-being & drugs The poor emotional health and well-being, possible conduct disorders, attention deficit hyperactive disorder (ADHD) depression and trauma remained unaddressed and seemed to become a normal state of being and behaving for the children. Regular cannabis use was highlighted, and it is possible that this can be a way of   blocking out traumatic events.56 In addition, children said that dealing                                                              56 Frontiers in Neuroscience cannabidiol as a therapeutic alternative for post-traumatic stress disorder. From Bench Research to confirmation in Human Trials June 2018 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6066583/ 47 | P a g e   drugs was a way to generate revenue to look after themselves, as family incomes were low and traditional employment routes were not within their grasp (having been excluded from school and leaving school without any qualifications). Parenting issues Many other wide-ranging interrelated issues have been established by the evidence gathered by this review. The impact of parental or sibling offending, and substance misuse may have established a pattern of behaviour, possibly indicating to the child that such behaviour is acceptable. Domestic abuse or child to parent abuse, absent fathers or absence of both parents, compounded by the implications of the poor mental health of the remaining parent undoubtedly had a significant impact on the child’s behaviour and relationship with figures of authority.   At the age of 16/17 many of the children were beyond parental control, parents struggled to maintain consistent boundaries and to implement consequences. Several parents were frustrated and angry; they felt that had endeavoured to do all they could and sought the support of agencies to assist them and their child, but they did not feel listened to or heard by professionals. Parents spoke about professional intervention compounding feelings that they were ‘the problem’, and not part of the solution, and for some this reinforced existing feelings of powerlessness and worthlessness.   Where were you when I was sixteen?  Key Learning Multi agency responses were reactive. Behaviours escalated, became more frequent, more violent, and ultimately more concerning. As children spent more time out of the home, they participated in high - risk behaviours in the community. It seemed that criminal justice agencies and children’s services struggled to strike a difficult balance between meeting the needs of the child, managing risk, protecting the public from further offending and keeping the child safe. In line with their statutory duties, the multi-agency network used criminal justice interventions, enforcement action, or the child protection framework to protect the children from significant harm but the risks to the children remained. Some children received custodial sentences or were remanded in custody due to the gravity of the offences.  48 | P a g e   Alternatively, where appropriate, the local authority applied for a placement in Secure Units via the courts. These placements were made on welfare grounds; there had to be evidence that the child was likely to suffer significant harm or be at risk of harming others if this accommodation was not provided.57  In the most part, agencies worked hard to do what they could with the resources available but the fast-paced dynamic nature of the emerging issues and the nature and frequency of their exploitation and offending behaviour presented a significant challenge.    Case Example – A system struggling to safeguard  When Child H was 2 months old, there were concerns that Child H was suffering significant harm - this led to the Local Authority removing Child H from her mother’s care. Child H remained in foster care until just before her 7th birthday, mother applied to court to have Child H returned to her care - the court decided she was now able to care for Child H.  When Child H was 8 years old, her school told the Local Authority they were worried about Child H; she was often seen out alone late at night in the neighbourhood. School said mother was using drugs, but mother denied this. The SW saw Child H regularly and was worried about her. Child H was made the subject of a child protection plan. Many attempts were made by agencies to keep Child H safe, but her behaviour became increasingly of concern.  From the age of 11 she was coming to the attention of the police for theft, she was excluded from school and regularly went missing. When Child H was 12 yrs. the SW sought mother’s agreement for Child H to become a Looked After Child, but mother refused. Mother acknowledged that she had a long-standing problem with using drugs and agreed to engage in a drug treatment programme. Mother complied with the treatment, and it seemed that Child H was now safe, multi-agency services continued to be provided.  Age 14 years Child H’s behaviour was escalating; she was known to be smoking cannabis, frequently missing and concerns were raised about sexual exploitation. Attempts were made to safeguard her though a CP plan as she was now beyond parental control. Mother accepted that Child H was beyond her control and agreed for her to be placed in care.  Over the next year, Child H was looked after in multiple foster placements, each placement ended with foster carers saying they could not keep her safe as she went missing so frequently and there were repeated concerns of sexual exploitation. She spent some time in a Secure Unit, to seek to keep her safe.                                                               57 Section 25, Children Act 1989: that accommodation for the purpose of restricting liberty cannot be provided unless, (i)he has a history of absconding and is likely to abscond from any other description of accommodation; and - (ii)if he absconds, he is likely to suffer significant harm; or  (b) that if he is kept in any other description of accommodation, he is likely to injure himself or other persons 49 | P a g e      Child H is still seen by a SW, she is now 17yrs. She has said she has suffered trauma in the past, but is ambivalent about engaging in therapy. She is currently living back home with her family.  Engaging parents and carers was problematic. The children’s relationships with many of their parents were fraught, relationships often broke down and some parents attempted to discipline or curb their child’s behaviour with physical punishment. Despite referrals being made for a child to access services in their own right, there were occasions when parents and carers did not give their consent or did not engage with services offered to their child.  Alternatively, some parents reported that they did not feel engaged by services. It seemed that the lack of engagement was not something that was routinely explored so the reasons for non-engagement were unknown. The parents own adverse experiences and previous experiences of working with statutory agencies, more often than not, may have impacted on their decision to give consent and to fully engage and this was felt to be an important area for further exploration.   The interrelated risks were not brought together into a coherent plan and although the specific risks of the children going missing, of being exploited within their peer group and/or communities and in their homes were considered by each of the agencies involved, the wider systemic risks associated with the offending behaviour of other family members such as parents or siblings was not fully understood and there was no overarching plan that considered the entirety of the risks.  A culture of referral and re-referral. Agency reports, prepared for this review, identified the cycle of referral and re-referral and this was confirmed in the audit of cases (15/15).58 These were made in an attempt to secure the support a child needed. Discussions at the practitioner events often illustrated that these were attempts to seek ‘the solution’, in a belief that this might be found somewhere within existing service provision. This meant that the case was often closed to one service as the referral was opened to another, and another cycle of assessment began.                                                               58The audit showed that in the Children’s Service cases were opened and closed between 4 – 12 times. Closure was often associated with a referral on to another service or a belief that another service was involved. The lower numbers represented cases where children were LAC - the average across the whole group was 8 times.       50 | P a g e   Multiple professional involvement and high turnover of staff had a significant impact on the relationships that were possible with the child. The length of time some of these children were known meant that numerous social workers were involved in their lives,59 whilst this is largely unavoidable for children who are known for many years, there were examples in the case audit of children experiencing frequent changes of SW over weeks and months. The sheer extent of multi-agency involvement and movement across service thresholds meant that very few children had the opportunity to develop a meaningful relationship with a key professional.    Children and young people were exposed to, and were exhibiting, more complex, violent and risky behaviours but the risks these children were exposed to, and presented, seemed to be managed by the workers on the front line – there did not seem to be a sufficient organisational response to managing these risks.   The children were discussed at various high-risk panels such as MASE, risk management panels in the Youth offending service (YOS) and gangs meetings, all of which were attended by several agencies.  The risks and vulnerabilities were discussed at more than one panel and this inevitably led to duplication and differences in the information shared and the actions agreed.   The Fair Access Panel did not appear to be linked to these panels and it was understood that this panel is inconsistently attended by multi-agency services involved with a child – this posed a risk of decision-making being hampered by a lack of information and plans for children lacking a coherent multi-agency approach. The learning from this review, and from the SCR’s : Child Y and Child Q, has illustrated how much crucial information the different agencies held on children that was not shared, or known about,  by the full multi-agency group . Had they known, a greater understanding of causal and contributory factors may have been gained that could have been utilised to shape more effective responses to address the needs of the children and mitigate risk.                                                                59 The audit showed that the number of social workers involved in the children’s lives ranged from 3 – 16. Most were only involved for a few weeks or months. None of the children were allocated the same SW for longer than 18 months 51 | P a g e   Additional Learning Bereavement  The increase in serious youth violence and knife crime in communities means that more children who live in gang affected areas may witness extreme violence or know someone who has died or been affected by violence. It appears that the impact of this on children and young people is not fully appreciated. This presents a significant risk to society and the next generation of children as violence can be seen by some children in gang affected areas as an everyday norm and part of growing up. As serious youth violence increases, and continues to be highlighted in the media, it is highly possible that more and more children and young people in gang affected areas will suffer loss, trauma and bereavement. All the children in prison described the impact of violence, trauma and loss on them, the true extent of this for all children is unknown.  ‘Further research is needed into the complexity of young people’s experiences, with particular attention on the social context of bereavement and why individuals may respond differently to it.’60 Disproportionality  The children in this cohort were those about whom agencies were most concerned. Within the cohort, the largest group were Caribbean, or Mixed White & Caribbean boys and girls. Boys made up 67% of the cohort (25/37) and girls 30% (7/23) which is disproportionate given that children with this ethnicity represent 15.42% of 10 to 17 year olds in Croydon.  This of itself requires further examination. See Appendix One Table 3  This cohort of boys were of greatest concern to agencies and featured disproportionately in respect of; receiving fixed term exclusions; being subject to managed moves; placements in pupil referral units; becoming victims and perpetrators of knife crime; being stopped and searched by police, and involved with gangs.  The disproportionate number of black children of Caribbean heritage in the cohort, provokes some difficult questions. When visiting young people in prison the Lead Reviewer and Chair were asked:                                                              60 The impact of bereavement and loss on young people: Joseph Rowntree Foundation, June 2005 52 | P a g e   Why are so many black kids from Croydon in prison? (YP in prison) The Lead Reviewer and Independent Chair were unable to answer this question, but it is clear from the evidence seen during this review that this is one of the most critical questions raised by this review. In order to respond to these children’s needs, an answer is required.  Chapter 6.  Children, family and practitioner perspectives Children’s perspectives The engagement of children was completed in two strands of activity. Firstly, interviews with children in the cohort. Eight of whom were visited in prison, out of which five fully engaged with the Lead Reviewer and Independent Chair.  Secondly, in order to gather a broader range of views from those who may also be affected, a group of 40 children were engaged via Croydon’s ‘Big Youth Forum’ (that brings together youth forums from across the borough) and ‘The Youth Congress’.  Pupils from Saffron Valley Collegiate and Beckmead, who are in the cohort, were invited to participate and one child provided their views in a one to one meeting.  The children involved in the group activity came from across the borough and debated pre-set questions and recorded their views. All children engaged were articulate, and open to sharing their experiences and insights into gangs and serious youth violence in London. They also discussed their ideas of what interventions, approaches or services they believed could have make a difference to their lives or could make a difference to other children involved in a gang lifestyle.  In total, 46 children provided their views to this review. The views of the children in custody, were similar to those engaged in the community and there were several common themes identified: Gang Membership, serious youth violence and associated trauma None of the children stated that they actively sought to join a gang, to be involved in criminality, or serious youth violence as victims or perpetrators. “You can’t just join a gang like joining a gym” (Male 18). The perception of family was a common factor for children who highlighted their need to be part of a family, where they felt safe, where they had a role or purpose, with people who they believed 53 | P a g e   ‘had their back’, could depend on, and they had a loyalty to. When speaking about his membership of a gang a young person in prison said:  ”It’s more about family” (Male 18) One child said they felt safest when they were with family, and another confirmed that they had grown up into the lifestyle as immediate and extended family members lived, what was described as, a ‘road life’ or gang lifestyle. Other children highlighted how they either got involved in criminal activity to generate revenue to live off, so they were not dependent on parents who did not have much money. Or, they associated with peers in the community and ‘before they knew it’ they were in a gang. All the children described the impact of the violence on them individually and collectively.  “I’ve seen some terrible things” (Male 17) One child highlighted that 4 of his extended family had died as a result of gang violence and all of the young people in prison said they had all lost at least one friend they were close to. None of them had received bereavement support or other counselling to deal with the trauma they felt. Perception of safety Children described the areas they live in as ‘dangerous’ or ‘not safe’. Several children identified that peer pressure has a significant factor as some children got involved in gangs or violence to feel safer and to avoid becoming victims themselves. Having nothing to do, or nowhere to go outside of school, meant that some children hung around the streets or fast food outlets, which they believed increased the risk of violence and heightened perceptions of not feeling safe, resulting in more children carrying weapons to protect themselves.  “Safety depends on how you go about living and where you live” (Male 17) “My mum has wanted to move since I got stabbed in Croydon when I was 13” (Male 16) “You never go to Thornton Heath naked (without a knife)” (Male 18) “Croydon is dangerous for young people, it’s not safe” (Male 16)   54 | P a g e   Schools, managed moves and pupil referral units. Most of the children and young people spoken to in custody described difficulties in school that resulted in managed moves to another school and attendance at pupil referral units. The general consensus was that managed moves were a ‘one-way street out of education’. “They target people like me, once they get you out, there is no way back – they gave me false hope I could go back” (male 18)  A common feature of the children and young people interviewed in custody was attendance at least one pupil referral unit. Some of those in custody believed education in jail was safer, and better, than the PRU’s they attended.  “PRU’s are for people who have given up on themselves or are beyond help – do everything before the PRU – it should be a last resort”.  (male 18) However, children and young people had contrasting opinions of their experiences of attending a PRU. One child described how supportive the PRU they attended had been, in response to the emotional and social challenges they had and was very clear that the PRU and teaching staff were a great assistance to them. The PRU really helped me – the teachers get me, and give me space when I need it                (female pupil at PRU) On the other hand, another young person said:  “PRU allowed me to sell drugs61  I carried a knife, I could come and go as I pleased without challenge – it was good but not good” (male 18).                                                               61 The interpretation of this comment is that in the child’s view, he was allowed to take phone calls in the PRU from people wishing to buy drugs, he would leave and return, and was not questioned. The PRU did not give permission to the child to sell drugs, but in the child’s view, they did not stop him either, so in his opinion they didn’t really care what he did.  55 | P a g e   Ethnicity The children and young people in custody were either black or mixed race and commented on their race being a key issue ‘they don’t care about black kids’. They spoke about being stereotyped as gang members, but in their experience, all ‘races’ were involved. They believed they were never recognised for doing anything good, but always punished for doing something bad. Whilst none of the children or young people described specific racism towards them, they said they felt targeted because of their race. Another issue highlighted related to the media -  they felt the media portrayed black children in a bad light and spoke about the constant media reports which in their view may be glamorising the issues and making it worse.                                               ‘They don’t care about black kids. (Male 18) Push and pull factors – drivers. The children were clear about the factors that pushed children towards gangs or violence, and the factors that kept children out of gangs. Children from both cohorts (community and custody) shared similar thoughts. The main themes showed good insight into the range of issues facing children, both at home and in the community.   Many of the ‘push factor’ comments centred on what a child or young person could be experiencing in their immediate family and peer environment:  • peer pressure, avoid being bullied, threats,  • poverty, lack of money and debt, • home life issues including divorce, loss, grief • lack of attention, no positive attention • lack of encouragement and appreciation  • poor role models • poor self-esteem •  loneliness  Some of the ‘pull factors’ described showed awareness of other significant and complex factors that might play out for a young person who becomes involved in a gang - including:  • sense of family, community, ‘safety’ in a gang • becoming part of a family and wanting a role model or father figure  • attracted to risk, rebellion and revenge  • money, power and status 56 | P a g e   • drugs In addition, other comments of note included:   Conflicts in the community that children believed were escalating and forcing children to forge allegiances to protect themselves.  Poverty and the need to have or want money so they were not reliant on parents who lived in poverty. Some children indicated that they would like to work to get money, but they either couldn’t get a job or were too young and they identified problems at home in their view that forced children to spend more time out of the home. Solutions The children were very keen to discuss what needs to happen to address gangs and serious youth violence. The most common protective factors identified by the children and young people was the belief that ‘relationships would assist children to stay away from gangs’. They highlighted the need for relationships to offer support, direction and purpose, as well as boundaries and containment to young people.  There were frequent comments about the need for places to be available to undertake activities (music, arts, leisure centres) and places to go to socialise with a wide group of other young people from across the community and learn new skills. It was suggested that skills needed to be built through a variety of structured activities, to include sports, music, arts, and a focus on developing life skills, skills for jobs, and building aspirations.  Raising awareness of the true impact of being involved in a gang, having these messages shared at an earlier age and the role of policing were also felt to be important.  Other comments of note were: “give them (gang members) a place to feel protected”, create “safe spaces” and provide assistance for parents, including with childcare (for those children home alone after school due to the parents work commitments).            “The government should stop reducing budgets for services that support young people”  “You need to build trust in the system” (Young people from The Youth Congress) 57 | P a g e   “They (politicians) don’t know what it’s like – they need to come and spend time in the community with young people” (Male 16)  Parent, carer and family perspectives In the main, parents and carers and extended family members were unhappy with how they believe they and their child were treated by agencies and the school (s) their child attended. Parents did not feel fully engaged, listened to, or heard, by practitioners and said their overriding feeling was that they had to constantly fight to be heard, which they said was ‘very stressful’. Most parents and family members said they felt they were seen as a ‘bad parent’, who contributed to the child’s behaviour. They did not believe they were treated as part of the solution, nor enabled or supported by services to effectively manage their child’s behaviour, mitigate risks, or to improve the resilience of their child.       “They made assumptions, were prejudiced and had stereotypical views” (Parent comment) When asked to describe the quality of services they or child received, a consistent theme was highlighted where all parents and family members spoken to were adamant that their child’s behaviour got worse after services got involved. More concerning was the belief held by some that agencies made their child’s behaviour worse. One parent went to hospital to see her son after he had been stabbed and described how she was made to feel by a treating consultant. She said: “I felt like they had a stereotypical view of a parent of child involved in knife crime – you are a black woman, been a teenage mom with children from different fathers” Education and schools were said to be a consistent source of frustration and anguish. This was either due to how schools managed situations when their child was the victim of bullying or assault or relating to punishments they received (such as detentions, fixed term exclusions or managed moves) as they believed that on occasion, they were treated unfairly.  Parents recalled instances where decisions had been made by the school, without any explanation offered to child or parent. “It became like a tit for tat with school – he was piggy in the middle” (Parent comment) 58 | P a g e   The evidence collated by this review suggests there was a lack of engagement with services by parents in general, which was demonstrated in the audit of cases. The parents and family members interviewed described how they were trying their best to look after their children and earn a living to support their families and attend multi-agency meetings when requested. The meetings they attended were described by some as tense, uncomfortable and volatile. The issue of race and ethnicity was a significant feature throughout the interviews with parents and family members, who believed their child received a poor service because they were black. An aunt of a child that had been killed asked:   “If white children were being killed, do you think the government would care more & do something about it?” This comment suggests that members of the black community may perceive that black children are not treated the same as other children and if they were of a different ethnicity, the government and the system would care more, and take more decisive action to keep their children safe. Multi-agency practitioner perspectives Multi-agency events were held with 84 practitioners across statutory and voluntary agencies and were attended by a broad range of services and disciplines. Several local issues were consistently highlighted at these Practitioner Learning Events (PLE) and in the 1:1 meetings that took place with nine practitioners. The most prevalent of which was the demand on services, and the limited availability of time and resources to do the work that is needed with children.  The availability of services to children and families has reduced since austerity measures were introduced in 2008. The pressure on resources has led to non-statutory community services, youth provision, and preventative services being removed or significantly cut reducing the overall capacity of services to provide intensive support required by some children and their families.  Members representing schools spoke about not having enough resources to provide adequate pastoral support to a growing number of children who display behavioural problems, or who have special educational needs.  It seemed that these reductions have also contributed to fragmentation in the multi-agency network, as some services are unable to fully contribute to multi-agency interventions. 59 | P a g e   Practitioners spoke about preventative programmes and teams being cut, creating gaps in services which, in their view, meant that more children who could have been diverted earlier came to notice later, with more entrenched issues that needed to be addressed. Many said that the impact of changes to service thresholds (or access criteria to services), means that children who would have previously met the criteria for a service may not currently. Practitioners were clearly committed to service improvement and spoke about the notion of a whole systems approach that begins pre-birth. However, they were not confident that sufficient changes to the current system would be made. They felt stretched, ill-equipped, and frustrated with the timeliness of decision making and exhausted by carrying full ownership and responsibility for the behaviour of high-risk children at the front door of service delivery. Practitioners described sometimes being consumed with worry, about children on their caseload. Outside of work many had experienced fear listening to news reports of knife crime as they were worried the victim would be a child known to them. Equipping the workforce and partnership development and ‘a whole systems approach’ were also consistent themes.  Chapter 7:  Findings and Recommendations  Five key multi-agency findings have been identified to inform future service developments.   A range of single agency learning has been identified in the SCRs and through the course of this review, the respective service developments are currently being implemented. Finding 1. Early help and prevention is critical.  Early Years  This review provides evidence to complement the established research that a child’s early years lay the foundation on which future outcomes are built. Services are currently not equipped or resourced to provide the interventions that are needed, be they short term intensive interventions focussed on the child’s relationship with immediate care givers or interventions that support the child and family over time.   Primary Years   The evidence presented to this review suggests there are windows of opportunity to intervene in children’s lives to safeguard them from exploitation and harm or to reduce offending behaviour 60 | P a g e   before behaviour becomes entrenched &/or risks escalate, but the limited range and availability of preventative services means these opportunities are missed. Recommendation 1: CSCB Multi-Agency partners to work together with the community & voluntary sector partners to consider how non-stigmatising early intervention and prevention services can be delivered. Evidence based models and approaches (such as Family Nurse Partnership) to inform future service design.    Recommendation 2: In light of the evidence presented in this review, CSCB to review the new Early Help offer in Croydon and consider whether more is needed to support services such as YOS, Police and the newly established Children’s Services Adolescent Team to deliver preventative work so that services are able to respond to the windows of opportunity in children’s lives.   Finding 2: Greater recognition of, and response to, children’s emotional health and wellbeing is needed.   This review has established that the emotional wellbeing of children was the most significant factor that influenced their behaviour and outcomes. It is recognised that this can be difficult to respond to as a child’s behaviour often propels, and requires, agencies to respond to the presenting risks. In addition, the child’s instability in teenage years means that treatment through established services such as CAMHS makes traditional treatment routes difficult to access. It is recommended that approaches are adopted that seek to address the child’s trauma, services provided that are flexible enough to adapt to the child’s circumstances and needs. There was a vast array of professionals involved in the lives of the children, it was clear that forming a meaningful relationship with a child was extremely difficult. Service boundaries that are threshold led, rather than needs led, often result in multiple people working with a child and frequent changes of worker, a different approach is needed that places the needs of the child as central to the decision making.      Recommendation 3:   CSCB to consider best practice examples of implementing a trauma informed response62 (demonstrated elsewhere in the UK) and consider how the multi-agency workforce might be suitably supported to implement this approach.                                                              62 Developing and leading trauma-informed practice: Leaders' Briefing. Research in Practice 2018 61 | P a g e   Recommendation 4: A gap analysis to be completed to establish the current availability of emotional wellbeing services offered in schools and within the community, to inform a flexible approach to the commissioning and delivery of these services.  Recommendation 5: The impact of loss & bereavement requires greater focus in understanding the emotional needs of children. CSCB to consider how this understanding might be promoted within the multi-agency workforce and in the services provided.   Recommendation 6: The benefits of a key worker relational approach63 needs to be better understood and the barriers to this approach addressed.   Finding 3: An integrated, whole systems approach, is needed across agencies, communities and families.  Multi-agency service provision  This review has found that the current service provision to children is characterised by fragmentation where a child and adults needs are viewed in isolation and agencies respond to the presenting need, in line with the primary duty of the respective agencies, this creates a split in service provision and engenders a culture of referral and re-referral. A holistic approach to the child and family is needed complemented by an integrated multi-agency response.      Families and communities Changing the trajectory of children’s lives, and making a significant difference to children’s outcomes, cannot be achieved by professional intervention alone. There is a need to understand and embrace family, kinship and communities.  Recommendation 7: The contextual safeguarding approach, outlined in new statutory guidance,64 provides an opportunity for agencies to adjust their approach to safeguarding children by understanding and responding to a child in the context of their environment. The findings of this review should inform how this approach will be implemented in Croydon.                                                               63 That Difficult Age: Developing a more effective response to risks in adolescence. ADCS Research in Practice 2014  64 Working Together to Safeguard Children HMG 2018  62 | P a g e   Recommendation 8: CSCB to consider how an integrated holistic multi agency response can be delivered that reduces the current fragmentation of service delivery and explore how the concept of a trusted adult can be implemented in practice. Recommendation 9: The model of an integrated holistic multi-agency response should be extended to include consideration of the risk management panels. Consideration to be given to how schools, including the Fair Access Panel, can be included.   Recommendation 10: CSCB to explore what service adjustments are needed to better engage children and families and to consider practice and service changes that may be needed to enable a child’s needs to be met when parental engagement is problematic.    Recommendation 11: CSCB to consider how improved community, family and business collaboration will be achieved to safeguard children and improve their outcomes, consideration to be given to supporting community-based activities to build resilience and to create more opportunities for children to aspire and achieve.  Recommendation 12: CSCB to consider how awareness raising about the impact of ACEs will be built upon to include multi-agency professionals, families and the community.        Finding 4: Schools should be at the heart of multi-agency intervention. This review has recognised that schools are a critical part of a child's community, often representing a safe place where relationships with trusted adults are formed and hopes for the future lie. This review is strongly recommending that schools are equipped to respond to the challenges presented by children with high risk behaviour and are placed at the very heart of multi-agency service provision. Recommendation 13: CSCB to invite senior leaders representing schools in Croydon to consider what is needed to equip and support schools to manage the challenges presented by children with high risk behaviour and explore how a multi-agency team around the school will be achieved.     63 | P a g e   Finding 5. Disproportionality, linked to ethnicity, gender and deprivation, requires attention and action.  This review has evidenced a clear disproportionality: black boys and girls of Caribbean heritage were over represented, as were children whose circumstances rated highly on deprivation indices.  National research data confirms the local findings of disproportionality and reveals that black boys, of Caribbean heritage, are over-represented in exclusions and placement in alternative education provision65, more likely to be brought into care66, more likely to be involved in gangs and be the victims of serious violence67, and are significantly over-represented in the criminal justice system68.   Recommendation 14: CSCB to build on the work completed by agencies as part of this review and establish a data set about the most vulnerable children in Croydon to inform risk management strategies and service provision.   Recommendation 15: CSCB to consider how the involvement of professionals, families and the local community might be achieved, to explore what might be done to address disproportionality. Chapter 8:  Conclusion  This Review has been championed and commissioned by Croydon’s strategic partners through the CSCB. They have shown commitment to understanding the lives of these young people in order to improve the effectiveness of the multi-agency response available to children and families in Croydon. The review has brought together evidence from across statutory partners, the private and voluntary sector, the community, children and their families, and front-line practitioners, which paints a tragic picture of many of these children’s lives. Several criticisms of the current system have been made about the nature of provision to children, these criticisms are not new. In 2014, the research scope: That Difficult Age69 echoed concerns across senior leaders in Children’s Services about services provided to adolescents who were displaying high risk behaviours such as those in                                                              65 Making the Difference, Institute for public policy research (IPPR) October 2017, p 18 66, IT CAN BE STOPPED A proven blueprint to stop violence and tackle gang and related offending in London and beyond. Centre for Social Justice August 2018. P15 67 Disproportionality in Child Welfare. The Prevalence of Black and Minority Ethnic Children within the ‘Looked After’ and ‘Children in Need’ Populations and on Child Protection Registers in England. Charlie Owen and June Statham Thomas Coram Research Unit Institute of Education, University of London 2009 68 The Lammy Review; An independent review into the treatment of, and outcomes for, Black, Asian and Minority Ethnic individuals in the Criminal Justice System. HMG 2017 – introduction p3, chapter 1 69 That Difficult Age: Developing a more effective response to risks in adolescence. ADCS Research in Practice 2014 64 | P a g e   this cohort. Central to the findings of this review is that early intervention and prevention is essential, yet these services have not weathered the funding cuts of recent years.  It is perhaps salutary to end this report with a mention of costs. It was beyond the scope of this review to examine the financial costs to agencies of the services provided to the children. It is well established that the nature of the children’s needs means that the cost of service provision is extremely high.70 The costs to these children, their families and communities and to society as a whole, of not providing the support these children needed at a time when needed most, is a cost that cannot easily be forgiven or forgotten particularly by those whose lives have been blighted by the consequences of their actions or by the tragic loss of a child’s life.  Making a difference will be the lasting legacy for these children and their families.                                                                            70 For example: Care placements for adolescents make up 30% of the care budget (DfE 2013) quoted in: That Difficult Age. Research in Practice 2014 65 | P a g e     APPENDIX ONE Vulnerable Adolescent Thematic Review (VA60):   Summary and analysis of Multi-Agency Data   Introduction All agencies that took part in the Vulnerable Adolescent Thematic Review examined their records of the 60 identified children and provided information and summary learning to the Review. This is a collation of that information with further analysis, including some national comparison data and for Croydon children.  The 60 children include 23 girls and 37 boys; we sought to answer the following questions: -  Who are they?      Who knew and worked with these families? Where did they live?     What would they say about services? What was life like at home?    What would they want us to know? How was their health?    What can we learn from their experiences? What was school like? What happened in their lives?   Where are they now?  Age, ethnicity and gender of the VA 60 cohort:         46841198126105101520141516171819No. of childrenCurrent age of ChildTABLE 1: Age of children in thematic review at 5 March 2018 by gender       (note: age at DOD for deceased YP)FemaleMale66 | P a g e     The largest numbers in the cohort are Caribbean and Mixed White and Caribbean boys and White British girls. However when the comparison is made against the census data for Croydon children there are some striking differences; namely that of the disproportionate number of Caribbean and Mixed White and Caribbean children, both boys and girls, in the cohort.  See table 3 below:  1021311414721860510152025White BritishAny other White backgroundTraveller of Irish HeritageWhite & Black CaribbeanWhite & AsianAny other mixed backgroundAny other Asian BackgroundCaribbeanAfricanAny other Black backgroundA1 A3 A4 B1 B3 B4 C4 D1 D2 D3Table 2: Ethnicity & Gender of the VA 60 cohortFemaleMale67 | P a g e    A list of all current ethnicity codes can be found on Page 74.    Parental and environmental factors This next set of data looks at parental and environmental factors that were inherent within the child’s background.  In conjunction with the experiences of the first 3 children considered, we sought to establish if there were common themes among their parents. Findings show that of the 60 children, their experience was affected by the following: - (Please note that these are not exclusive figures, i.e. one parent could feature in more than one section.)  41.09%3.79%0.11%5.55%2.15%2.50%5.11%9.87%10.13%6.95%43.47%8.70%4.35%13.04%4.35%4.35%0.00%17.39%0%4.35%10.81%0%0%18.92%0%0%5.40%48.65%16.22%0.00%A1 White BritishA3 Any other White BackgroundA4 Traveller of Irish HeritageB1 White & Black CaribbeanB3 White & AsianB4 Any other Mixed BackgroundC4 Any other Asian BackgroundD1 CaribbeanD2 AfricanD3 Any other Black BackgroundTable 3: Comparison between Ethnicity of VA 60 Cohort by Gender and 10-17 year olds in Croydon (2011 Census data)% Ethnicity of Boys% Ethnicity of Girls% Ethnicitiy of Croydon 10-17 year olds68 | P a g e    Despite these significant issues impacting upon the child’s daily life, the majority of whom were living with one parent, only 3 of the 60 children had ever been known to the Croydon Young Carers Service.  Domestic Abuse Nine of the families were known to the Family Justice Centre (15%) with 7 of those being presented to the Multi-Agency Risk Assessment Conference (MARAC) due to the seriousness of the domestic abuse concerns.  Family Members  From the group 37% had a parent or sibling with criminal convictions.  2%5%13%15%17%17%22%23%27%27%28%37%42%72%0%10%20%30%40%50%60%70%80%Medical issues - fatherMental health - fatherMedical issues - motherAlcohol misuse - fatherDeath of a parentDrug misuse - fatherMental health - motherAlcohol misuse - motherDrug misuse - motherParental Absence - motherHomelesssnessParent or sibling known to policeDomestic AbuseParental Absence - fatherTable 4: Parental Issues of the VA 60 cohort00.511.522.533.51236789101112n/kAge of child of first report Table 5: Age of first reported exposure to Domestic Abuseby GenderCohort  23/60 Police DataGirlsBoys69 | P a g e   At the time of undertaking this analysis nine of the parents were actively known to Probation as a result of criminal convictions for offences committed within the family and/or wider offending behaviour.  Housing  Currently 17.9% of Croydon households are classed as social housing: of the VA 60 families the proportions are much greater than this Croydon average: -   17 of the 60 families (28%) have spent periods in homeless and temporary accommodation (TA) for a variety of reasons, including eviction for rent arrears, eviction from parental home, fleeing domestic abuse.   None of the families have lost their homes because of either their own or their child’s unacceptable behaviour. Of the 17 families who have spent periods in homeless and temporary accommodation, when offered council accommodation, 7 were later evicted as they struggled to sustain their tenancies. Examples of housing history from the 17 families: -   Example 1:  5 moves since 2004 - evicted from private tenancy, 1 month in TA Hotel, 11 years in Council tenancy, evicted 2015, 2 days in B&B Hotel, 4 months in self-contained emergency accommodation, 9 months in leased temporary accommodation, evicted as intentionally homeless Example 2 5 moves since Nov 2002 – evicted for rent arrears, 11 months at TA Hotel, 4 years as Housing Association (HA) temporary tenant; moved to another HA property; moved to further HA property Example 3 4 moves since 2014; 2 months in emergency accommodation outside London, moved to Council tenancy, evicted Oct 2017, 2 months in emergency accommodation out of Borough; current accommodation position unclear  Poverty and Deprivation We sought to identify if there was any link with deprivation, i.e. is poverty one of the factors in their experiences?  The predominance of the cohort lived in the more densely populated areas of Croydon and closest to areas of deprivation. See Table 6: Of the 60 children:  9 (15%) lived in an area that is one of the 10% most deprived areas in the country  23 (38%) lived in area that is one of the 10-20% most deprived areas in the country 49 families known to Croydon Housing (82%)  33 families currently live in Council or HA properties (55%)17 families have lived in temporary accommodation (28%)7 families evicted from council property (12%)70 | P a g e    28 (47%) lived in an area not in the 20% most deprived in the country.  Free school meals (FSM) 22 of the 60 children, have been recipients of Free School Meals at some period during their time in school, which represents 37%, approximately double the Croydon average. Percentage of children entitled to free school meals in 2017:   19% in Croydon primary schools (the national average was 15%)   17% in Croydon secondary schools (the national average was 13%). Please note Croydon Council does not carry out FSM checks for all schools as some academies carry out their own checks. So, while the local authority’s FSM data gives indication of eligibility it is not a definitive list. Link to Gang Territories The main areas where the cohort lived also link with the geographical areas of the current main five Croydon gangs, all of which encompass the most deprived areas of Croydon.  71 | P a g e   Table 6: Home postcode of each child overlaid on Deprivation map.  The red dots signify the child’s last known family home address.                                 72 | P a g e   Individual child related data; their history and contact with agencies Education: - Primary (Infant & Junior School) 42 (70%) of the 60 children started school in a Croydon Primary school, the other 30% of children were educated in other local authorities or came from abroad. 20/42 (48%) of the Croydon children attended the same primary school throughout this phase and for a further 9 the only change of school was the transition from infant to junior school, which is a recognised transition point. Therefore, it would be reasonable to state that 29 of the 42 children (69%) of the cohort had a stable primary school history.  Primary School Attendance We have primary school attendance data for 48 of the 60 children. In their final year of primary school, the average attendance was 88%. There was no significant gender difference in the attendance with the average attendance rates being the same for boys and girls.  14 of the 48 (29%) children would be classified as persistent absentees. Though the average overall attendance of boys and girls was the same, the girls were slightly more likely to be classified as persistent absentees in their final year at primary school. A persistent absentee is a pupil whose attendance is less than 90%. Six of the 23 girls (26%) and eight of the 37 boys (21.6%) were classified as persistent absentees. Fixed Term Exclusions in Primary School 19/42 (45%) of the cohort are known to have received a fixed term exclusion in their Croydon Primary School. Exclusion information from schools in other local authority areas was not available.               73 | P a g e   Table 7: Fixed Term Exclusions in Primary School Of the 19 children in the cohort, there were 16 boys and 3 girls. 16 children were BAME and 3 White British.  The ethnicity and gender split is not broadly dissimilar to that of all 406 children excluded from Croydon primary schools in 2017/18, although there are some slight differences.  See Table no 8.   0246A1 A2 A3 A4B1B2B3B4C1C2C3C4D1D2D3E2E3E4100000000000101000200030020000531000Number of children Ethnicity CodeTable No 7: Fixed Term Exclusions in Primary School by Gender & Ethnicity - cohort 19 children VA 60 GirlsVA 60 Boys020406080100A1 A2A3A4A5B1B2B3B4C1C2C3C4D1D2D3E1E2E3E4120600230010000125200407801410766112110182421001411Number of children excluded *Ethnicity CodeTable No 8: 2017/18 Fixed Term Exclusion in Primary Schools by   Ethnicity & Gender - cohort 406 childrenPRIMARY GirlsPRIMARY Boys74 | P a g e   * Ethnicity Codes currently in use are listed below:   Code Description A1 White British A2 White Irish A3 Any other White background A4 Traveller of Irish Heritage A5 Gypsy/Roma B1 White and Black Caribbean B2 White and Black African B3 White and Asian B4 Any other mixed background C1 Indian C2 Pakistani C3 Bangladeshi C4 Any other Asian background D1 Caribbean D2 African D3 Any other black background E1 Chinese E2 Any other ethnic group E3 Refused E4 Information not yet obtained                  Background information of the 19 children who received Fixed Term Exclusions in Primary School:     11 children were known to Children’s Social Care by the age of 2 (58%)18 children were known to Children’s Social Care by the age of 11 (95%)6 children went on to Special Schools (32%)13 children went on to Pupil Referral Units or Alternative Provision (68%)17 went on to have Fixed Term Exclusions in Secondary School (89%)14 children were placed in a Secure Unit or Young Offender Institute 74%Of the 19 children16 were BAME and 3 were WhiteOf the 19 children 16 were boys and 3 were girls All 19 children who received a Primary School Fixed Term Exclusion received a Criminal Conviction. (100%)  75 | P a g e   Table No 9, looks at the breakdown of the behaviour issues for the cohort of 19 children.  Table No 10, looks at the background to the fixed term exclusion for each individual child.  The total number of days they were excluded, plus the different range of reasons for the exclusions.   84.753729.55Table No 9: Days lost to Fixed Term Exclusions in Primary School by cohort of 19 children by reason Physical AbusePersistent Disruptive BehaviourVerbal Abuse/Threatening BehvaiourOther12142102033016232.560.252329.511279.5214.54115211211234567891 01 11 21 31 41 51 61 71 81 9NO OF DAYS EXCLUDED BY REASON EACH CHILD'S EXCLUSION HISTORY IN PRIMARY SCHOOL TABLE NO:10 NO. OF DAYS AND REASONS FOR EXCLUSION IN PRIMARY SCHOOL  COHORT 19/42Physical AssaultPersistent disruptive behaviourVerbal abuse /Threatening BehaviourOther76 | P a g e    Education – Secondary (Mainstream, PRUs & Special Schools) 42 (70%) of the 60 children started their secondary education in a mainstream Croydon secondary school. 5 children attended a Croydon special school. 15 of the 42 children (36%) attended the same secondary school from Years 7 through to 11. Of these, six were boys and nine were girls.  Attendance  We have mainstream secondary school attendance data for 25 of the 60 children. Of that cohort the average attendance in their last year of mainstream secondary education was 74.78%. There is attendance data for 15 boys and 10 girls, and the average attendance was 74.7% and 73.7% respectively. Of those 25 children, 18 (72%) were classified as being persistent absentees; 11 were boys (61%) and 7 were girls (39%).  Fixed Term Exclusions in Secondary School We have secondary school exclusion data in respect of 56 children of the 60 cohort. The gender breakdown being 22 girls and 34 boys. 41 of those 56 children (73%) received fixed term exclusions.  This was made up by 18 girls (82% of the girls’ cohort of 22) and 23 boys (68% of the boys’ cohort of 34).   Croydon Council does not receive exclusion information from schools in other local authority areas therefore this number could be higher. Primary Exclusions  The youngest age for exclusion from primary school was 4 years old.  Two children were excluded at the age of 4. One was excluded at the age of 6 and a further three children were first excluded from primary school at the age of 7.  These 19 children were in attendance at 15 different primary schools. Two schools had 2 children each and one had 3 children.  All age exclusions For one child of the cohort of 19 children who received a Fixed Term Exclusion in Primary School, this was the only occurrence of exclusion throughout their schooling in Croydon.   For the other 18 children they ranged from receiving 2 exclusions to 21 exclusions during their whole schooling history in Croydon.  CAMHS referrals 15 of the 19 children were referred to CAMHS    77 | P a g e    Education: Statements, School Action, EH& C Plans 10 of the 60 (17%) attended a Special School indicating all ten children had a Statement of Special Educational Needs or an Education, Health & Care Plan.  Only six of the Statements or EHCPs were initiated by Croydon SEN department and of these:  Two statements started at the age of 8  Three started at the age of 10 and   One started at the age of 14  All of the Statements had a primary need recorded as Social, Emotional and Mental Health. This figure of 17% within our cohort is disproportionately higher than the current figure for Croydon children with a Statement or EH&C Plan which is 3.3%. The England figure is 2.9%.  A further 22 of the cohort are recorded as being supported at School Action or School Action Plus under the old SEND Code of Practice or School Support under the current SEND Code of Practice.  15 boys (40% of boys’ cohort)  7 girls (30% of girls’ cohort)     11103052305101520253035Fixed Term ExclusionPermanent ExclusionFair Access PanelNo of childrenTable 11: Secondary Exclusions & Fair Access Panel Reviews by Gender - Cohort 41 MaleFemale32/60 children needed extra support in school 53% 15 of the 60 children (25%) were not subject to any exclusions during their secondary schooling in Croydon. It is not known if the remaining 4 children were subject to any exclusions during their secondary education. (Cohort of 41, plus 15, leaves 4 children, for whom we have no information) 78 | P a g e   Pupil Referral Unit or Alternative Provision  32 (53%) of the 60 children attended a secondary Pupil Referral Unit or Alternative Provision setting for part of their education. This was usually their final education placement after it was no longer possible to secure a place in a mainstream school. Of the 32 children 21 were boys and 11 were girls. This represents 57% of the total boys’ cohort and 48% of the total girls’ cohort. 28 children attended the Croydon PRU (Saffron Valley Collegiate). The main points of entry into the PRU were in years 9 and 10, with 36% (10 children) joining in each of those years.  SEE PAGE 74 FOR ETHNICITY CODES  PRU Provision type – behaviour and mental health. Table 13 shows the broad ethnic breakdown of all the children attending the 2017/18 provision in the two types of Pupil Referral Units. The first type being the Behaviour provision for those children excluded or at risk of exclusion and the second type for those with mental health needs.  The proportion of white girls in the mental health provision is completely disproportionate to the predominance of Black or Mixed ethnicity boys in the behavioural provision.   5121011171813012345678910A1A3B1B3B4D1D2D3No of children Ethnic categoryTable 12: Secondary PRU attendance by Gender and Ethnicity Cohort 32GirlsBoys79 | P a g e     Views of children  The PRU conducted a survey of Key Stage 3 pupils across a range of issues, including what the issues were that were affecting them - Key Stage 3 refers to 12 – 14-yrs.    We have sought to compare the Fixed Term Exclusion data for this cohort against the general Croydon population 31.70%40.10%13.80%14.40%85.70%4.80%9.50%00.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%White BritishBlack (Caribbean orAfrican)Mixed (White/ BlackCaribbean orWhite/Black African)OtherTable 13: Pupil Referral Unit Ethnicity Breakdown by Provision Type 2017/18Behaviour Mental Health231421131418160510152025Knife CrimeGun CrimeGangsCyber BullyingPovertyPressure from friendsPoor mental healthNumber of children Table No 14: 2018 Survey of PRU KS3 Pupils regarding issues affecting children80 | P a g e   Table No 15: Fixed Term Exclusions 2017/18 Croydon Pupils and VA 60 cohort data: School Type Primary Secondary Special PRU/AP No of pupils 33649 19840 826 326 No of FTEs 406 1055 23 38 % rate of FTEs 1.21% 5.32% 2.78% 11.66% VA 60 cohort 19 41 10 32 % rate of FTEs 31.67% 68.33% N/K N/K         Family engagement with services London Borough of Croydon Early Help Service 31 of the children (52%) were known to Croydon Early Help services.  Generally, these were being provided to the age group of 13+, mainly relating to education issues such as :-   school attendance  multiple school placements  exclusions  permanent exclusions  Social Care All 60 children of the cohort were known to Croydon Children’s Social Care as the cohort was selected on the basis of being known to social care and other agencies.  This table shows their age at first contact with Croydon Children’s Social Care.   024681012141618before the age of onebetween 1 and  5between 6  and 11from 12 plusNo of children in the 60 cohortAge range in years Table 16: Age of Child when first known to Croydon Children's Social Care Please note that some children were known to social care in other Boroughs at a younger age prior to becoming known in Croydon  81 | P a g e   Findings of note are:-  27% (16/60) were known to Croydon Social Care before they reached the age of one   52% (31/60) were known by the age of five.   73% (44/60) were known by the age of 11  100% (60/60) were known by 12+    Child Protection 53% (32/60) of children were subject to a Croydon Child Protection Plan. 8276810910024681012Under 11 to 45 to 1112+No. of Children Age Group Table 17: Age group at first contact with Croydon Social Careby gender FemalesMales012345678024681012141618Number of ChildrenAge at first Child Protection PlanTable 18: Number of Children and Age at First Child Protection Plan - Cohort  3282 | P a g e   8 children (25%) were subject to more than one CP Plan, 6 boys and 2 girls.  Of those 8 children, 7 went on to become Looked After by Croydon Social Care, 6 boys and 1 girl (87.5%) Looked After Children 45 of the 60 children (75%) were looked after by the London Borough of Croydon at some stage in their childhood. 29 of the 37 boys (78%) and 16 of the 23 girls (70%). Over 80% of the children came into care age 12+.  Engagement with Croydon Social Care Table 20 shows the age and different types of engagement with Croydon Children’s Social Care, from referral, to Child Protection Plans and becoming Looked After.  The peaks are when the children were young with a growing trend to require CSC intervention as they become teenagers, the peak for CP Plans is at age 14 and becoming Looked After at age 15.  18% (11/60) of the cohort had a CP Plan or were Looked After by the age of 8 yet remained of significant concern at least 6 years later as teenagers. The children in the cohort are all 14+.   012345678123456789101112131415161718No. of Children No of different LAC PlacementsTable 19: Number of LAC Placements per Child by gender Cohort 45/60 FemaleMale83 | P a g e    Secure Units & Young Offender Institutions 30 of the children have spent time in either a Secure Unit, or a Young Offender Institution. Both of these placement types remove the child’s liberty, i.e. they are locked up away from wider society. Children are placed in YOIs by way of Youth Offending courts for criminal matters, either placed on Remand or on conviction for a criminal offence.  Welfare Secure Units can also only be used by way of a court order through Family Proceedings Courts. The child has to be regarded as likely to suffer significant harm if not provided with such accommodation.71  There is a significant difference between the ratio of girls and boys being placed in such placements.   5 girls were placed in secure and 1 in a YOI; 6/23 (26%)    4 boys were placed in secure and 20 in YOIs. 24/37 (65%)                                                                                                                                                                                                                                                         71 Section 25, Children Act 1989: that accommodation for the purpose of restricting liberty cannot be provided unless,  (i)he has a history of absconding and is likely to abscond from any other description of accommodation; and - (ii)if he absconds, he is likely to suffer significant harm; or  (b) that if he is kept in any other description of accommodation he is likely to injure himself or other persons 02468101214No. of children Age of child Table 20: Social Care engagement type by age First contact to Croydon Social CareFirst CP PlanFirst Looked After84 | P a g e    CAFCASS – Care Proceedings Cafcass has worked directly with 26 of the 60 cohort (43%). This represents 17 children who were the sole child in proceedings and a further 9 children whose siblings were also included in their care proceedings.  12 of the 26 care proceedings (46%) were undertaken when the child was incarcerated or in specialist care: - 7 in secure accommodation (welfare)  - 5 were in young offenders’ institutions or specialist residential care.  CAFCASS were able to examine 22 of the 26 case files and have drawn the following conclusions; Without exception the 22 children reviewed experienced significant loss and trauma in their early childhood. In many of the case files, these issues were evident much earlier in the children’s lives. Earlier intervention may have supported them and improved their outcomes.  Five children had experienced the death of at least one parent; and the father of another had been deported.   Four children had parents/carers with serious medical conditions.    At least nine of the children had experiences of neglect and abuse because of parenting where domestic abuse, mental health and drug and alcohol issues (toxic trio) were key risk factors.   Nine out of the 22 children were stabbed or injured, whilst a further two exhibited self-harming behaviour.  Three girls made allegations of sexual abuse.  1321267801234567891314151617No. of ChildrenAge at PlacementTable 21: Children placed in a Secure Unit or YOI by  age and gender 30/60 cohortPlacement in Secure Unit or YOI FemalePlacement in Secure Unit or YOI Male85 | P a g e    Four of the children had a diagnosed disability which included autism and autistic spectrum disorders and learning disability which increased their vulnerability. Some of the other children were diagnosed with conduct disorders or refused to engage in assessment.   These children were clearly vulnerable and so particularly susceptible to gang membership and child sexual exploitation.   Half of the children (11) lived in the postcode CR0 constituency.   General Health  Report from Croydon Health Service • 59 of the children were in good physical health.  • 3 children had severe dental caries were identified within the notes which further included multiple “Did Not Attend” (DNA) for follow up appointments. This may have been an early indicator of neglect. • Out of the 60 children, 25 were referenced to have been in receipt of universal services by Croydon Health Services including both Health Visiting and School Nursing. Croydon University Hospital (CUH) Emergency Department (ED) Presentation to CUH Emergency Department for this cohort has been as teenagers. The following themes were noted: knife attacks, assault, substance misuse, and sexual health, conflict related injuries and mental health. For 11 children (18%) presentation to ED was as a result of being a victim of assault. This was made up of 9 males and 2 females. The two females were assaulted by a family member. Of note: Male victims denied knowing their attacker and were not willing to disclose information.  7 males (12%) presented to ED with varying degrees of stab wounds from minor to life threatening and were aged between 15 and 18 years. 3 of those died as a result of their injuries.  From the attendances for knife injuries, a thread throughout linked criminality, gang affiliation, multiple exclusions from education, attendance at PRU and missing episodes throughout their teenage years. There were 6 attendances for substance misuse (10%), largely for alcohol misuse with the highest prevalence being female. The attendance often highlighted an associated link to Child Sexual Exploitation (CSE)         86 | P a g e   Croydon Health Services – Mental Health   Out of the 60 children, 19 were receiving CAMHS intervention (32%) which commenced in teenage years at tier 3, requiring multi-disciplinary outpatient CAMHS intervention.  9 of those were direct referrals from Croydon University Hospital Emergency Department following presentation with overdose, suicidal ideation and deliberate self-harm. The gender difference was unremarkable regarding the attendance. Croydon Health Services – Special Educational Needs and Emotional Health   There were 15 children identified with Education Health & Care Plans predominately for behavioural related disorders such as Attention Deficit Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD) which promoted additional analysis of the health records. The theme which became apparent was a link between the 15 children and an increase in risk taking behaviour in their teenage years.   One out of the 15 was identified for having anger and violent behaviour from the age of 4, there was evidence of short-term targeted intervention, but it is unclear whether the interventions were effective. The records highlight that the angry and violent behaviour escalated throughout childhood and into the teenage years.  The voice of the child is noted in the records following a violent outburst, “I want help with my anger, I can’t stop myself”. The child became a victim and perpetrator of violent crimes.  Croydon Health Service - Adverse Childhood Experiences  Death of a parent was a contributing factor for 4 children with clear documentation that there had been an escalation in risk taking behaviour following their parent’s death.    Poor parent-child relationship and poor attachment was highlighted in a further 4 cases with clear links to escalating behaviour in criminality and risk taking behaviour in the teenage years of these children.  Death of a sibling was noted for one child   The trio of domestic abuse, parental mental health and substance misuse was a prevalent theme, with at least one of the elements being present in the most vulnerable cases.  Domestic Abuse was recorded for 11 of the children.   12 children were living with parents or step-parents with substance misuse and 7 were exposed to poor parental mental health.   Health records evidence a theme for these children affected by parental mental health, domestic abuse and substance misuse and experienced involvement with criminality and violence at varying stages of their lives.  It is significant to note that the health review identified high level violence and criminality as a parental factor for 6 children.    87 | P a g e   CAMHS – Child & Adolescent Mental Health Service In 2015, Croydon was estimated to have 5,557 children aged 5-16 with a mental health disorder, equating to 9.3% of the child population.   (This data is from Public Health) This compares to 70% of the VA cohort who were referred to CAMHS:  16/23 girls and 26/37 boys  The youngest referral was at age 4 and the eldest age 17.     1362353444124678911121314151617Number of ReferralsReferral Age in Years  Table 21: Referrals to CAMHS by Age & NumberCohort 38Table 22: Mental Health Diagnosis for each Child - Cohort 42  Attention Deficit Hyperactive Disorder (ADHD)    2 ADHD/Conduct Disorder   2 Conduct Disorder    4 Conduct/Emotion    7 Emotion     5 Generalised Anxiety     1 Adjustment Disorder    1 Depressive Episode    1 No formal diagnosis   18 Total                 42   In the majority of cases there was no clear diagnosis, or behaviour problems, indicating the likely presence of psychosocial factors in contributing to the children’s vulnerability, rather than severity of mental health problems alone.  PLEASE NOTE:  Whilst 42 children were known to CAMHS detail was only available for 38 children.  Therefore, the charts show only the data that can be verified.  88 | P a g e      7.030.030.070.0110.089.116.050.090.002.004.006.008.0010.0012.004-6 year olds 7-9 year olds11-13 yearolds14+Time CAMHS involved in Years & Months  00.00Age GroupsTable 23: CAMHS Age at Referral & length of time involved - Cohort 38MinimumMaximumLength of involvement in the service was very variable, in some cases dating back to early childhood, with periods of being closed to the service and then being re-referred.   In table 23, there were: 4 children referred age 4-6 years old  11 children referred age 7-9 years old  12 children referred age 11-13 years old 11 children referred age 14+    The length of time CAMHS support was offered to teenagers seems minimal compared to the other age groups. In looking at the individual information in more detail, it would appear to be related to the lack of engagement with the child and/or their family.  13 teenagers did not engage with the service, either beyond the initial engagement or to even be assessed in the first instance.         Explanation of timescales used in Table 23 0.01 represents One Month 0.03 represents Three Months 0.07 represents Seven Months 0.09 represents Nine Months 6.05 represents Six Years Five Months 7.03 represents Seven Years Three Months  9.11 represents Nine Years Eleven Months 10.08 represents Ten Years Eight Months  89 | P a g e   Croydon Recovery Network - Young People’s Substance Misuse Team (CRN)  14 of the 60 children (23%) were referred to CRN, 7 boys and 7 girls, see table 22 for Ethnicity of the children. CRN have three different types of interventions available to Croydon children: 1. Treatment: 9 children were referred for Treatment (although 6 did not go beyond referral).  – 1:1 key working with children and young people who have problematic substance misuse and wish to change, this consists of an assessment, weekly 1:1 sessions, care plans and goal reviews 2. Group work: 3 children were referred for Group work – one-off workshop delivered to young people referred by YOS Early Intervention who have been arrested for possession of Cannabis 3. Early Intervention: 2 children were referred to the Early Intervention Group work – a 4/6-week programme delivered to children who have been identified as being at risk of problematic substance misuse   The children referred had a range of substance misuse, primary, secondary and even a third. This table shows the mix of substance misuse addressed by the CRN team.   422132012345Table 24: Ethnicity of children referred to Croydon Recovery Network - Cohort 14 A1 White BritishB1 White & Black CaribbeanD1 CaribbeanD2 AfricanD3 Any other Black backgroundUnknown85141 1Table 25: Substances used by 14 children referred to Croydon Recovery Network CannabisUnknownMDMAAlcoholKetamineCocaine90 | P a g e   Ment4 – Mentoring service to Croydon children  Ment4 provide specialist mentoring programmes to Croydon children aged 12 to 17 with significant emotional and behavioural difficulties.    Average programme length of 4 - 6 months, with 6 hours direct contact weekly. Each programme is based on goals in 9 areas of focus for monitoring & evaluation:  o Behaviour x 2,  o Education,  o Employment,  o Family,  o Social Interaction,  o Use of free time,  o Substance abuse,  o Crime  Mentoring includes home visits, role modelling, accompanying the child on professional meetings, listening and building trust to help make positive decisions.   Referrals come from PRUs, Schools, Social Services, LAC, Youth Offending Service, Families  Ment4 worked with 9 of the 60 cohort (15%). There were 7 boys and 2 girls their average age was 16.  Primary issues the children were seeking help with: -   Parents Missing: 7  Mental Health: 2  Drugs: 5  Care: 2  Educational Exclusions: 5  Children’s Social Care: 4  Police information  The very young age by which these children were first known to Police predominantly relates to being present during incidents of Domestic Violence and the significant number of parents and siblings (over a third) known to Police for their criminal behaviour. 25 children (42%) were known by the age of 9, which is before the criminal age of responsibility at 10. See Table 26.  91 | P a g e    Victims of Crime  • 42 out of the 60 (70%) were shown as a victim of crime on police indices.   • Whilst 14 (23%) were also a victim of knife crime. • 3 of the 5 child deaths (60%) were as a result of knife crime.  Criminal Convictions/Offences  83% of the cohort had a criminal conviction; this would include youth referrals, cautions and court convictions.  The range of offences was varied and included: -   • Street robbery  • GBH    • Kidnapping  • Causing a child to engage in sexual activity  • Attempted murder, and murder • Possession of drugs with intent to supply  • Burglary  • Possession of points and blades (knives)  • Sexual assault etc.   The most common offence was drug possession; 45/60 of the cohort (75%) were suspected of possession of drugs or held a conviction.   Whilst 39/60 were shown as a suspect in relation to knife crime (65%), this would include possession of a knife or a criminal accusation whereby a knife was used such as robbery or GBH.   01234561234567891011121314151617Nos. of children Age of childTable 26: Age first became known to Police, by gender GirlsBoys92 | P a g e    Police Merlin A Merlin is an electronic record and formal notification of a child coming to the notice of Police; which is then noted against one of the following five categories: 1. Healthy 2. Staying Safe 3. Enjoy & Achieve 4. Make a Positive Contribution 5. Economic Wellbeing Merlins are completed by Police, they are RAG rated Red, Amber & Green and copies are sent to Children’s Social Care for their records and action as required. A Merlin is issued for each individual child and merlins are also issued for children associated with the incident and recorded as, ‘Other’.  These charts document the individual number generated for each child in the cohort for an incident involving that child or in association as an ‘Other’. Whilst there is Merlin data for 20 girls and 33 boys, see Tables 27 and 28 below, we did not have access to the RAG rating for each of the Merlins recorded.  Therefore, it is impossible to tell the level of seriousness of each of the Merlins. The high numbers give an indication of the vulnerability of the child, additionally it gives an indication of the level of repeated time and attention given to the child by the Police.    2883 101 8620331311736431361151121713212153041118345181919722110501001502002503003501234567891011121314151617181920No. of Merlins per childTable 27: Police Merlins - 20 Girls SelfRe Other93 | P a g e    Stop & Search 38 out of the 60 children (63%) have been stopped and searched by police.  The average age of the first encounter of those searched was 14.3 years.  The average age is similar to the average for the first missing episode and a prominent age with relation to CSE/CCE. Gang affiliations  Police data records 33 of the cohort (55%) were shown as having links to known gangs in the Croydon area or linked to associates from these groups.  The Gangs team have supported 18 of these children who were classed as gang members, with a further 15 also supported, although it is less clear if they were actual members, perhaps more on the periphery.    The Gangs team total of 33 concurs with the Police data, which indicates that 27 children (45%) were not thought to be involved or associated with gangs.   The YOS data records that 29 of the 44 children (66%) involved with YOS were known to gangs.  Terminology in respect of gangs and their membership can be difficult to quantify; i.e. this can relate to being a known gang member or an associate, or linked to gangs, in that their friends may be associated with gangs.   3 465 60834015940 241162752 422044 57 7137 22 13 28 16471691533 15 224116 20 5152511644281229451438 713252 33977292744151 215 205010015020025012345678910 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33No. of merlins per ChildTable 28: Police Merlins - 33 BoysSelfRe Other94 | P a g e   These are often moot points and would invariably be disputed by family members.  Some of the children have described them as the local friends they have lived and grown up with and remain in contact but not actively being ‘gang members’.  Some parents have suggested to the Gangs team their child is part of a gang although there is no hard evidence to support this view.   Knife Crime 14 children, all male, were victims of knife crime, 38% of the boys’ cohort. 39 children were themselves a suspect of knife crime, 65% of the whole cohort.  This is broken down by gender; 9 female, (39%) and 30 male, (81%)  Redthread Redthread’s Youth Violence Intervention Programme employs youth workers in hospitals to intervene with children and young people at risk of serious youth violence. The teams meet the children and young people as soon as they can: in the A&E waiting room, on the ward, or even in the resuscitation bay. Redthread sought to work with 9 of the cohort in hospital and beyond in relation to their presentation with violence related injuries.  Some children did not engage beyond the initial couple of contacts whereas others are noted as having been supported with education, legal status, family mediation, housing, and emotional wellbeing.   Youth Offending Service Data (YOS) Of the 60 children, 44 (73%) were known to YOS;  44 between 13 and 17 years old   34 from a BAME background   9 female  12 were identified as county lines/exploitation   9 were new to the criminal justice system of which 6 were female   35 children had re-offended   13 of those were in custody.  In terms of the offences the children committed they tended to be offences of violence, Possession with Intent to Supply (PWITS) and a small number of burglaries.   Missing Children   56 out of the 60 cohort have been reported as missing on at least one occasion. The average number of missing episodes is 16.8 per child.  Three individuals have been reported on a combined 200 occasions.  The average age for the first time missing was 13.9 years.  In total 1010 missing episodes were reported by the cohort.  An episode could range from one day to 60 days. 100% of the girls went missing 95 | P a g e   The youngest girl first reported missing was at the age of 7 and the oldest 16 The 23 girls had 486 missing episodes – an average of 21 missing episodes each. • The range was from 1 missing episode to 77 episodes • The 3 girls with the most prolific missing episodes had 187 episodes between them. 86% of the boys went missing  The youngest boy first reported missing was at the age of 11 and the oldest 16 The 32 boys had 524 missing episodes – an average of 16 episodes each • The range was from 1 missing episode to 78 episodes • The 3 boys with the most prolific missing episodes had 185 episodes between them    Safer London Services 17 of 58 children (29%) were referred to the Safer London services which are available to Croydon children. The majority were referred to: -   Safer London’s Empower programme for one to one support due to concerns around child sexual exploitation   Croydon commissioned Child Sexual Exploitation & Missing service.   Two were referred to Safer London’s London Gang Exit (LGE) service.  In 8 of the cases there was minimal or no contact with the child and the referral did not progress to an open case so there was no engagement.   In another 5 of the cases, the intervention did not progress due to dis-engagement by the child.  These cases’ engagement ranged from a few weeks to a few months for some, an escalation in missing episodes was a factor.   Only 4 of the children completed their intervention and one partly completed but could not fully complete due to a move out of the borough. 01234567897891011121314151617No of ChildrenChild age when first went missing Table 29: Child age at first missing episode, by genderNo  of girlsNo of boys96 | P a g e   Most of the children from this cohort had adverse childhood experiences (ACEs) e.g. parenting issues, trauma, domestic violence, homelessness, sexual abuse.   Child Sexual Exploitation & Child Criminal Exploitation (CSE & CCE) – Police data • 22 of the cohort were exposed to CSE (37%) • 16 of the cohort were exposed to CCE (27%) • 4 were exposed to both CSE and CCE (7%)  Table 30: Victims or Villains – by gender  23 Girls – Victims or Villains?   100% at risk of Child Sexual Exploitation 57% subjected to Child Sexual Exploitation  52%  victim of crime  48% suffered assaults including sexual assault & rape 35% self-harm & suicide attempt  22% bullied at school 22% subject to Stop & Search     52% noted as violent by Police  39% suspect of knife crime 17% caught for shoplifting  17% drug involvement & county lines.  37 Boys - Victims or Villains?   38% were victims of knife crime 70% were victims of crime 92%  were stopped and searched by police  *The age for Stop and Search ranged from ages 9 to 16 years  76% were in gangs or affiliated to gangs 81% convictions linked to drugs possession  84% were shown as a suspect in a knife-related crime   60 Children - Victims or Villains?                                                                                                           83% have a criminal conviction                                              70% were referred to CAMHS for help                           50% spent time in a Secure Unit or Young Offender Institute   97 | P a g e   Where are they now? Table 34 shows where the children were on 31 January 2019.   23/60 children (38%) are held in formal establishments removed from wider society (Prison, YOI, and Secure Training Centres & Secure Units).  5 children (8%) remain looked after in foster care or a children’s home.  12 children (20%) have taken the step into adulthood and moved to independent types of accommodation. 6 girls and 4 boys have moved to fully independent accommodation (17%), of those, 2 children remain in education and 3 of the girls are pregnant.   We know that some of the boys are fathers but have not been able to confirm with any definitive data. The greatest individual group (23%) is those who are living with their families, 14/60. Of those at home with family, 6 of the girls are in education, with one preparing for university; and two of the boys are currently undertaking formal trade training, one in construction and the other in plumbing.        0246810121456193423210141Table 31: Where are they now?Whereabouts of the 60 Vulnerable Adolscents as at 31 January 201998 | P a g e   Appendix Two References This list of references is sequenced in the order they appear in the report.  Adverse childhood experiences: retrospective study to determine their impact on adult health behaviours and health outcomes in a UK population. Bellis, M.A et al. Journal of Public Health, Volume 36, Issue 1, 1 March 2014, pp 81–91. Mental Health of Children and Young People in England – summary of key findings. NHS England November 2018, pp 6 - 8. Dying to Belong: An In-depth Review of Street Gangs in Britain. Centre for Social Justice 2009 www.centreforsocialjustice.org.uk/library/dying-belong-depth. IT CAN BE STOPPED - A proven blueprint to stop violence and tackle gang and related offending in London and beyond. Centre for Social Justice. August 2018. p15. Serious Violence Strategy. HMG 2018.  Tackling Child Sexual Exploitation Progress Report. HM Government February 2017. London Borough of Croydon Opportunity and Fairness Plan 2016-2020. Work to support CSE Profile Mapping in the London Borough of Croydon: Final report by Safer London Foundation May 2015. Serious Violence Strategy. HMG April 2018, p 48. The Mental Health Needs of Young Offenders. London: Mental Health Foundation 2002. Children of the new century: mental health findings from the Millennium Cohort Study. Morrison Gutman, L., Joshi, H., Parsonage, M. & Schoon, I. London: Centre for Mental Health 2015. A Chance to Change: Delivering effective parenting programmes to transform lives. London: Brown, E.R., Khan, L. and Parsonage, M. Centre for Mental Health 2012. Review of children and young people’s mental health services: Phase one report, Care Quality Commission, 2017. Making the Difference, Breaking the link between school exclusion and social exclusion. Institute for Public Policy Research (IPPR) October 2017, pp 12–13 & p.16. Permanent and fixed-period exclusions in England: 2015 to 2016, DfE July 2017, p 5. 99 | P a g e   Forgotten children: alternative provision and the scandal of ever-increasing exclusions. House of Commons Education Select Committee, Fifth Report of Session 2017–19. No Good Options: All Parliamentary Group for Children. NCB 2017.  Storing up Trouble: All Parliamentary Group for Children. NCB 2018 p3. Public Spending on Children in England: 2000 to 2020.  The Institute for Fiscal Studies 2018 p5. Vulnerable children and social care in England – a review of the evidence. Witney Crenna- Jennings The Education Policy Institute 2018.  The London Knife Crime Strategy 2017, Mayor’s Office for Policing and Crime, Greater London Authority. June 2017. https://www.london.gov.uk/what-we-do/mayors-office-policing-and-crime-mopac/violence-reduction-unit Croydon Inspection of services for children in need of help and protection, children looked after and care leavers and review of the effectiveness of the Local Safeguarding Children Board. Ofsted September 2017. https://www.nct.org.uk/about-us/first-1000-days We are Croydon: Early Experiences Last a Life time. The first 1000 days from conception to the age of 2: Director of Public Health Annual Report 2018– chapter one. Intervening Early to Prevent Youth Violence – The Role of Primary schools. Early intervention Foundation 2018, p10. Review: The traumagenic neurodevelopmental model of psychosis revisited, Read, J., Fosse, R., Moskowitz, A. and Perry, B. (2014), Neuropsychiatry, Vol. 4 No. 1, Future Science Group 2014 pp. 65-79. The impact of bereavement and loss on young people. Joseph Rowntree Foundation, June 2005. Teenagers at risk. The safeguarding needs of young people in gangs and violent peer groups. NSPCC March 2009.    https://www.rcpsych.ac.uk/mental-health/parents-and-young-people/information-for-parents-and-carers/domestic-violence-and-abuse-effects-on-children Intervening Early to Prevent Gangs and Serious Youth Violence. The Role of Primary Schools Foreword: Dr Jo Casebourne, Chief Executive, Early Intervention Foundation March 2018. EIF policy briefing Social & emotional learning: supporting children and young people’s mental health. Early intervention Foundation December 2017. 100 | P a g e   Frontiers in Neuroscience cannabidiol as a therapeutic alternative for post-traumatic stress disorder. From Bench Research to confirmation in Human Trials, June 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6066583  Developing and leading trauma-informed practice: Leaders' Briefing. Research in Practice 2018. That Difficult Age: Developing a more effective response to risks in adolescence. ADCS Research in Practice 2014. Working Together to Safeguard Children- A guide to inter-agency working to safeguard and promote the welfare of children. HMG 2018. Making the Difference. Institute for public policy research - October 2017, p 18 Disproportionality in Child Welfare. The Prevalence of Black and Minority Ethnic Children within the ‘Looked After’ and ‘Children in Need’ Populations and on Child Protection Registers in England. Charlie Owen and June Statham. Thomas Coram Research Unit Institute of Education, University of London 2009. The Lammy Review: An independent review into the treatment of, and outcomes for, Black, Asian and Minority Ethnic individuals in the Criminal Justice System. HMG 2017 – Introduction, chapter 1, p 3. 