Co-producing an intervention to prevent mental health problems in children in contact with child welfare services

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There is a paucity of evidenced-based preventative interventions provided to this population. Objective This project worked in partnership with CYP, their parents/caregivers and the professionals who support them to co-produce a preventative mental health intervention for CYP in contact with child welfare services. Participants and setting: We recruited a purposive sample of CYP in contact with child welfare services (n = 23), parents/caregivers (n = 18) and practitioners working within child welfare services and mental health services (n = 25) from the North East of England and convened co-production workshops (n = 4). Methods This project followed the established principles for intervention development, applying the six steps to quality intervention development (6SQUID) approach. The mixed method research consisted of four work packages with continuous engagement of stakeholders throughout the project. These were: a systematic review of reviews; focus groups with practitioners; interviews with parents/caregivers and young people; co-production workshops. Results We identified that the primary risk factor affecting CYP in contact with child welfare services is the experience of childhood adversity. The quality of relationships that the CYP experiences with both their parent/caregivers and the professionals involved in their care were considered to be the main factors amenable to change. Conclusions We found that a trauma-informed, activity-based intervention with an embedded family-focused component provided to CYP who have experienced adversity is most likely to prevent mental health problems in those in contact with child welfare services. Children and young people mental health adversity trauma-informed secondary prevention intervention development Figures Figure 1 Figure 2 1. Background There is growing concern about the prevalence of mental health problems in children and young people (CYP) worldwide. In the UK, a national survey found that 1 in 9 children aged 5–16 years had a probable mental health problem in 2017 [ 1 ]. This rate then rose to 1 in 6 in 2020 [ 2 ], and has remained stable in 2021 and 2022 [ 3 ]. The prevalence of mental health problems, however, is not evenly distributed within society. CYP people in contact with child welfare services are particularly vulnerable to experiencing mental health problems. A recent meta-analysis estimated that 49% of children and adolescents in out-of- home placements have a mental health disorder [ 4 ] and child mental health is the third most common risk factor identified in all ‘Child in Need’ assessments conducted in the UK [ 5 ]. These CYP experience poor outcomes including an increased risk of substance use [ 6 ], involvement in offending behaviour [ 7 ], difficulties in their relationships with family and friends [ 8 ], diminished educational opportunities, [ 9 ] and unplanned pregnancy/parenthood [ 10 ]. Further, many go on to experience persistent mental health problems into adulthood [ 11 ] and reduced life opportunities [ 12 ], creating a pathway for disadvantage [ 13 ]. Child and Adolescent Mental Health Services (CAMHs) provide treatment to CYP experiencing moderate to severe mental health problems in the UK. However, it has been shown that treatment services are often not the most appropriate services for CYP in contact with child welfare services [ 14 ], who maybe ambivalent about help-seeking [ 15 ]. Mental health treatment services may not take account of the structural and material disadvantage experienced by the family [ 16 ]. There is a high prevalence of conduct difficulties in this population, which can be challenging for health focused systems to respond to [ 17 ]. Children and young people in contact with child welfare services often find the retelling of their stories to be difficult and potentially retraumatising [ 18 ]; they typically experience substantial mistrust [ 19 ] and prefer to invest in one relationship with a lead professional [ 14 ]. Further, long waiting lists for mental health services have been reported to be a deterrent to seeking help in the first instance, as well as negatively impacting upon engagement with mental health services once offered [ 14 , 20 ]. A consequence of these barriers is that many children who are in contact with child welfare services do not have their mental health needs met [ 21 ]. To better respond to the mental health needs of CYP in contact with child welfare services, interventions should be tailored for this population as part of a holistic response around the person [ 22 ]. This response should further take account of their social context [ 23 ]. CYP come into contact with child welfare services for a wide variety of reasons including special education needs and disability, physical disability, unaccompanied children seeking asylum, family dysfunction, family break down and child maltreatment [ 5 ]. Each of these contexts introduces different risk factors which increase the likelihood of CYP experiencing mental health problems and the type of mental health care they need. Secondary prevention interventions have a large evidence base which report improvements in child mental health outcomes [ 24 ]. These interventions are typically delivered by generalist practitioners outside of specialist mental health services as part of a three-tier prevention framework. Whilst primary prevention is an intervention provided to whole populations prior to the development of a disease or health condition, and tertiary prevention is an intervention provided when a disease is established, secondary prevention is a targeted intervention provided in situations of elevated risk but before clinical thresholds for mental health disorders are met [ 25 ]. However, there is a paucity of research examining secondary mental health prevention interventions for CYP in contact with child welfare services. Preventative interventions within this context may offer an opportunity to intervene within situations of elevated mental health risk, address poor access to mental health services [ 26 ] and prevent the development of persistent mental health problems in this population [ 27 ]. However, little is known about the best approach to providing a secondary preventative intervention to CYP in contact with child welfare services including which CYP to focus support upon, the risk and protective factors that may be malleable to change and how to achieve change in these factors. This paper reports on a project which aimed to co-produce a secondary preventative intervention for CYP in contact with child welfare services, who are at risk of developing a mental health problem. 2. Methods This project followed established guidance for intervention development [ 28 , 29 ] and adheres to reporting standards for intervention development studies [ 30 ]. We implemented the ten key actions recommended within intervention development [ 28 ]. These are: planning the development process; involving stakeholders; bringing together a team and establishing decision-making processes; reviewing published research evidence; drawing upon existing theories; articulating the programme theory; undertaking primary data collection; understanding context; paying attention to future implementation of the intervention in the real world; designing and refining the intervention. For simplicity, we present our methods and overall process as a series of actions. However, intervention development is not a linear process [ 28 ] and, as such, these actions were addressed in a dynamic, iterative way throughout the project, as illustrated in Fig. 1. INSERT FIGURE 1 We drew upon published approaches to intervention development [ 28 ], applying the ‘six steps in quality intervention development’ (6SQUID) method [ 31 ] and embedding this within on-going stakeholder involvement [ 29 ] and co-production [ 32 ]. Based upon the taxonomy of intervention development approaches, we define our method as a combination of a stepped approach and a partnership approach [ 33 ]. CYP in contact with child welfare services are a highly heterogeneous group, with the ‘problem’ of mental health in this population being similarly multifaceted and complex. As such, the stepped approach detailed within the 6SQUID provided an opportunity to understand the mental health need within its context [ 34 ] as recommended by the updated Medical Research Council guidance [ 29 ], whilst becoming progressively focused upon specific subgroups within the population, risks and factors that are deemed malleable to change [ 31 , 34 ]. Our continuous stakeholder involvement and approach to co-production further enabled us to move back and forth between the steps to iteratively refine our understanding throughout the development process. To date, we have not piloted the intervention or gathered evidence of effectiveness, which are phases in complex intervention research which can lead to intervention refinement [ 29 ]. As such, this paper will report on the first four steps of the 6SQUID approach. Our mixed method approach consisted of four work packages (WP): WP1: systematic review of reviews WP2: focus groups with practitioners WP3: semi-structured interviews with CYP and parents/caregivers WP4: co-production workshops A favourable ethical opinion was granted by the Health Research Authority West Midlands – Coventry & Warwickshire Research Ethics Committee (reference 22/WM/0034) on 28th March 2022. All research participants provided informed consent to participate (aged 16 years and over). Children and young people under the age of 16 years provided assent to participate and informed consent was provided by their parent/legal guardian. 2.1 Work Package 1: Systematic Review of Reviews We conducted a systematic review of systematic reviews to map available evidence relating to secondary preventative interventions and identify effective interventions to prevent mental health problems in CYP aged 3–17 years. The review, which was guided by a pre-registered protocol (PROSPERO CRD42021290457), identified 49 unique systematic reviews (reported in 54 papers) which met our inclusion criteria. Each of the reviews included between 2 and 249 (mean 34) unique studies; the majority of which were reviews of only or mostly randomised controlled trials (70%). The reviews examined selective interventions (defined as interventions which are delivered to sub-group populations of young people at increased risk of mental health problems on the basis of biological, psychological, or social risk factors) (n = 22), indicated interventions (defined as interventions which target young people who are found to have pre-clinical symptoms) (n = 15) or a synthesis of both (n = 12). The certainty of the evidence in the reviews was rated as high, (n = 12) moderate (n = 5), low (n = 9) and critically low (n = 23), using the Assessment of Multiple Systematic Reviews (AMSTAR 2) tool [ 35 ]. 2.2 Work Package 2: Focus groups with practitioners We conducted four focus groups with child welfare and mental health practitioners across three local authority areas in the North East of England between April and May 2022. The final sample included a total of 25 practitioners (ranged from 4–9 practitioners per group). Practitioners were purposively sampled to achieve a maximum variation sample by service setting; mental health, children welfare service including early help, community safeguarding teams and those working with children in care/out-of-home placements. Practitioner characteristics are detailed in Table 1 . A semi-structured topic guide was developed for the project to explore the risk and protective factors for mental health problems in children in contact with social care, their impact and consider factors that are malleable to change (the topic guid has been uploaded as a supplementary file). The audio recorded focus group discussions were transcribed verbatim and uploaded to NVivo for data management. Data was analysed thematically [ 36 ] and guided by the socio-ecological model [ 37 , 38 ]; a theoretical framework used to examine the complex interplay between individual, interpersonal, community and society level determinants of health. Additionally, analysed data was used to inform the development of case vignettes utilised in interviews with CYP within WP3. 2.3 Work Package 3: Interviews with CYP and parents/caregivers We conducted interviews with 23 CYP recruited via child welfare services and children in care councils (forums for children in out-of-home placement) and 18 interviews with parents/caregivers of CYP in contact with child welfare services in the North East of England between September 2022 and February 2023. The mean age of CYP who participated was 15 (range: 11-21yrs) and included both female (n = 12) and male (n = 11) participants. Most were White British (n = 19). The parents/caregivers were mostly mothers (n = 7) or residential care staff (n = 7). We also interviewed grandparents (n = 2) and foster carers (n = 2). The participant characteristics for CYP and parent/caregivers are detailed in Table 1 . All CYP selected one or more case vignettes (from a selection of four), which detailed hypothetical scenarios relating to the main risk and protective factors identified within practitioner focus groups in work package 2. The vignettes were implemented to promote the increasing focus upon the ‘problem’ whilst also promoting ethical data collection. Vignettes enabled CYP to discuss mental health risk, resilience and support in detail whilst not being required to disclose personal details which may be distressing to them. The participating CYP engaged in a semi-structured interview relating to the vignette, examining the mental health impact of this scenario, factors that they considered malleable to change and possible intervention approaches. In addition, 21 CYP completed an optional semi-structured exercise designed to support CYP to explore their own experiences of mental health problems. Parent/caregiver interviews all examined these topics as they related to their own experiences of caregiving to a CYP in contact with child welfare services who has mental health concerns. Interviews were audio recorded with consent, transcribed verbatim and thematically coded as described in WP2. All case vignettes, topic guides and exercises have been uploaded used within this work package have been uploaded as a supplementary file. INSERT Table 1 2.4 Work Package 4: Co-Production Workshops We presented our findings from WP1-3 at a regional children’s mental health conference held in June 2023, attended by practitioners, operational and strategic managers and leaders from both child welfare and mental health services. Delegates were invited to participate in an interactive exercise by submitting responses to questions around the prioritisation of intervention ideas via OMBEA, a web-enabled response option integrated with Microsoft PowerPoint. A total of n = 57 practitioners, mangers and leaders participated in the exercise. In addition to the conference, we convened separate workshops at two timepoints during July and August 2023 with: i) CYP in contact with child welfare services, and ii) mental health and child welfare practitioners. The research team worked in partnership with the participants to iteratively co-produce the intervention. At timepoint 1, we presented the findings of WPs 1–3 and the prioritisation exercise to CYP (n = 6) and practitioners (n = 11). Workshop participants were encouraged to consider these findings during semi-structured activities, which were designed to support discussion relating to prioritised intervention ideas. Activities included listing strengths and weaknesses of the approaches, preferred mechanisms of change, and examining intended and unintended outcomes which may come from the mechanisms. At timepoint 2, a sub-group of participants attended a further workshop (n = 4 in CYP workshop; n = 4 practitioner workshop). These workshops focused upon refining the detail of the intervention and producing a detailed intervention logic model. 3. Results 3.1 Step 1: Define and understand the problem The first step of the 6SQUID approach is to clarify the ‘problem’. We commenced the formal intervention development process with a clear understanding that the mental health of CYP in contact with child welfare services is a priority public health and social care concern. This was informed by a review of existing evidence [4, 39-41] and stakeholder involvement within project design stage. What we did not yet know, and needed to clarify, was what the social distribution of this problem was within the population of children in contact with child welfare services. We were concerned with the future implementation of the intervention within the child welfare sector, and as such we sought to understand which groups of children within the larger population of CYP were of greatest concern to child welfare and mental health practitioners, and who they perceive to be most or least likely to benefit from intervention. We were also concerned to examine the causal pathways linked to mental health problems and determine which immediate (proximal) and underlying (distal) influence give rise to mental health problems in CYP in contact with child welfare services and in what ways these CYP are affected by mental health problems. Childhood adversity: We drew upon the findings of the practitioner focus groups (WP2) and interviews with CYP and parents/caregivers (WP3) to examine the mental health needs of children in contact with child welfare services. Our application of the socio-ecological model highlighted the prevalence of interpersonal risk factors for CYP in contact with child welfare services. Adversity and trauma within the home environment was thought to be a particularly prominent risk to CYP’s mental health and a substantial priority issue for child welfare workers, CYP and parents/caregivers, and further reinforced by stakeholders. This distal, underlying influence of adversity typically consisted of parental risk factors such as parental mental health problems, parental substance use, domestic violence, and having a parent in prison. Participants highlighted the complexity within the context of adversity. Interpersonal risk factors were thought to interact synergistically with other risks present, resulting in accumulative stress for CYP in contact with child welfare services. Participants also reported a series of immediate, proximal influences. CYP were thought to often experience shame and stigmatisation relating to experiencing adversity and trauma within the home and would exhibit externalising difficulties including risk-taking or challenging behaviours as well as internalising difficulties such as low mood and self-esteem. These factors were reported to compound CYP vulnerability through exacerbating conflict in CYP-parent/caregiver interactions and increasing behavioural problems exhibited within other settings such as school and within local communities. Poverty was also highlighted as contributing to very difficult contexts for CYP and contributing to the impact of mental health problems within families. “It comes from home, as a result of really struggling to manage and move on, and recover from traumatic situations, and/or believing that they were the cause of those, in some way, shape or form. So, believing that they are bad, that they are the cause of difficulties within their family…if there’s a pervasive sense of shame that exists within the child, wherever that comes from, that essentially leads fundamentally to poor self-esteem, difficulties in relationships, and poor mental health outcomes” (female, child and adolescent mental health practitioner). “Back at school when I got angry, I was taking it out on the wrong people, I was attacking my fellow pupils and that. Thinking about it now, I feel sorry that I was doing that, that I was using this anger and I was just using it against other people and hurting them, I was hurting my own teachers, I was attacking them and they had to restrain us. I feel guilty and I feel so sorry” (male, 12years, child in care). Failing to recognise trauma: It was reported by participants that parents/caregivers and the professionals involved in their care often did not know how to best support the CYP or deal with their related behaviours. Participants highlighted that early ‘warning signs’ were typically overlooked resulting in missed opportunity to intervene before CYP developed diagnosable mental health disorders. Our findings further suggested that there is a tendency for early indicators to be perceived as ‘bad behaviour’, rather than being symptomatic of CYP’s experience of adversity. When the CYP’s mental health needs were identified, participants reported that care was further delayed by lengthy waiting lists for mental health treatment, leading to increased mental health vulnerability in CYP and a worsening of their social situation. “From my own experience. Growing up, there was a lot of issues raised to social services, to school and things and they, sort of, waited until it was at crisis point to actually do any intervention whatsoever. Whereas if I think, you know, if they’d came in and actually just tried to do little things earlier, it might not have got to the point it did” ( female, 20 years, care leaver ). “The waiting list is huge. You’re talking over a year, to be able to just have an initial appointment. We waited 14 months. Bearing in mind, [daughter’s name] was already in CAMHS, but for an autistic assessment, we waited 14 months. In fact, I think it was longer, because COVID hit…And there’s nothing you can do except get on with it, and just try and struggle along” (female, mother, child in need) . Retraumatising: Within focus groups and interviews, participants frequently highlighted that when CYP attended mental health services they were required to retell their story as a prerequisite to receiving treatment, and without first paying adequate attention to building a trusting relationship. This was found to be unhelpful, and at times distressing for CYP. This typically led to CYP not disclosing their concerns to mental health professionals, and their needs going unmet. “Some of them come in as if you’re going to trust them straight away… When they come in the house and they just sit down and they’ll be like, “Tell me how you’re feeling. How are you feeling today? How have you been feeling lately?” I don’t open up as easy as they may have thought… [they should] probably try and build a relationship, doing something like even if it’s just going to the beach…and then we can build a relationship from there” (female, 15 years, child in need) “So, you take these extremely traumatised children to an appointment, and obviously, they don't trust the professionals, and if the kids don't engage in one or two sessions, then they close the case for them ” ( female, residential children’s home, registered manager ). 3.2 Step 2: Clarify which causal or contextual factors are malleable and have the greatest scope for change Intervening early: Having developed an understanding of the proximal and distal influences upon the mental health of CYP in contact with child welfare services, our next task was to identify which of these factors are malleable to change. Our systematic review of reviews (WP1) found a large evidence-base suggesting secondary prevention targeting children who had experienced adversity is effective at reducing mental health problems. Similarly, interventions with CYP with subclinical externalising problems were found to offer promise. Within the review, both risk and resilience factors were found to be highly malleable to change. We presented findings from WP1-3 to practitioners within the prioritisation exercise conducted within WP4, and asked stakeholders to respond to questions about causal or contextual factors which the intervention should target. Stakeholders overwhelmingly (83%) opted for an intervention with CYP who had experienced adversity, and at a point before symptoms of mental health problems are evident. This was further considered within the co-production workshops with CYP in contact with child welfare and practitioners (WP4). Workshop participants agreed that intervening early in the disease trajectory (and before symptoms were evident) was important. Further, we identified a convincing evidence of an association between child adversity and mental health problems identified within our on-going engagement with research literature [41-45]. This combined evidence supports the provision of a selective intervention for CYP in contact with child welfare services who have experienced adversity, without first requiring the CYP to make potentially distressing disclosures within an assessment of mental health need. Building supportive relationships: Throughout the qualitative work packages and in co-production workshops, participants focused upon the quality of the relationship and emotional support provided between the parent/caregiver and child. The home environment was perceived as an area where the scope for change was greatest both in terms of alleviating an important proximal factor, and the likely benefits of doing so. This was informed further by our consideration of research evidence showing an association between good CYP mental health and high emotional support, high parent-child closeness, and low parent-child conflict [46, 47]. Additionally, practitioners participating in focus groups within WP2 reported observing improvements in child mental health where parental support was high. “I think probably in terms of protective factors, I think probably the parents, in the sense of that’s where, you know, they’re in school all day, yes, but that’s where, like we’ve just said, from a young age as well, that’s where, kind of, they’re nurturing, where they’re learning, I think. Even if they were in school all day and had a great protective network, if they go home and there’s absolutely no protection there – for teenagers especially, no boundaries, no rules, no independent living skills, and all that, we’re on a losing battle if the parents aren’t, kind of, putting that in place 24/7” ( female, care leavers team, social worker ) The development of strong support systems such as supportive friendships and intimate relationships, wider family networks and positive relationships with professionals were also highlighted as important protective factors which could be fostered with the potential for substantial benefit for CYP. “ It would be having a relationship with a positive role model adult in their life that allows them to see themselves in a bit of a different way. Because I guess a lot of the kids that we work with have had really difficult early relationships and difficult, maybe, parent/child relationships, or difficulties with other adults…So whether that's a member of staff, or it could be a member of educational staff, it's having that positive role model that maybe they haven't had earlier on, so that they can start to develop those trusted relationships, be able to see themselves in a bit of a different way and start to internalise some of that” ( female, child and adolescent mental health practitioner ). 3.3 Step 3: Identify how to bring about change: the change mechanism Interventions are ‘theories incarnate’ [48] and may include implicit or explicit theory [31, 49]. It is recommended that intervention development draws upon established theory [28] which can support the identification of what is important, relevant and feasible in achieving the intervention goals [50]. During this project we were influenced by attachment theory and related attachment-focused interventions. Attachment theory explains how childhood adversity and trauma can reduce the security of attachments a child has with their caregiver [51]. In the early years, a child’s sense of safety and security comes primarily from their caregiver and they learn to trust/mistrust according to this experience [52]. Children who experience adversity and trauma experience the world as unsafe [53]. They learn that their caregiver cannot or does not protect them from this danger and they learn to mistrust [54]. In the absence of trusting and secure attachments, children’s development maybe organised around a nervous system which is prepared for danger [53]. This may result in emotional dysregulation [55] and behaviours which are deemed socially unacceptable [56]. This in turn compounds the problems of the CYP (for example generating conflict in the home of disruptive behaviours within school) [53], whilst also creating a barrier for help-seeking [57]. During stakeholder consultation and within co-production workshops we examined mechanisms of change. Attachment-focused interventions such as the Solihull Parenting Approach [58] and Dyadic Developmental Psychotherapy (DPP) [59] where highlighted as important mid-range theories [50] with explanatory potential relating to the change mechanism. Both approaches emphasise the importance of CYP feeling safe and developing relationships with key caregivers, before learning how to regulate emotion within the safety of those relationships. An additional mechanism of change includes recognising and understanding the impact of adversity and trauma upon the CYP’s feelings and behaviours. We were further influenced by the Solihull Parenting Approach which recognises parental anxiety as an important factor, and provides a means of the parent and child developing reciprocity [60] and reflexive functioning [61] in order to achieve change [58]. 3.4 Step 4: Identify how to deliver the change mechanism We iteratively developed and refined the intervention within a series of four co-production workshops (WP4). A detailed intervention logic model is presented in figure 2 wherein we depict how the intervention may work and its anticipated intended and unintended outcomes. Co-production workshops were based upon the outcomes of the prioritisation exercise and informed by the findings of work packages 1-3 and the iterative refinement of the previously described intervention development steps. Within the prioritisation exercise (WP4), practitioners were asked to rank their preferred three intervention approaches. Activity-based interventions with CYP, family/caregiver interventions and trauma-informed approaches were selected as the three highest priority approaches from a shortlist of 10 possible interventions. It was agreed within co-production workshops conducted at timepoint 1 that any intervention with CYP who have experienced adversity should take a trauma-informed approach. Whilst there is no consensus on how trauma-informed care is defined [62], the most widely used definition of trauma-informed care comes from the Substance Abuse and Mental Health Services Administration who define the “Four R’s” of trauma-informed care, which are: realisation about trauma and its affects; recognition of the signs of trauma; responding to trauma and resist re-traumatisation through practices which inadvertently cause further trauma [63]. We proceeded to consider the strengths and weaknesses of the two remaining intervention approaches of activity-based intervention and family/caregiver intervention, with a view to agree which of these approaches was perceived to be the better approach. We moved back and forth between step 3 and step 4, refining our change mechanism and our approach to delivering this. During this iterative process, it became apparent that both approaches were considered necessary to bring about change within the mechanism and prevent mental health problems in CYP in contact with child welfare services. This led to a decision within the co-production workshops to develop a trauma-informed activity-based youth intervention with an embedded family component. The key characteristics of the intervention are: Selective secondary preventative intervention for CYP in contact with child welfare services who have experienced adversity (e.g. parental substance use, mental health, domestic violence, incarceration of a parent). A youth activity-based intervention which would consist of three phases: A relationship building phase (approx. 8-12 weeks): practitioner getting to know the CYP and their interests, agreeing and supporting involvement in a range of activities (e.g. going for walks, visiting places of interest, jointing research topics of interest, attending organised activities) A family component phase (approx. 6-8 weeks) – see below. Ending phase (approx. 4-6 weeks): practitioner reinforces CYP learning and related behaviour change and supports access to youth activities and established networks in community. An embedded family component : Practitioner meets with CYP and family together and agrees plan for work. Practitioner has weekly sessions separately with CYP and parents/caregivers focused on supporting family members to understand each other; the emotional and behavioural impact of adversity on CYP/wider family and reflective family functioning. INSERT FIGURE 2 4. Discussion This project has co-produced an intervention with, and been informed by, CYP in contact with child welfare services, their parents/caregivers and the practitioners who support them. We identified that the primary risk factor affecting CYP in contact with child welfare services is the experience of adversity. The quality of relationships that the CYP experiences both with their parent/caregivers and the professionals involved in their care were considered to be the main factors amenable to change. By focusing upon building secure and trusting relationships with the CYP and promoting understanding how adversity and trauma impacts upon the CYP within the family, our project suggests the CYP mental health maybe best supported. The findings of our study have resulted in the development of a trauma-informed, activity-based intervention with an embedded family/caregiver intervention. The importance of taking a trauma-informed approach to intervening with CYP in contact with child welfare was evident throughout our project. This finding is in line with emerging evidence supporting such practices with vulnerable populations of CYPs [ 64 – 68 ]. The CYP involved in our project emphasised the potential for existing mental health support to re-traumatise, as CYP are often required to repeatedly discuss distressing matters with unknown professionals within clinical interactions. Our findings emphasise that a trusting relationship with a familiar and non-threatening practitioner is necessary to allow CYP the space and opportunity to choose to talk about their mental health concerns at a pace that is comfortable to them. This supports previous intervention research with CYP in contact with child welfare services [ 69 ]. Both youth and family focused components were considered a priority within our co-production activities. As has been found in other studies of children experiencing adversity [ 70 – 72 ] and/or mental health problems [ 73 ], participants highlighted the need for CYP to be supported both separate to and within family structures. The initial phase of the intervention is an activity-based, youth focused intervention consisting of one-to-one interactions with a consistent practitioner with the primarily focus being upon building a relationship. This gradual building of rapport would enable the practitioner to facilitate naturally occurring conversations about mental health and concerns. After establishing a relationship with the CYP, this practitioner is then able to progress onto the family-focused component of the intervention; providing the consistent relationship that research highlights as particularly necessary with vulnerable groups of CYP [ 14 , 74 ]. The family-focused component aims to improve parent/caregiver-child relationship through increasing the reflective function (the capacity of family members to understand one another’s behaviour in-light of underlying mental states and intentions) and reciprocity; attributes that research has found to be beneficial to CYP mental health and wellbeing [ 61 , 75 ]. However, a theme throughout our project was the importance of avoiding stigmatising practices and approaches which made parents/caregivers feel that their parenting skills were being questioned. As such, particular care is needed to be given to the relationship between the CYP, parent/caregiver and practitioner during an intervention in this context [ 69 , 76 ]. 4.1 Strengths and limitations To our knowledge this is the first project to co-produce a preventative intervention for CYP in contact with child welfare services with young people themselves, their parent/caregivers and the practitioners who support them. The meaningful stakeholder involvement we have achieved throughout the project is a great strength. Whilst we envisage that this approach has resulted in an intervention which is most likely to respond to the needs of CYP in contact with child welfare services, further research is required to pilot the intervention, refine it and determine effectiveness [ 29 ]. A further limitation of our study is that the sample was recruited exclusively from the North-East of England. Further research may be required to examine transferability to other areas of the UK. 5. Conclusion A trauma-informed, selective secondary preventative intervention consisting of an activity-based intervention with an embedded family-focused component maybe most likely to respond to the mental health needs of CYP in contact with child welfare services who have experienced adversity. Further research is needed to pilot this intervention and gather evidence of its effectiveness. Declarations Ethical Approval and Consent to Participate A favourable ethical opinion was granted by the Health Research Authority West Midlands – Coventry & Warwickshire Research Ethics Committee (reference 22/WM/0034) on 28 th March 2022. Consent to Publish Not applicable Availability of data and materials The research team do not have ethical approval to share data. Competing interests The authors declare they have no competing interests. Funding This project is independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) programme (Grant Reference Number PB-PG-203477). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Ruth McGovern holds an NIHR Advanced Fellowship. Eileen Kaner is in receipt of support from NIHR Senior Scientist Award. Authors’ contribution RM conceptualised had overall responsibility for the project and drafted the manuscript. ABK, BA undertook data collection and analysis. EB, TD, RL, PM, JR, PT & EK developed contributed to the project management and commented on the manuscript. Acknowledgements Additionally, the authors would like to acknowledge Mary Connor, Northumberland County Council and Janette Brown from Newcastle City Council their support during the development of the project. Author details 1 Population Health Sciences Institute, Newcastle University, United Kingdom 2 Children and Young People's Primary Care Mental Health Service, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, United Kingdom 3 Children’s Social Care, Newcastle City Council, United Kingdom 4 Population Child Health Research Group, School of Women and Children’s Health, University New South Wales, Australia 5 Child and Adolescent Mental Health Services, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, United Kingdom 6 Children’s Social Care, Cumberland Council, United Kingdom References Digital NHS. Mental Health of Children and Young People in England, 2017 . 2018, NHS Digital: https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017 . Digital NHS. Mental Health of Children and Young People in England, 2020: Wave 1 follow up to the 2017 survey . 2020. Digital NHS. 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Quantifying the contribution of poverty and family adversity to adverse child outcomes in the UK: evidence from the UK Millennium Cohort Study. Lancet. 2022b;400:S16. Hughes K, et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health. 2017;2(8):e356–66. Bellis MA, et al. Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis. Lancet Public health. 2019;4(10):e517–28. Adjei NK et al. Impact of child poverty and adversity on perceived family support in adolescence. Eur J Pub Health, 2023. 33(Supplement_2): p. ckad160.067. Adjei N et al. Impact of poverty and adversity on perceived family support in adolescence: findings from the UK Millennium Cohort Study. European Child & Adolescent Psychiatry, 2024. in press. Pawson R. Evidence-based policy: a realist perspective. London: Sage; 2006. De Silva MJ, et al. Theory of Change: a theory-driven approach to enhance the Medical Research Council's framework for complex interventions. Trials. 2014;15:267. Davidoff F, et al. Demystifying theory and its use in improvement. BMJ Qual Saf. 2015;24(3):228–38. Pickreign Stronach E, et al. Child maltreatment, attachment security, and internal representations of mother and mother-child relationships. Child Maltreat. 2011;16(2):137–45. Bowlby J. The making and breaking of affectional bonds. London: Routledge; 1998. Golding KS. Understanding and helping children who have experienced maltreatment. Paediatrics Child Health. 2020;30(11):371–7. Erikson E. Youth: Change and challenge. New York: Basic Books; 1963. Dunn EC, et al. Developmental timing of trauma exposure and emotion dysregulation in adulthood: Are there sensitive periods when trauma is most harmful? J Affect Disord. 2018;227:869–77. Oshri A, et al. Child maltreatment types and risk behaviors: Associations with attachment style and emotion regulation dimensions. Pers Indiv Differ. 2015;73:127–33. Salmon P, Young B. Dependence and caring in clinical communication: The relevance of attachment and other theories. Patient Educ Couns. 2009;74(3):331–8. Douglas H, Ginty M. The Solihull approach: Changes in health visiting practice. J Health Visitors' Association Community Practitioner. 2001;74(6):222. Hughes DA. Attachment-focused family therapy. WW Norton & Company; 2007. Douglas H, Brennan A. Containment, reciprocity and behaviour management: preliminary evaluation of a brief early intervention (the Solihull Approach) for families with infants and young children. Infant Observation. 2004;7:89–107. Barlow J, Sleed M, Midgley N. Enhancing parental reflective functioning through early dyadic interventions: A systematic review and meta-analysis. Infant Ment Health J. 2021;42(1):21–34. Office for Health Disparties. Working definition of Trauma-informed practice. London: OHID; 2022. Substance Abuse and Mental Health Services Administration. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. SAMHSA: Rockville MD; 2014. Asmussen K, et al. Trauma-informed care: Understanding the use of trauma-informed approaches within children's social care. London: Early Intervention Foundation; 2022. Bailey C, et al. Systematic review of organisation-wide, trauma-informed care models in out-of-home care (OoHC) settings. Health Soc Care Community. 2019;27(3):e10–22. Bunting L et al. Trauma Informed Child Welfare Systems-A Rapid Evidence Review. Int J Environ Res Public Health, 2019. 16(13). Zhang S, et al. Trauma-informed care for children involved with the child welfare system: A meta-analysis. Child Abuse Negl. 2021;122:105296. Lowenthal A. Trauma-informed care implementation in the child- and youth-serving sectors: A scoping review. Int J Child Adolesc Resil. 2020;7:178–94. Alderson H, et al. The key therapeutic factors needed to deliver behavioural change interventions to decrease risky substance use (drug and alcohol) for looked after children and care leavers: a qualitative exploration with young people, carers and front line workers. BMC Med Res Methodol. 2019;19(1):38. Muir C et al. A Systematic Review of Qualitative Studies Exploring Lived Experiences, Perceived Impact, and Coping Strategies of Children and Young People Whose Parents Use Substances. Trauma Violence Abuse, 2022: p. 15248380221134297. Burns S et al. Interventions to reduce parental substance use, domestic violence and mental health, and their impacts upon children’s wellbeing: a systematic review of reviews plus an evidence and gap map. 2021. McGovern R et al. Psychosocial Interventions to Improve Psychological, Social and Physical Wellbeing in Family Members Affected by an Adult Relative's Substance Use: A Systematic Search and Review of the Evidence. Int J Environ Res Public Health, 2021b. 18(4). Geijer-Simpson E et al. Effectiveness of Family-Involved Interventions in Reducing Co-Occurring Alcohol Use and Mental Health Problems in Young People Aged 12–17: A Systematic Review and Meta-Analysis. International Journal of Environmental and Public Health Research., 2023. In press. Engen M. Care as a relational practice: The possibility of solidary authority , in Care in Social Work with Children and Families . Routledge; 2023. pp. 34–49. Jordan M, Kane M, Bibbly J. A healthy foundation for the future . 2019, The Health Foundation: https://www.health.org.uk/publications/reports/a-healthy-foundation-for-the-future . McGovern R, et al. Preferences for Delivering Brief Alcohol Intervention to Risky Drinking Parents in Children’s Social Care: A Discrete Choice Experiment. Alcohol Alcohol. 2022;57(5):615–21. Tables Table 1: Participant characteristics Practitioner focus groups ID Gender Practitioner role Service P001 female Social Worker Emergency Duty Team P002 female Therapist (working with YP 11-17) Multi Systemic Therapy team P003 female Clinical Psychologist Children and Young People Service (mental health) P004 female Early Help Intensive Family Support P005 female Family Support Worker Long-term children's support care P006 female Mental Health OT Newcastle residential homes P007 female Social Worker Youth Justice Service P008 female Social Worker Initial Response Service P009 female Social Worker Long-term team P010 female Clinical Psychologist Residential Therapeutic Support Team P011 female Clinical Psychologist Residential Therapeutic Support Team P012 female Social Worker/Early Help Early Help Team P013 female Student Social Worker Long Term Planning P014 female Front door: social worker Initial Assessment P015 female Social Worker Long Term Planning P016 female Children's Wellbeing Practitioner Family Hub P017 female Leaving Care Support Worker Care Leavers Team P018 female Social Worker Care Leavers Team P019 female Family help worker Early Intervention and Prevention P020 female Advanced Practitioner Children and Young People Service (mental health) P021 female Children's Wellbeing Practitioner Central Early Help Team P022 female Social Worker Children's Assessment & Safeguarding Team P023 female Family Support Worker Children's Social Care P024 female Social Worker Emergency Duty Team P025 male Children's Social Worker Supporting and Strengthening Families Team Child participants ID Gender Age Ethnicity Child welfare status CYP01 Female 16 Chinese Child in need CYP02 Male 12 White British Child in Need CYP03 Female 21 White British Child in Need CYP04 Female 20 White British Care Leaver CYP05 Female 19 White British Care Leaver CYP07 Male 14 White British Early Help CYP08 Female 12 White British Child in care CYP09 Male 13 White British Child in care CYP010 Non-binary 12 White British Child in need CYP011 Male 11 White British Child in need CYP012 Male 12 Black African Child in care CYP013 Female 13 White British Child in care CYP014 Male 21 White British Care Leaver CYP016 Female 21 White British Care Leaver CYP017 Female 16 White British Child in need CYP019 Male 14 White British Child in care CYP022 Male 14 White British Child in need CYP023 Female 11 White British Child in care CYP024 Female 12 White British Child in care CYP025 Female 16 Black British Child in need CYP026 Non-binary 18 White British Child in need CYP027 Female 15 Mixed British Child in need CYP030 Male 12 White British Child in care Parent interviews ID Parent/ caregiver role Gender Ethnicity Child welfare status PC01 Grandparent Male White British Child in need PC02 Mother Female White British Child Protection PC03 Mother Female White British Early Help PC04 Mother Female White British Early Help PC05 Foster parent Female White British Child/ren in care PC06 Mother Female White British Child in need PC08 Mother Female White British Early Help PC09 Foster parent Female White British Child in need PC010 Mother Female White British Child in need PC011 Residential carer Female White British Child/ren in care PC012 Mother Female White British Child in need PC013 Residential carer Female White British Child/ren in care PC014 Residential carer Female White British Child/ren in care PC015 Residential carer Female White British Child/ren in care PC016 Residential carer Female White British Child/ren in care PC017 Residential carer Male White British Child/ren in care PC018 Residential carer Male White British Child/ren in care PC02 Grandparent Female White British Child in need Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 21 Aug, 2024 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 12 Mar, 2024 Editor assigned by journal 11 Mar, 2024 Submission checks completed at journal 11 Mar, 2024 First submitted to journal 23 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3982675","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":278560777,"identity":"e9337f8c-dfe7-4bda-895a-6de4552e420d","order_by":0,"name":"Ruth 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2","display":"","copyAsset":false,"role":"figure","size":260813,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntervention logic model\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3982675/v1/20e55458f80bc3ec0bd26e3d.png"},{"id":63300180,"identity":"b8704137-93e9-4dd0-a57a-4e5fa31e50b6","added_by":"auto","created_at":"2024-08-26 16:12:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1148468,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3982675/v1/4f93a949-c8a8-4078-b633-8c945970068d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Co-producing an intervention to prevent mental health problems in children in contact with child welfare services","fulltext":[{"header":"1. Background","content":"\u003cp\u003eThere is growing concern about the prevalence of mental health problems in children and young people (CYP) worldwide. In the UK, a national survey found that 1 in 9 children aged 5\u0026ndash;16 years had a probable mental health problem in 2017 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This rate then rose to 1 in 6 in 2020 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and has remained stable in 2021 and 2022 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The prevalence of mental health problems, however, is not evenly distributed within society. CYP people in contact with child welfare services are particularly vulnerable to experiencing mental health problems. A recent meta-analysis estimated that 49% of children and adolescents in out-of- home placements have a mental health disorder [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and child mental health is the third most common risk factor identified in all \u0026lsquo;Child in Need\u0026rsquo; assessments conducted in the UK [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These CYP experience poor outcomes including an increased risk of substance use [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], involvement in offending behaviour [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], difficulties in their relationships with family and friends [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], diminished educational opportunities, [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and unplanned pregnancy/parenthood [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Further, many go on to experience persistent mental health problems into adulthood [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and reduced life opportunities [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], creating a pathway for disadvantage [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eChild and Adolescent Mental Health Services (CAMHs) provide treatment to CYP experiencing moderate to severe mental health problems in the UK. However, it has been shown that treatment services are often not the most appropriate services for CYP in contact with child welfare services [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], who maybe ambivalent about help-seeking [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Mental health treatment services may not take account of the structural and material disadvantage experienced by the family [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. There is a high prevalence of conduct difficulties in this population, which can be challenging for health focused systems to respond to [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Children and young people in contact with child welfare services often find the retelling of their stories to be difficult and potentially retraumatising [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]; they typically experience substantial mistrust [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and prefer to invest in one relationship with a lead professional [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Further, long waiting lists for mental health services have been reported to be a deterrent to seeking help in the first instance, as well as negatively impacting upon engagement with mental health services once offered [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A consequence of these barriers is that many children who are in contact with child welfare services do not have their mental health needs met [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo better respond to the mental health needs of CYP in contact with child welfare services, interventions should be tailored for this population as part of a holistic response around the person [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This response should further take account of their social context [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. CYP come into contact with child welfare services for a wide variety of reasons including special education needs and disability, physical disability, unaccompanied children seeking asylum, family dysfunction, family break down and child maltreatment [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Each of these contexts introduces different risk factors which increase the likelihood of CYP experiencing mental health problems and the type of mental health care they need. Secondary prevention interventions have a large evidence base which report improvements in child mental health outcomes [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. These interventions are typically delivered by generalist practitioners outside of specialist mental health services as part of a three-tier prevention framework. Whilst primary prevention is an intervention provided to whole populations prior to the development of a disease or health condition, and tertiary prevention is an intervention provided when a disease is established, secondary prevention is a targeted intervention provided in situations of elevated risk but before clinical thresholds for mental health disorders are met [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, there is a paucity of research examining secondary mental health prevention interventions for CYP in contact with child welfare services. Preventative interventions within this context may offer an opportunity to intervene within situations of elevated mental health risk, address poor access to mental health services [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] and prevent the development of persistent mental health problems in this population [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, little is known about the best approach to providing a secondary preventative intervention to CYP in contact with child welfare services including which CYP to focus support upon, the risk and protective factors that may be malleable to change and how to achieve change in these factors. This paper reports on a project which aimed to co-produce a secondary preventative intervention for CYP in contact with child welfare services, who are at risk of developing a mental health problem.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThis project followed established guidance for intervention development [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and adheres to reporting standards for intervention development studies [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. We implemented the ten key actions recommended within intervention development [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. These are: planning the development process; involving stakeholders; bringing together a team and establishing decision-making processes; reviewing published research evidence; drawing upon existing theories; articulating the programme theory; undertaking primary data collection; understanding context; paying attention to future implementation of the intervention in the real world; designing and refining the intervention. For simplicity, we present our methods and overall process as a series of actions. However, intervention development is not a linear process [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and, as such, these actions were addressed in a dynamic, iterative way throughout the project, as illustrated in Fig.\u0026nbsp;1.\u003c/p\u003e \u003cp\u003e \u003cem\u003eINSERT FIGURE 1\u003c/em\u003e \u003c/p\u003e \u003cp\u003eWe drew upon published approaches to intervention development [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], applying the \u0026lsquo;six steps in quality intervention development\u0026rsquo; (6SQUID) method [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and embedding this within on-going stakeholder involvement [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and co-production [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Based upon the taxonomy of intervention development approaches, we define our method as a combination of a stepped approach and a partnership approach [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. CYP in contact with child welfare services are a highly heterogeneous group, with the \u0026lsquo;problem\u0026rsquo; of mental health in this population being similarly multifaceted and complex. As such, the stepped approach detailed within the 6SQUID provided an opportunity to understand the mental health need within its context [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] as recommended by the updated Medical Research Council guidance [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], whilst becoming progressively focused upon specific subgroups within the population, risks and factors that are deemed malleable to change [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Our continuous stakeholder involvement and approach to co-production further enabled us to move back and forth between the steps to iteratively refine our understanding throughout the development process. To date, we have not piloted the intervention or gathered evidence of effectiveness, which are phases in complex intervention research which can lead to intervention refinement [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. As such, this paper will report on the first four steps of the 6SQUID approach.\u003c/p\u003e \u003cp\u003eOur mixed method approach consisted of four work packages (WP):\u003c/p\u003e \u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eWP1: systematic review of reviews\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eWP2: focus groups with practitioners\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eWP3: semi-structured interviews with CYP and parents/caregivers\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eWP4: co-production workshops\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e \u003cp\u003eA favourable ethical opinion was granted by the Health Research Authority West Midlands \u0026ndash; Coventry \u0026amp; Warwickshire Research Ethics Committee (reference 22/WM/0034) on 28th March 2022. All research participants provided informed consent to participate (aged 16 years and over). Children and young people under the age of 16 years provided assent to participate and informed consent was provided by their parent/legal guardian.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Work Package 1: Systematic Review of Reviews\u003c/h2\u003e \u003cp\u003e We conducted a systematic review of systematic reviews to map available evidence relating to secondary preventative interventions and identify effective interventions to prevent mental health problems in CYP aged 3\u0026ndash;17 years. The review, which was guided by a pre-registered protocol (PROSPERO CRD42021290457), identified 49 unique systematic reviews (reported in 54 papers) which met our inclusion criteria. Each of the reviews included between 2 and 249 (mean 34) unique studies; the majority of which were reviews of only or mostly randomised controlled trials (70%). The reviews examined selective interventions (defined as interventions which are delivered to sub-group populations of young people at increased risk of mental health problems on the basis of biological, psychological, or social risk factors) (n\u0026thinsp;=\u0026thinsp;22), indicated interventions (defined as interventions which target young people who are found to have pre-clinical symptoms) (n\u0026thinsp;=\u0026thinsp;15) or a synthesis of both (n\u0026thinsp;=\u0026thinsp;12). The certainty of the evidence in the reviews was rated as high, (n\u0026thinsp;=\u0026thinsp;12) moderate (n\u0026thinsp;=\u0026thinsp;5), low (n\u0026thinsp;=\u0026thinsp;9) and critically low (n\u0026thinsp;=\u0026thinsp;23), using the Assessment of Multiple Systematic Reviews (AMSTAR 2) tool [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Work Package 2: Focus groups with practitioners\u003c/h2\u003e \u003cp\u003e We conducted four focus groups with child welfare and mental health practitioners across three local authority areas in the North East of England between April and May 2022. The final sample included a total of 25 practitioners (ranged from 4\u0026ndash;9 practitioners per group). Practitioners were purposively sampled to achieve a maximum variation sample by service setting; mental health, children welfare service including early help, community safeguarding teams and those working with children in care/out-of-home placements. Practitioner characteristics are detailed in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A semi-structured topic guide was developed for the project to explore the risk and protective factors for mental health problems in children in contact with social care, their impact and consider factors that are malleable to change (the topic guid has been uploaded as a supplementary file). The audio recorded focus group discussions were transcribed verbatim and uploaded to NVivo for data management. Data was analysed thematically [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] and guided by the socio-ecological model [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]; a theoretical framework used to examine the complex interplay between individual, interpersonal, community and society level determinants of health. Additionally, analysed data was used to inform the development of case vignettes utilised in interviews with CYP within WP3.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Work Package 3: Interviews with CYP and parents/caregivers\u003c/h2\u003e \u003cp\u003eWe conducted interviews with 23 CYP recruited via child welfare services and children in care councils (forums for children in out-of-home placement) and 18 interviews with parents/caregivers of CYP in contact with child welfare services in the North East of England between September 2022 and February 2023. The mean age of CYP who participated was 15 (range: 11-21yrs) and included both female (n\u0026thinsp;=\u0026thinsp;12) and male (n\u0026thinsp;=\u0026thinsp;11) participants. Most were White British (n\u0026thinsp;=\u0026thinsp;19). The parents/caregivers were mostly mothers (n\u0026thinsp;=\u0026thinsp;7) or residential care staff (n\u0026thinsp;=\u0026thinsp;7). We also interviewed grandparents (n\u0026thinsp;=\u0026thinsp;2) and foster carers (n\u0026thinsp;=\u0026thinsp;2). The participant characteristics for CYP and parent/caregivers are detailed in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. All CYP selected one or more case vignettes (from a selection of four), which detailed hypothetical scenarios relating to the main risk and protective factors identified within practitioner focus groups in work package 2. The vignettes were implemented to promote the increasing focus upon the \u0026lsquo;problem\u0026rsquo; whilst also promoting ethical data collection. Vignettes enabled CYP to discuss mental health risk, resilience and support in detail whilst not being required to disclose personal details which may be distressing to them. The participating CYP engaged in a semi-structured interview relating to the vignette, examining the mental health impact of this scenario, factors that they considered malleable to change and possible intervention approaches. In addition, 21 CYP completed an optional semi-structured exercise designed to support CYP to explore their own experiences of mental health problems. Parent/caregiver interviews all examined these topics as they related to their own experiences of caregiving to a CYP in contact with child welfare services who has mental health concerns. Interviews were audio recorded with consent, transcribed verbatim and thematically coded as described in WP2. All case vignettes, topic guides and exercises have been uploaded used within this work package have been uploaded as a supplementary file.\u003c/p\u003e \u003cp\u003e \u003cem\u003eINSERT\u003c/em\u003e Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Work Package 4: Co-Production Workshops\u003c/h2\u003e \u003cp\u003eWe presented our findings from WP1-3 at a regional children\u0026rsquo;s mental health conference held in June 2023, attended by practitioners, operational and strategic managers and leaders from both child welfare and mental health services. Delegates were invited to participate in an interactive exercise by submitting responses to questions around the prioritisation of intervention ideas via OMBEA, a web-enabled response option integrated with Microsoft PowerPoint. A total of n\u0026thinsp;=\u0026thinsp;57 practitioners, mangers and leaders participated in the exercise.\u003c/p\u003e \u003cp\u003eIn addition to the conference, we convened separate workshops at two timepoints during July and August 2023 with: i) CYP in contact with child welfare services, and ii) mental health and child welfare practitioners. The research team worked in partnership with the participants to iteratively co-produce the intervention. At timepoint 1, we presented the findings of WPs 1\u0026ndash;3 and the prioritisation exercise to CYP (n\u0026thinsp;=\u0026thinsp;6) and practitioners (n\u0026thinsp;=\u0026thinsp;11). Workshop participants were encouraged to consider these findings during semi-structured activities, which were designed to support discussion relating to prioritised intervention ideas. Activities included listing strengths and weaknesses of the approaches, preferred mechanisms of change, and examining intended and unintended outcomes which may come from the mechanisms. At timepoint 2, a sub-group of participants attended a further workshop (n\u0026thinsp;=\u0026thinsp;4 in CYP workshop; n\u0026thinsp;=\u0026thinsp;4 practitioner workshop). These workshops focused upon refining the detail of the intervention and producing a detailed intervention logic model.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cem\u003e3.1 Step 1: Define and understand the problem\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe first step of the 6SQUID approach is to clarify the \u0026lsquo;problem\u0026rsquo;. We commenced the formal intervention development process with a clear understanding that the mental health of CYP in contact with child welfare services is a priority public health and social care concern. This was informed by a review of existing evidence [4, 39-41] and stakeholder involvement within project design stage. What we did not yet know, and needed to clarify, was what the social distribution of this problem was within the population of children in contact with child welfare services. We were concerned with the future implementation of the intervention within the child welfare sector, and as such we sought to understand which groups of children within the larger population of CYP were of greatest concern to child welfare and mental health practitioners, and who they perceive to be most or least likely to benefit from intervention. We were also concerned to examine the causal pathways linked to mental health problems and determine which immediate (proximal) and underlying (distal) influence give rise to mental health problems in CYP in contact with child welfare services and in what ways these CYP are affected by mental health problems.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChildhood adversity:\u003c/strong\u003e We drew upon the findings of the practitioner focus groups (WP2) and interviews with CYP and parents/caregivers (WP3) to examine the mental health needs of children in contact with child welfare services. Our application of the socio-ecological model highlighted the prevalence of interpersonal risk factors for CYP in contact with child welfare services. Adversity and trauma within the home environment was thought to be a particularly prominent risk to CYP\u0026rsquo;s mental health and a substantial priority issue for child welfare workers, CYP and parents/caregivers, and further reinforced by stakeholders. This distal, underlying influence of adversity typically consisted of parental risk factors such as parental mental health problems, parental substance use, domestic violence, and having a parent in prison. Participants highlighted the complexity within the context of adversity. Interpersonal risk factors were thought to interact synergistically with other risks present, resulting in accumulative stress for CYP in contact with child welfare services. Participants also reported a series of immediate, proximal influences. CYP were thought to often experience shame and stigmatisation relating to experiencing adversity and trauma within the home and would exhibit externalising difficulties including risk-taking or challenging behaviours as well as internalising difficulties such as low mood and self-esteem. These factors were reported to compound CYP vulnerability through exacerbating conflict in CYP-parent/caregiver interactions and increasing behavioural problems exhibited within other settings such as school and within local communities. Poverty was also highlighted as contributing to very difficult contexts for CYP and contributing to the impact of mental health problems within families.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It comes from home, as a result of really struggling to manage and move on, and recover from traumatic situations, and/or believing that they were the cause of those, in some way, shape or form. So, believing that they are bad, that they are the cause of difficulties within their family\u0026hellip;if there\u0026rsquo;s a pervasive sense of shame that exists within the child, wherever that comes from, that essentially leads fundamentally to poor self-esteem, difficulties in relationships, and poor mental health outcomes\u0026rdquo; (female, child and adolescent mental health practitioner).\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Back at school when I got angry, I was taking it out on the wrong people, I was attacking my fellow pupils and that. Thinking about it now, I feel sorry that I was doing that, that I was using this anger and I was just using it against other people and hurting them, I was hurting my own teachers, I was attacking them and they had to restrain us. I feel guilty and I feel so sorry\u0026rdquo; (male, 12years, child in care).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003cstrong\u003eFailing to recognise trauma:\u0026nbsp;\u003c/strong\u003eIt was reported by participants that parents/caregivers and the professionals involved in their care often did not know how to best support the CYP or deal with their related behaviours.\u0026nbsp;Participants highlighted that early \u0026lsquo;warning signs\u0026rsquo; were typically overlooked resulting in missed opportunity to intervene before CYP developed diagnosable mental health disorders. Our findings further suggested that there is a tendency for early indicators to be perceived as \u0026lsquo;bad behaviour\u0026rsquo;, rather than being symptomatic of CYP\u0026rsquo;s experience of adversity. When the CYP\u0026rsquo;s mental health needs were identified, participants reported that care was further delayed by\u0026nbsp;lengthy waiting lists for mental health treatment,\u0026nbsp;leading to increased mental health vulnerability in CYP and a worsening of their social situation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;From my own experience. Growing up, there was a lot of issues raised to social services, to school and things and they, sort of, waited until it was at\u0026nbsp;\u003c/em\u003e\u003cem\u003ecrisis\u003c/em\u003e\u003cem\u003e\u0026nbsp;point to actually do any intervention whatsoever. Whereas if I think, you know, if they\u0026rsquo;d came in and actually just tried to do little things earlier, it might not have got to the point it did\u0026rdquo;\u003c/em\u003e (\u003cem\u003efemale, 20 years, care leaver\u003c/em\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The waiting list is huge. You\u0026rsquo;re talking over a year, to be able to just have an initial appointment. We waited 14 months. Bearing in mind, [daughter\u0026rsquo;s name] was already in CAMHS, but for an autistic assessment, we waited 14 months. In fact, I think it was longer, because COVID hit\u0026hellip;And there\u0026rsquo;s nothing you can do except get on with it, and just try and struggle along\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;(female, mother, child in need)\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRetraumatising:\u0026nbsp;\u003c/strong\u003eWithin focus groups and interviews, participants frequently highlighted that when CYP attended mental health services they were required to retell their story as a prerequisite to receiving treatment, and without first paying adequate attention to building a trusting relationship. This was found to be unhelpful, and at times distressing for CYP. This typically led to CYP not disclosing their concerns to mental health professionals, and their needs going unmet.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some of them come in as if you\u0026rsquo;re going to trust them straight away\u0026hellip; When they come in the house and they just sit down and they\u0026rsquo;ll be like, \u0026ldquo;Tell me how you\u0026rsquo;re feeling. How are you feeling today? How have you been feeling lately?\u0026rdquo; I don\u0026rsquo;t open up as easy as they may have thought\u0026hellip; [they should] probably try and build a relationship, doing something like even if it\u0026rsquo;s just going to the beach\u0026hellip;and then we can build a relationship from there\u0026rdquo; (female, 15 years, child in need)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So, you take these extremely traumatised children to an appointment, and obviously, they don\u0026apos;t trust the professionals, and if the kids don\u0026apos;t engage in one or two sessions, then they close the case for them\u003c/em\u003e\u0026rdquo;\u0026nbsp;(\u003cem\u003efemale, residential children\u0026rsquo;s home, registered manager\u003c/em\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.2 Step 2: Clarify which causal or contextual factors are malleable and have the greatest scope for change\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervening early:\u0026nbsp;\u003c/strong\u003eHaving developed an understanding of the proximal and distal influences upon the mental health of CYP in contact with child welfare services, our next task was to identify which of these factors are malleable to change. Our systematic review of reviews (WP1) found a large evidence-base suggesting secondary prevention targeting children who had experienced adversity is effective at reducing mental health problems. Similarly, interventions with CYP with subclinical externalising problems were found to offer promise. Within the review, both risk and resilience factors were found to be highly malleable to change. We presented findings from WP1-3 to practitioners within the prioritisation exercise conducted within WP4, and asked stakeholders to respond to questions about causal or contextual factors which the intervention should target. Stakeholders overwhelmingly (83%) opted for an intervention with CYP who had experienced adversity, and at a point before symptoms of mental health problems are evident. This was further considered within the co-production workshops with CYP in contact with child welfare and practitioners (WP4). Workshop participants agreed that intervening early in the disease trajectory (and before symptoms were evident) was important. Further, we identified a convincing evidence of an association between child adversity and mental health problems identified within our on-going engagement with research literature [41-45]. This combined evidence supports the provision of a selective intervention for CYP in contact with child welfare services who have experienced adversity, without first requiring the CYP to make potentially distressing disclosures within an assessment of mental health need.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBuilding supportive relationships:\u0026nbsp;\u003c/strong\u003eThroughout the qualitative work packages and in co-production workshops, participants focused upon the quality of the relationship and emotional support provided between the parent/caregiver and child. The home environment was perceived as an area where the scope for change was greatest both in terms of alleviating an important proximal factor, and the likely benefits of doing so. This was informed further by our consideration of research evidence showing an association between good CYP mental health and high emotional support, high parent-child closeness, and low parent-child conflict [46, 47]. \u0026nbsp; Additionally, practitioners participating in focus groups within WP2 reported observing improvements in child mental health where parental support was high. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think probably in terms of protective factors, I think probably the parents, in the sense of that\u0026rsquo;s where, you know, they\u0026rsquo;re in school all day, yes, but that\u0026rsquo;s where, like we\u0026rsquo;ve just said, from a young age as well, that\u0026rsquo;s where, kind of, they\u0026rsquo;re nurturing, where they\u0026rsquo;re learning, I think. Even if they were in school all day and had a great protective network, if they go home and there\u0026rsquo;s absolutely no protection there \u0026ndash; for teenagers especially, no boundaries, no rules, no independent living skills, and all that, we\u0026rsquo;re on a losing battle if the parents aren\u0026rsquo;t, kind of, putting that in place 24/7\u0026rdquo;\u003c/em\u003e (\u003cem\u003efemale, care leavers team, social worker\u003c/em\u003e)\u003c/p\u003e\n\u003cp\u003eThe development of strong support systems such as supportive friendships and intimate relationships, wider family networks and positive relationships with professionals were also highlighted as important protective factors which could be fostered with the potential for substantial benefit for CYP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eIt would be having a relationship with a positive role model adult in their life that allows them to see themselves in a bit of a different way. Because I guess a lot of the kids that we work with have had really difficult early relationships and difficult, maybe, parent/child relationships, or difficulties with other adults\u0026hellip;So whether that\u0026apos;s a member of staff, or it could be a member of educational staff, it\u0026apos;s having that positive role model that maybe they haven\u0026apos;t had earlier on, so that they can start to develop those trusted relationships, be able to see themselves in a bit of a different way and start to internalise some of that\u0026rdquo;\u003c/em\u003e (\u003cem\u003efemale, child and adolescent mental health practitioner\u003c/em\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.3 Step 3:\u003c/em\u003e\u003cem\u003e\u0026nbsp;Identify how to bring about change: the change mechanism\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInterventions are \u0026lsquo;theories incarnate\u0026rsquo; [48] and may include implicit or explicit theory [31, 49]. It is recommended that intervention development draws upon established theory [28] which can support the identification of what is important, relevant and feasible in achieving the intervention goals [50]. During this project we were influenced by attachment theory and related attachment-focused interventions. Attachment theory explains how childhood adversity and trauma can reduce the security of attachments a child has with their caregiver [51]. In the early years, a child\u0026rsquo;s sense of safety and security comes primarily from their caregiver and they learn to trust/mistrust according to this experience [52]. Children who experience adversity and trauma experience the world as unsafe [53]. They learn that their caregiver cannot or does not protect them from this danger and they learn to mistrust [54]. In the absence of trusting and secure attachments, children\u0026rsquo;s development maybe organised around a nervous system which is prepared for danger [53]. This may result in emotional dysregulation [55] and behaviours which are deemed socially unacceptable [56]. This in turn compounds the problems of the CYP (for example generating conflict in the home of disruptive behaviours within school) [53], whilst also creating a barrier for help-seeking [57].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring stakeholder consultation and within co-production workshops we examined mechanisms of change. Attachment-focused interventions such as the Solihull Parenting Approach [58] and Dyadic Developmental Psychotherapy (DPP) [59] where highlighted as important mid-range theories [50] with explanatory potential relating to the change mechanism. Both approaches emphasise the importance of CYP feeling safe and developing relationships with key caregivers, before learning how to regulate emotion within the safety of those relationships. An additional mechanism of change includes recognising and understanding the impact of adversity and trauma upon the CYP\u0026rsquo;s feelings and behaviours. We were further influenced by the Solihull Parenting Approach which recognises parental anxiety as an important factor, and provides a means of the parent and child developing reciprocity [60] and reflexive functioning [61] in order to achieve change [58].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.4 Step 4: Identify how to deliver the change mechanism\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe iteratively developed and refined the intervention within a series of four co-production workshops (WP4). A detailed intervention logic model is presented in figure 2 wherein we depict how the intervention may work and its anticipated intended and unintended outcomes. Co-production workshops were\u0026nbsp;based upon the outcomes of the prioritisation exercise and informed by the findings of work packages 1-3 and the iterative refinement of the previously described intervention development steps. Within the prioritisation exercise (WP4), practitioners were asked to rank their preferred three intervention approaches. Activity-based interventions with CYP, family/caregiver interventions and trauma-informed approaches were selected as the three highest priority approaches from a shortlist of 10 possible interventions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt was agreed within co-production workshops conducted at timepoint 1 that any intervention with CYP who have experienced adversity should take a trauma-informed approach.\u0026nbsp;Whilst there is no consensus on how trauma-informed care is defined\u0026nbsp;[62], the most widely used definition of trauma-informed care comes from the Substance Abuse and Mental Health Services Administration who define the \u0026ldquo;Four R\u0026rsquo;s\u0026rdquo; of trauma-informed care, which are: realisation about trauma and its affects; recognition of the signs of trauma; responding to trauma and resist re-traumatisation through practices which inadvertently cause further trauma\u0026nbsp;[63].\u0026nbsp;We proceeded to consider the strengths and weaknesses of the two remaining intervention approaches of activity-based intervention and family/caregiver intervention, with a view to agree which of these approaches was perceived to be the better approach. We moved back and forth between step 3 and step 4, refining our change mechanism and our approach to delivering this. During this iterative process, it became apparent that both approaches were considered necessary to bring about change within the mechanism and prevent mental health problems in CYP in contact with child welfare services. This led to a decision within the co-production workshops to develop a trauma-informed activity-based youth intervention with an embedded family component. The key characteristics of the intervention are:\u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eSelective secondary preventative intervention for CYP in contact with child welfare services who have experienced adversity (e.g. parental substance use, mental health, domestic violence, incarceration of a parent).\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eA youth activity-based intervention\u003c/u\u003e which would consist of three phases:\u003c/li\u003e\n \u003cli\u003eA relationship building phase (approx. 8-12 weeks): practitioner getting to know the CYP and their interests, agreeing and supporting involvement in a range of activities (e.g. going for walks, visiting places of interest, jointing research topics of interest, attending organised activities)\u003c/li\u003e\n \u003cli\u003eA family component phase (approx. 6-8 weeks) \u0026ndash; see below.\u003c/li\u003e\n \u003cli\u003eEnding phase (approx. 4-6 weeks): practitioner reinforces CYP learning and related behaviour change and supports access to youth activities and established networks in community. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eAn embedded family component\u003c/u\u003e:\u003c/li\u003e\n \u003cli\u003ePractitioner meets with CYP and family together and agrees plan for work.\u003c/li\u003e\n \u003cli\u003ePractitioner has weekly sessions separately with CYP and parents/caregivers focused on supporting family members to understand each other; the emotional and behavioural impact of adversity on CYP/wider family and reflective family functioning.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eINSERT FIGURE 2\u003c/em\u003e\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis project has co-produced an intervention with, and been informed by, CYP in contact with child welfare services, their parents/caregivers and the practitioners who support them. We identified that the primary risk factor affecting CYP in contact with child welfare services is the experience of adversity. The quality of relationships that the CYP experiences both with their parent/caregivers and the professionals involved in their care were considered to be the main factors amenable to change. By focusing upon building secure and trusting relationships with the CYP and promoting understanding how adversity and trauma impacts upon the CYP within the family, our project suggests the CYP mental health maybe best supported. The findings of our study have resulted in the development of a trauma-informed, activity-based intervention with an embedded family/caregiver intervention.\u003c/p\u003e \u003cp\u003eThe importance of taking a trauma-informed approach to intervening with CYP in contact with child welfare was evident throughout our project. This finding is in line with emerging evidence supporting such practices with vulnerable populations of CYPs [\u003cspan additionalcitationids=\"CR65 CR66 CR67\" citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. The CYP involved in our project emphasised the potential for existing mental health support to re-traumatise, as CYP are often required to repeatedly discuss distressing matters with unknown professionals within clinical interactions. Our findings emphasise that a trusting relationship with a familiar and non-threatening practitioner is necessary to allow CYP the space and opportunity to choose to talk about their mental health concerns at a pace that is comfortable to them. This supports previous intervention research with CYP in contact with child welfare services [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBoth youth and family focused components were considered a priority within our co-production activities. As has been found in other studies of children experiencing adversity [\u003cspan additionalcitationids=\"CR71\" citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e] and/or mental health problems [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e], participants highlighted the need for CYP to be supported both separate to and within family structures. The initial phase of the intervention is an activity-based, youth focused intervention consisting of one-to-one interactions with a consistent practitioner with the primarily focus being upon building a relationship. This gradual building of rapport would enable the practitioner to facilitate naturally occurring conversations about mental health and concerns. After establishing a relationship with the CYP, this practitioner is then able to progress onto the family-focused component of the intervention; providing the consistent relationship that research highlights as particularly necessary with vulnerable groups of CYP [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. The family-focused component aims to improve parent/caregiver-child relationship through increasing the reflective function (the capacity of family members to understand one another\u0026rsquo;s behaviour in-light of underlying mental states and intentions) and reciprocity; attributes that research has found to be beneficial to CYP mental health and wellbeing [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. However, a theme throughout our project was the importance of avoiding stigmatising practices and approaches which made parents/caregivers feel that their parenting skills were being questioned. As such, particular care is needed to be given to the relationship between the CYP, parent/caregiver and practitioner during an intervention in this context [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Strengths and limitations\u003c/h2\u003e \u003cp\u003eTo our knowledge this is the first project to co-produce a preventative intervention for CYP in contact with child welfare services with young people themselves, their parent/caregivers and the practitioners who support them. The meaningful stakeholder involvement we have achieved throughout the project is a great strength. Whilst we envisage that this approach has resulted in an intervention which is most likely to respond to the needs of CYP in contact with child welfare services, further research is required to pilot the intervention, refine it and determine effectiveness [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. A further limitation of our study is that the sample was recruited exclusively from the North-East of England. Further research may be required to examine transferability to other areas of the UK.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eA trauma-informed, selective secondary preventative intervention consisting of an activity-based intervention with an embedded family-focused component maybe most likely to respond to the mental health needs of CYP in contact with child welfare services who have experienced adversity. Further research is needed to pilot this intervention and gather evidence of its effectiveness.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA favourable ethical opinion was granted by the Health Research Authority West Midlands \u0026ndash; Coventry \u0026amp; Warwickshire Research Ethics Committee (reference 22/WM/0034) on 28\u003csup\u003eth\u003c/sup\u003e March 2022.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team do not have ethical approval to share data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project is independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) programme (Grant Reference Number PB-PG-203477). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Ruth McGovern holds an NIHR Advanced Fellowship. Eileen Kaner is in receipt of support from NIHR Senior Scientist Award.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRM conceptualised had overall responsibility for the project and drafted the manuscript. ABK, BA undertook data collection and analysis. EB, TD, RL, PM, JR, PT \u0026amp; EK developed contributed to the project management and commented on the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, the authors would like to acknowledge Mary Connor, Northumberland County Council and Janette Brown from Newcastle City Council their support during the development of the project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003ePopulation Health Sciences Institute, Newcastle University, United Kingdom\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e Children and Young People\u0026apos;s Primary Care Mental Health Service, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, United Kingdom\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eChildren\u0026rsquo;s Social Care, Newcastle City Council, United Kingdom\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003ePopulation Child Health Research Group, School of Women and Children\u0026rsquo;s Health, University New South Wales, Australia\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e5\u003c/sup\u003eChild and Adolescent Mental Health Services, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, United Kingdom\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e6\u0026nbsp;\u003c/sup\u003eChildren\u0026rsquo;s Social Care, Cumberland Council, United Kingdom\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDigital NHS. \u003cem\u003eMental Health of Children and Young People in England, 2017\u003c/em\u003e. 2018, NHS Digital: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017\u003c/span\u003e\u003cspan address=\"https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDigital NHS. \u003cem\u003eMental Health of Children and Young People in England, 2020: Wave 1 follow up to the 2017 survey\u003c/em\u003e. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDigital NHS. \u003cem\u003eMental Health of Children and Young People in England 2022 - wave 3 follow up to the 2017 survey\u003c/em\u003e. 2022, NHS Digital: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2022-follow-up-to-the-2017-survey\u003c/span\u003e\u003cspan address=\"https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2022-follow-up-to-the-2017-survey\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBronsard G, et al. 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The ecology of human development: experiments by nature and design. Cambridge MA: Harvard University Press; 1979.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDahlgren G, Whitehead M. Policies and strategies to promote social equity in health. Institute for Futures Studies: Stockholm; 1991.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Institute for Health and Care Excellence. Looked-after chilren and young people: NICE Guideline [NG205]. London: NICE; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAi AL, et al. Reshaping Child Welfare\u0026rsquo;s Response to Trauma:Assessment, Evidence-Based Intervention, and New Research Perspectives. Res Social Work Pract. 2013;23(6):651\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGriffin G, et al. Addressing the impact of trauma before diagnosing mental illness in child welfare. Child Welfare. 2011;90(6):69\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdjei NK, et al. Impact of poverty and family adversity on adolescent health: a multi-trajectory analysis using the UK Millennium Cohort Study. Volume 13. Lancet Reg Health Eur; 2022a. p. 100279.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdjei NK, et al. Quantifying the contribution of poverty and family adversity to adverse child outcomes in the UK: evidence from the UK Millennium Cohort Study. Lancet. 2022b;400:S16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHughes K, et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health. 2017;2(8):e356\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBellis MA, et al. Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis. Lancet Public health. 2019;4(10):e517\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdjei NK et al. Impact of child poverty and adversity on perceived family support in adolescence. Eur J Pub Health, 2023. 33(Supplement_2): p. ckad160.067.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdjei N et al. \u003cem\u003eImpact of poverty and adversity on perceived family support in adolescence: findings from the UK Millennium Cohort Study.\u003c/em\u003e European Child \u0026amp; Adolescent Psychiatry, 2024. in press.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePawson R. Evidence-based policy: a realist perspective. London: Sage; 2006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Silva MJ, et al. Theory of Change: a theory-driven approach to enhance the Medical Research Council's framework for complex interventions. Trials. 2014;15:267.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavidoff F, et al. Demystifying theory and its use in improvement. BMJ Qual Saf. 2015;24(3):228\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePickreign Stronach E, et al. Child maltreatment, attachment security, and internal representations of mother and mother-child relationships. Child Maltreat. 2011;16(2):137\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowlby J. The making and breaking of affectional bonds. London: Routledge; 1998.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGolding KS. Understanding and helping children who have experienced maltreatment. Paediatrics Child Health. 2020;30(11):371\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErikson E. Youth: Change and challenge. New York: Basic Books; 1963.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunn EC, et al. Developmental timing of trauma exposure and emotion dysregulation in adulthood: Are there sensitive periods when trauma is most harmful? J Affect Disord. 2018;227:869\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOshri A, et al. Child maltreatment types and risk behaviors: Associations with attachment style and emotion regulation dimensions. Pers Indiv Differ. 2015;73:127\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalmon P, Young B. Dependence and caring in clinical communication: The relevance of attachment and other theories. Patient Educ Couns. 2009;74(3):331\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDouglas H, Ginty M. The Solihull approach: Changes in health visiting practice. J Health Visitors' Association Community Practitioner. 2001;74(6):222.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHughes DA. Attachment-focused family therapy. WW Norton \u0026amp; Company; 2007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDouglas H, Brennan A. Containment, reciprocity and behaviour management: preliminary evaluation of a brief early intervention (the Solihull Approach) for families with infants and young children. Infant Observation. 2004;7:89\u0026ndash;107.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarlow J, Sleed M, Midgley N. Enhancing parental reflective functioning through early dyadic interventions: A systematic review and meta-analysis. Infant Ment Health J. 2021;42(1):21\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOffice for Health Disparties. Working definition of Trauma-informed practice. London: OHID; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSubstance Abuse and Mental Health Services Administration. SAMHSA\u0026rsquo;s concept of trauma and guidance for a trauma-informed approach. SAMHSA: Rockville MD; 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsmussen K, et al. Trauma-informed care: Understanding the use of trauma-informed approaches within children's social care. London: Early Intervention Foundation; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBailey C, et al. Systematic review of organisation-wide, trauma-informed care models in out-of-home care (OoHC) settings. Health Soc Care Community. 2019;27(3):e10\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBunting L et al. Trauma Informed Child Welfare Systems-A Rapid Evidence Review. Int J Environ Res Public Health, 2019. 16(13).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang S, et al. Trauma-informed care for children involved with the child welfare system: A meta-analysis. Child Abuse Negl. 2021;122:105296.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLowenthal A. Trauma-informed care implementation in the child- and youth-serving sectors: A scoping review. Int J Child Adolesc Resil. 2020;7:178\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlderson H, et al. The key therapeutic factors needed to deliver behavioural change interventions to decrease risky substance use (drug and alcohol) for looked after children and care leavers: a qualitative exploration with young people, carers and front line workers. BMC Med Res Methodol. 2019;19(1):38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuir C et al. \u003cem\u003eA Systematic Review of Qualitative Studies Exploring Lived Experiences, Perceived Impact, and Coping Strategies of Children and Young People Whose Parents Use Substances.\u003c/em\u003e Trauma Violence Abuse, 2022: p. 15248380221134297.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurns S et al. \u003cem\u003eInterventions to reduce parental substance use, domestic violence and mental health, and their impacts upon children\u0026rsquo;s wellbeing: a systematic review of reviews plus an evidence and gap map.\u003c/em\u003e 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGovern R et al. \u003cem\u003ePsychosocial Interventions to Improve Psychological, Social and Physical Wellbeing in Family Members Affected by an Adult Relative's Substance Use: A Systematic Search and Review of the Evidence.\u003c/em\u003e Int J Environ Res Public Health, 2021b. 18(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeijer-Simpson E et al. \u003cem\u003eEffectiveness of Family-Involved Interventions in Reducing Co-Occurring Alcohol Use and Mental Health Problems in Young People Aged 12\u0026ndash;17: A Systematic Review and Meta-Analysis.\u003c/em\u003e International Journal of Environmental and Public Health Research., 2023. In press.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEngen M. \u003cem\u003eCare as a relational practice: The possibility of solidary authority\u003c/em\u003e, in \u003cem\u003eCare in Social Work with Children and Families\u003c/em\u003e. Routledge; 2023. pp. 34\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJordan M, Kane M, Bibbly J. \u003cem\u003eA healthy foundation for the future\u003c/em\u003e. 2019, The Health Foundation: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.health.org.uk/publications/reports/a-healthy-foundation-for-the-future\u003c/span\u003e\u003cspan address=\"https://www.health.org.uk/publications/reports/a-healthy-foundation-for-the-future\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGovern R, et al. 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Alcohol Alcohol. 2022;57(5):615\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1: Participant characteristics\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"697\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.16618911174785%\" colspan=\"14\" valign=\"bottom\"\u003e\n \u003cp\u003ePractitioner focus groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.83381088825215%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eID\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003ePractitioner role\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eService\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eSocial Worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eEmergency Duty Team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eTherapist (working with YP 11-17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eMulti Systemic Therapy team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eClinical Psychologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eChildren and Young People Service (mental health)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eEarly Help\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eIntensive Family Support\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eFamily Support Worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eLong-term children\u0026apos;s support care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eMental Health OT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eNewcastle residential homes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eSocial Worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eYouth Justice Service\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eSocial Worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eInitial Response Service\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eSocial Worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eLong-term team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eClinical Psychologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eResidential Therapeutic Support Team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eClinical Psychologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eResidential Therapeutic Support Team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eSocial Worker/Early Help\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eEarly Help Team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eStudent Social Worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eLong Term Planning\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eFront door: social worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eInitial Assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eSocial Worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eLong Term Planning\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eChildren\u0026apos;s Wellbeing Practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eFamily Hub\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eLeaving Care Support Worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eCare Leavers Team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eSocial Worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eCare Leavers Team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eFamily help worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eEarly Intervention and Prevention\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eAdvanced Practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eChildren and Young People Service (mental health)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eChildren\u0026apos;s Wellbeing Practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eCentral Early Help Team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eSocial Worker\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eChildren\u0026apos;s Assessment \u0026amp; Safeguarding Team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eFamily Support Worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eChildren\u0026apos;s Social Care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eSocial Worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eEmergency Duty Team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.48206599713056%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eP025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.60832137733142%\" valign=\"bottom\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.01578192252511%\" colspan=\"10\" valign=\"bottom\"\u003e\n \u003cp\u003eChildren\u0026apos;s Social Worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.89383070301291%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eSupporting and Strengthening Families Team\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"697\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.664275466284074%\" colspan=\"4\" valign=\"bottom\" style=\"width: 9.2547%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChild participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.2955523672883786%\" valign=\"bottom\" style=\"width: 1.2098%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.051649928263988%\" colspan=\"4\" valign=\"bottom\" style=\"width: 5.3834%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.486370157819225%\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.7948350071736%\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eID\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChild welfare status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eChinese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in need\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in Need\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in Need\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP04\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eCare Leaver\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP05\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eCare Leaver\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP07\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eEarly Help\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP08\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP09\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP010\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eNon-binary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in need\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP011\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in need\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP012\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eBlack African\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP013\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP014\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eCare Leaver\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP016\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eCare Leaver\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP017\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in need\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP019\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP022\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in need\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP023\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eBlack British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in need\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP026\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eNon-binary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in need\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP027\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eMixed British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in need\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.312320916905444%\" valign=\"bottom\" style=\"width: 3.9317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCYP030\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.893982808022923%\" colspan=\"3\" valign=\"bottom\" style=\"width: 5.7464%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.739255014326648%\" colspan=\"3\" valign=\"bottom\" style=\"width: 3.7503%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.908309455587393%\" colspan=\"2\" valign=\"bottom\" style=\"width: 7.6215%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.484240687679083%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.1054%;\"\u003e\n \u003cp\u003eChild in care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.206303724928368%\" colspan=\"5\" valign=\"bottom\" style=\"width: 9.6781%;\"\u003e\n \u003cp\u003eParent interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.5787965616045847%\" valign=\"bottom\" style=\"width: 1.1493%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.458452722063038%\" colspan=\"2\" valign=\"bottom\" style=\"width: 4.4156%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.61031518624642%\" valign=\"bottom\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.770773638968482%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eID\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParent/ caregiver role\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"bottom\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"bottom\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChild welfare status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePC01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eGrandparent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"bottom\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"bottom\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eChild in need\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePC02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eMother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"bottom\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"bottom\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eChild Protection\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePC03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eMother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"top\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"bottom\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eEarly Help\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePC04\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eMother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"top\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"top\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eEarly Help\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePC05\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eFoster parent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"top\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"top\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eChild/ren in care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePC06\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eMother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"top\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"top\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eChild in need\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePC08\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eMother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"top\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"top\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eEarly Help\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePC09\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eFoster parent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"top\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"top\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eChild in need\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePC010\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eMother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"top\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"top\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eChild in need\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePC011\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eResidential carer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"top\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"top\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eChild/ren in care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePC012\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eMother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"top\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"top\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eChild in need\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePC013\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eResidential carer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"top\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"top\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eChild/ren in care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePC014\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eResidential carer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"top\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"top\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eChild/ren in care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePC015\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eResidential carer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"top\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"top\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eChild/ren in care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n 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\u003cp\u003e\u003cstrong\u003ePC017\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eResidential carer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"bottom\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"top\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eChild/ren in care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePC018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eResidential carer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"bottom\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"top\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eChild/ren in care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.890961262553802%\" valign=\"bottom\" style=\"width: 3.3268%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePC02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.647058823529413%\" colspan=\"7\" valign=\"bottom\" style=\"width: 7.9239%;\"\u003e\n \u003cp\u003eGrandparent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.612625538020087%\" valign=\"bottom\" style=\"width: 3.9922%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.629842180774748%\" valign=\"top\" style=\"width: 5.8673%;\"\u003e\n \u003cp\u003eWhite British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.79913916786227%\" colspan=\"2\" valign=\"bottom\" style=\"width: 8.4683%;\"\u003e\n \u003cp\u003eChild in need\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Children and young people, mental health, adversity, trauma-informed; secondary prevention, intervention development","lastPublishedDoi":"10.21203/rs.3.rs-3982675/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3982675/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChildren and young people (CYP) in contact with child welfare services are at high risk of developing mental health problems. There is a paucity of evidenced-based preventative interventions provided to this population.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis project worked in partnership with CYP, their parents/caregivers and the professionals who support them to co-produce a preventative mental health intervention for CYP in contact with child welfare services.\u003c/p\u003e\u003ch2\u003eParticipants and setting:\u003c/h2\u003e \u003cp\u003e We recruited a purposive sample of CYP in contact with child welfare services (n\u0026thinsp;=\u0026thinsp;23), parents/caregivers (n\u0026thinsp;=\u0026thinsp;18) and practitioners working within child welfare services and mental health services (n\u0026thinsp;=\u0026thinsp;25) from the North East of England and convened co-production workshops (n\u0026thinsp;=\u0026thinsp;4).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis project followed the established principles for intervention development, applying the six steps to quality intervention development (6SQUID) approach. The mixed method research consisted of four work packages with continuous engagement of stakeholders throughout the project. These were: a systematic review of reviews; focus groups with practitioners; interviews with parents/caregivers and young people; co-production workshops.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe identified that the primary risk factor affecting CYP in contact with child welfare services is the experience of childhood adversity. The quality of relationships that the CYP experiences with both their parent/caregivers and the professionals involved in their care were considered to be the main factors amenable to change.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe found that a trauma-informed, activity-based intervention with an embedded family-focused component provided to CYP who have experienced adversity is most likely to prevent mental health problems in those in contact with child welfare services.\u003c/p\u003e","manuscriptTitle":"Co-producing an intervention to prevent mental health problems in children in contact with child welfare services","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-13 17:26:39","doi":"10.21203/rs.3.rs-3982675/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-12T04:31:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-11T11:51:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-11T11:51:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-02-23T17:37:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"153983cb-c1dd-43ac-ae7e-de6165b80deb","owner":[],"postedDate":"March 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-26T16:02:22+00:00","versionOfRecord":{"articleIdentity":"rs-3982675","link":"https://doi.org/10.1186/s12889-024-19770-6","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2024-08-21 15:57:30","publishedOnDateReadable":"August 21st, 2024"},"versionCreatedAt":"2024-03-13 17:26:39","video":"","vorDoi":"10.1186/s12889-024-19770-6","vorDoiUrl":"https://doi.org/10.1186/s12889-024-19770-6","workflowStages":[]},"version":"v1","identity":"rs-3982675","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3982675","identity":"rs-3982675","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}