Multidisciplinary research priorities for the COVID-19 pandemic

We read with interest Emily A Holmes and colleagues' call for action regarding research around the current national COVID-19 pandemic.¹ Their suggestion that UK research funding agencies collaborate with researchers, people with lived experience, and others to establish a high-level coordination group and ensure that priorities are actioned, is welcomed by us as Child and Adolescent Forensic Psychiatrists.

Young people who present with complex forensic mental health needs are particularly difficult to engage, even without the current restrictions arising from COVID-19. Paradoxically, this national health crisis might provide a unique opportunity to gain data that would not otherwise be available. Information gained at this time might allow for the long-term optimisation of psychological and digital interventions for individuals who are difficult to engage, challenging, and a high-risk group for neglect, violence, and criminal exploitation; with whom adolescent forensic mental health services work.

Young people who present with complex and high forensic risks are a highly vulnerable group, often experiencing early trauma, repeated loss, attachment issues, learning difficulties, and mental health problems.2, 3 As of 20 May, 2020, the current reduced access to support and structure arising from school closures and agencies working in different ways (remotely, reduced direct contact), with lower staffing numbers, is exacerbating these young people's vulnerability. Challenging behaviours were previously mitigated by the provision of protective factors including education and other pro-social activities; the absence and reduction of these activities might translate into increased violence in homes or placements. Gaining a greater understanding of the wider impact of COVID-19 on this group of young people is an opportunity to understand how short-term support can be provided using different ways of working. This understanding will most likely lead to optimisation of long-term service delivery.

Holmes and colleagues highlight that children and young people with neurodevelopmental difficulties are at particular risk from social distancing, specifically spending long periods at home and not being able to attend school. We suggest that this risk also applies to young people who present with complex, high-risk forensic mental health needs. We want to highlight two specific vulnerable groups with whom we work.

The first is a group of vulnerable, isolated young people with social, communication, cognitive or emotional difficulties, or both, which increase their risk of exploitation by others. The COVID-19 pandemic has resulted in further reduction of social care specialist residential placements, coupled with decreased activity of courts, police, and admissions to secure welfare accommodation, which means that community workers are facing higher expectations to deliver and implement community risk management plans. Specific risks relevant to this patient group are wider than their risk of direct offending or harm to others, and include being groomed into gang-related activities (including County Lines and other criminal exploitation) and online manipulation. Child criminal exploitation into County Lines activity involves young people being asked to transport and deal drugs from one city hub into another community at risk to themselves and profit to the adult running these activities. The risk of adolescents going missing has also increased. We are concerned that these longer-term risk behaviours might only become apparent in the next 6–12 months, once the societal impact of COVID-19 becomes clear.

The second group involves young people who show challenging behaviour within their family homes or at local authority placements. A reduction in multi-agency support and therapeutic offers from schools, respite placements, youth groups, and secure youth justice placements, means that these young people are probably spending more time in the community, where their risk profile is more likely to increase. This change is compounded by the UK public health directive to self-isolate, resulting in reduced specialist professional support. The effect on these young people is also most likely to be long term, arising from their need for increased future input to help address traumatic events they might have gone through during this pandemic, including understanding the impact of loneliness and disconnection from the community.

We therefore suggest that young people who present with complex forensic mental health needs are particularly vulnerable in these extraordinary times. We suggest that a coordinated action plan should be developed, with input from the UK children's social care services, educational services, and the criminal justice system, to support this vulnerable group. We support the call for this plan to commence with a greater understanding through research and data collection.