Scottish Government

Executive summary

Introduction

• This report considers what research tells us about the health of children and young people in general living in Scotland, and the looked after and accommodated population in particular.
• Research from across the UK has been included, as many children and young people who are looked after and accommodated in Scotland share similar characteristics and experiences with their peers elsewhere in the UK. It should be borne in mind, however, that in England and Wales, the term looked after children for the most part corresponds with children described in Scotland as looked after and accommodated, but there are some differences. For example, a young person counts as looked after in England and Wales even when placed at home under a care order, while a child on home supervision in Scotland is looked after, but not looked after and accommodated.
• A drive to improve the health of the Scottish nation has been taken forward by the Scottish Executive. For Scotland's Children sets out a vision for all children and young people in Scotland by emphasising that all should have access from birth to the services and environments necessary to ensure they fulfil their potential. Health policy documents such as the White Paper Towards a Healthier Scotland and Our National Health: A plan for action, a plan for change aim to improve the health of children and young people and tackle inequalities in health provision, often through interventions early in life.
• Low income, deprivation and social exclusion are related to poorer mental, physical and emotional health and diet. Smaller rises in household income, unemployment, poorer quality of housing or homelessness and lack of access to private means of transport are all associated with poorer health outcomes.

The health needs of children and young people across Scotland

• In Scotland, many children are born into families from lower socio-economic groups with the characteristics that may impact adversely on their health. Many unhealthy lifestyles are more common in those who are economically deprived or socially excluded.

Health related behaviour and lifestyles

• Despite efforts by professionals and government, the average Scottish diet remains unhealthy, being high in fat, salt and sugar and low in fruit and vegetables. Childhood obesity is on the increase.
• Smoking is another significant component of health inequalities; it is related to deprivation and leads to poor health outcomes. Associations have been found between adolescent smoking (boys and girls) and the number of smoking parents a young person has, perceptions of parental disapproval and where the head of household is unemployed. There is a link between smoking, a poorer diet and lack of physical exercise. Research studies have found increases during the past decade in daily smoking among boys (12.4% to 19.2%) and girls (12% to 24%). This is the highest rate in Europe for smoking among 15 year olds.
• In Scotland, there has been an increase in the number of children and young people under 16 using alcohol and an increase in the frequency of use. In 2000, there were 1,428 emergency admissions of young people aged 10 to 19 with a diagnosis of acute intoxication, the majority of which (1,036) were between 15 and 19.
• Recent surveys of Scotland's young population have showed that the awareness and use of legal and illegal drugs is prevalent across the country; by their mid-teens around 40% of 15 to 16-year-olds will have tried at least one illegal drug.
• Early pregnancy brings health risks for the mothers and, on average, poor outcomes for the resulting children. The lowest proportion of contraception or condom use was found in cases where intercourse was unexpected and/or carried out for the first time with a partner of less than a month's duration. Such unprotected sex carries the greatest health risks.

Mental health and emotional wellbeing

• In Scotland, about 125,000 young people experience mental health problems that interfere with their daily lives.
• A follow-up survey of the mental health of children and adolescents in Great Britain found that almost a fifth (573) of the total sample (2,938) was identified as having a mental disorder. Three years later, 43% of the 573 children and young people were again assessed as having conduct disorders and 25% were assessed as having a clinically-rated emotional disorder.
• One key factor that emerged linked the presence of an emotional disorder in a child with the mother's poor mental health.
• Children and young people with a persistent mental disorder missed more days at school than their peers without a disorder, and young people aged 16 and over with persistent mental health problems were twice as likely to have no qualification as those with no disorder.

Suicide and deliberate self-harm

• In 2001, there were 887 suicides and indeterminate deaths - an increase of 22% since the 1980s - with boys and men aged 11 to 24 as the group at particular risk. Scotland's rate is much higher than for other areas in the UK and one of the highest in Europe.

Oral health

• In Scotland, child oral health remains poor with only 45% of Scottish five year olds free from dental decay in 2000; 15% short of the national target of 60% by 2010.

The health needs of looked after and accommodated children and young people

General health

• Despite the adverse factors in the backgrounds of children who are looked after and accommodated, and the discontinuities of placement and school, the current general health of the majority is good. This applies largely to physical health, and is subject to two important qualifications. Firstly, many of the young people have lifestyles that present major threats to their present or future wellbeing. Secondly, there is a high incidence of mental health problems (including conduct disorders).
• The general health of looked after and accommodated children seems to improve as placements become more secure.

Health related behaviour and lifestyles

• Just under half of looked after and accommodated children in Scotland aged 11 to 17 are smokers, and over a quarter of all children who smoked reported that they had started smoking at the age of ten or under.
• From a sample of 96 looked after and accommodated young people, 50% drank alcohol once a week. Although this sample is small, high levels of alcohol use by young people in the care of local authorities has been found in other studies in Scotland and England.
• There is a significant uptake of drugs by young people with the experience of being looked after compared with other teenagers. Around a third (31%) have first tried drugs while in care, but just over two-thirds had taken drugs before coming into care.
• Looked after and accommodated children in Scotland aged 11 to 17 were twice as likely to smoke, drink or take drugs as their English counterparts.
• A survey of 96 young people in and leaving care in Glasgow found gaps in young peoples' access to information on sexual health generally and safer sex in particular.

Mental health and emotional wellbeing

• A number of studies, including several in Scotland, have identified that the mental health problems for looked after and accommodated children and young people are markedly greater than that of their peers in the community. Reasons include the child's experience in terms of poor parenting, trauma, bereavement or serious illness, including mental health difficulties in one or both parents, and the impact on the child of the environment such as poor neighbourhoods, deprivation, social exclusion and poverty.
• Similar numbers of children placed with parents experience mental health difficulties as those in foster and residential care. However much less is known about the support and services offered to these equally vulnerable children and their families.

Suicide and deliberate self-harm

• The key factors, events or triggers for suicidal thoughts and attempted suicide are often disproportionately present in the lives of children and young people looked after and accommodated. The recent Child Protection review undertaken by the Scottish Executive found that from 50 deaths of looked after children between 1997 and 2001, 11 were completed suicides.

Oral Health

• Oral health was highlighted as a neglected area by respondents to a small survey of 96 young people who were looked after and accommodated; half had not visited a dentist during the last year, 70% of that figure being male.

Factors affecting the health of looked after and accommodated children and young people

• Many looked after children have been born into families from lower socio-economic groups. So before a child is looked after and accommodated, factors within their circumstances, such as dysfunction or discord within the family, can mean that they are at risk of missing routine health surveillance checks and participating in an immunisation programme.
• The process of conducting health checks and assessments for a child in the care of the local authority, through the medical or health assessment, has not always been satisfactory.
• Looked after children experience a greater number of moves than children in the general population. Moving between different homes or units can mean that issues get overlooked. Moves may involve changing health board areas, resulting in appointments being changed, missed, delayed or cancelled. Changes in placement can also result in changes in schools and this, together with higher truancy rates, can mean looked after children miss out on routine medical checks and health promotion initiatives within school.
• The potential loss of the family health history can mean important information about a child's future health may be lost. There is also an absence of accurate up-to-date recording of children's needs in the files of many looked after children.
• The research would suggest that fewer changes in placement and more stable placements is a factor in promoting the health and wellbeing of looked after and accommodated children. More accurate recording of a child's health history and current health and wellbeing would provide a clearer picture of the child's needs and the supports required for the child to develop as well as the needs of their carers.

The health needs of young people leaving or who have recently left care

• Research in several countries has shown how poorly equipped many young people leaving care are to cope with life after care - practically, emotionally and educationally - and has made connections with their subsequent experiences of loneliness, isolation, poor mental health, unemployment, poverty, drift and homelessness.
• From research in England, it is estimated that a quarter of young women leaving care are pregnant or have a child and that the numbers of young women who give birth increases within 18-24 months of leaving care.
• Young people have criticised the timing and poor preparation for leaving care which result in high levels of depressive moods, low self esteem and deliberate self harm.

What do young people think about health issues?

• Evidence suggests that children generally view health as primarily to do with diet, exercise and dental hygiene. Many young people have a different view of the meaning of the terms 'mental health' and 'mental illness' compared to health professionals. Accessing services can be seen as stigmatising.
• A survey of looked after and accommodated young people in Glasgow showed that they identified exactly the same factors contributing to good health as the general youth population: physical fitness, healthy eating and physical attractiveness.
• Young people wished to be listened to during consultations whether for a routine health check or for more specialist intervention, often reporting that they did not feel listened to and that professionals and the organisations were difficult to approach.

Messages for policy and practice

The wider context

• While the health of children in general is often good, the incidence of some health problems, such as asthma and psychiatric difficulties, have increased considerably over the last few decades. A sizeable number of our young population struggles with mental health problems as well as dealing with the stresses related to growing up in a society where the structure of our families and communities is changing.
• Children and young people who are looked after and accommodated tend to express exactly the same concerns about their health as children and young people across Scotland. The difference, however, is the context in which these challenges are faced - discord within their own families, moves of home, changes in school or interrupted school careers, and a lack of access to the support and advice of trusted adults.

The health risks and needs of looked after and accommodated children and young people

• Looked after and accommodated children and young people share many of the health risks and problems of their peers, but often to a greater degree.
• Research on the physical and mental health of children and young people who are looked after and accommodated has shown that in most respects this group is doing less well than their peers and these children have extensive health care needs.
• The health issues or concerns for looked after and accommodated children are usually multifaceted. A concern in one area of a child's life should not be addressed in isolation from its impact on other parts of the child's development. Solutions to health concerns should be provided as a partnership across agencies and with carers.
• Much of the literature about looked after and accommodated children focuses on those in residential or foster care. Little is known about the needs of children looked after at home by their families, or about how families are supported to care for their children.
  A better understanding of how to meet the needs of these families is essential in order not to fail the children and young people.

Variations in health risk

• Certain groups within the looked after and accommodated population have higher health risks than others; males are reportedly more at risk than females. Recent reports have also identified the growing mental health needs of black and minority ethnic communities within Scotland.
• A particularly vulnerable group comprises those young adults preparing to leave care and move to (semi-) independent living while still in their teens. This contrasts with the majority of young people in the community who remain dependent, to varying degrees, upon their families until their mid twenties.

Access to appropriate health care

• It is important to consider how services are delivered. Much evidence exists that many children who are looked after and accommodated do not receive the health assessments and treatments they need from conventional health services.
• Even when needs are identified, it has been argued that there is a gap in the delivery of effective interventions to children and young people with mental health problems.
• Recent initiatives have begun to consider more flexible approaches to delivering health services, especially through the recent, but fast developing, use of specialist looked after children nurses in schools. Innovative approaches to mental health services have developed, such as Open Door, LACES and the Residential Health Care Project, which put the needs and wishes of the young person at the centre, and consider more flexible approaches to service delivery.
• Greater attention should be given to the health and mental health of children before they become looked after and accommodated through activities that support families and provide access to enhanced community-based resources.
• Many looked after and accommodated children return to the birth families once they care. Strategies to support positive change need to be considered well before the child or young person leaves the care of the local authority if change is to be maintained.
• Opportunities exist for professionals to work together with politicians, policymakers, children, young people and their families to improve the health of all children in our society and, in particular, those for whom we have legal responsibilities.