3 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 those resulting from discontinuities of placement and school, the current general health of the majority is good. This applies largely to physical health, however, and is subject to two important qualifications. Firstly, many of the young people have lifestyles that present major threats to their present of future wellbeing. Secondly there is a high incidence of mental health problems (including conduct disorders).
The literature suggests that for around three quarters of young people looked after and accommodated in Scotland, their health is assessed as good or very good by both the young people themselves and those who care for them (Triseliotis et al. 1995; Meltzer et al. 2004). A survey by Meltzer and colleagues (2004) of children looked after in Scotland asked carers and parents to rate the health of the children they care for. Children living with foster carers were more likely to be rated as having very good health (70%) compared to children living in other types of placement, particularly residential care (38%).
An important point made by Meltzer and colleagues (2004) was that the general health of children seemed to improve as placements became more secure. Over two-thirds of children who had been in placement for two years or more were assessed as having very good health, but this reduced to just under half for those who had been in placement for less than two years.
Health-related behaviour and lifestyles
In a recent survey of looked after and accommodated children, information about the use of legal and illegal substances was asked for. Meltzer and colleagues (2004) found that 44% of looked after and accommodated children in Scotland aged 11 to 17 were smokers and over a quarter of all children who smoked reported that they had started smoking at the age of ten or under. This reflects the responses from young people themselves. Scottish Health Feedback (2003) found that from 96 survey responses of looked after and accommodated young people, 75% were smokers and that more females smoked (79%) than males (73%), in line with national trends.
The same survey (Scottish Health Feedback 2003) also identified high levels of under-age and problem drinking among the sample. Fifty per cent of respondents 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 (Triseliotis et al. 1995; Saunders and Broad 1997).
Griesbach and Currie (2001) found a significant uptake of drugs by young people who had experienced care, compared to other teenagers. Among the many reasons given by those in public care was that it helped them to forget 'bad things', to relax or to give them more confidence. Around a third (31%) had first tried drugs while in care, but just over two-thirds had taken drugs before coming into care.
Meltzer and colleagues (2004) found that 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 (Scottish Health Feedback 2003) found gaps in young peoples' access to information on sexual health generally and safer sex in particular. Sexual health programmes are often delivered through schools but, as mentioned above, looked after and accommodated children and young people often miss school more frequently than their peers. Forty percent did not know where the nearest sexual health or contraception service was and a significant number (26%) worried about getting pregnant or getting their girlfriend pregnant. Other studies have also shown gaps in young people's knowledge around the risks of unsafe sex in terms of sexually transmitted disease and pregnancies (Triseliotis et al. 1995).
Corlyon and McGuire (1997) concluded that for many teenagers there is an attitude of 'it won't happen to me'. However, looked after and accommodated children are often having to deal with feelings of loss and rejection and must prepare for independent living at an earlier age, and with fewer supports than their peers. This can contribute to a lack of confidence and self esteem. Young people in the care system aspire to the same things as young people within the community including access to education, training and employment. However, early marriage and parenting are also considered as options to a greater extent than their peers.
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 (McCann, James, Wilson and Dunn 1996; Dimigen et al. 1999; Ward and Skuse 1999; Ridley and McCluskey 2003; Meltzer et al. 2004). 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 (van Beinum, Martin and Bonnett in Scott and Ward (eds)). What is also clear is that a considerable proportion of children suffer mental health problems at the time they enter the care of the local authority (Dimigen et al. 1999).
In the late nineties, some publications reported that looked after children living in residential care in England experienced more difficulties than children placed in foster care (McCann et al. 1996; Dimigen et al. 1999). A more recent survey of 355 children in the looked after system in Scotland found that looked after children, including those looked after at home, experienced higher levels of mental health difficulties than that of their peers (Meltzer et al. 2004). Similar numbers of children living with parents experienced mental health difficulties as those in foster and residential care, at around 40%. However much less is known about the support and services offered to these equally vulnerable children and their families.
From this survey (Meltzer et al. 2004), 45% of those aged between 5 to 17 years of age were assessed as having a mental disorder. Those aged 5 to 10 who were looked after at home or accommodated were six times more likely to have a mental disorder than those children living with families in the community (52% compared with 8%). The rates for the different types of disorder were as follows:
- emotional disorders: 14% compared with 4%
- conduct disorders: 44% compared with 4%
- hyperkinetic disorders: 11% compared with 1%
Some children had more than one type of disorder and these were more likely to be boys.
Those aged 11 to 15 and either looked after at home or looked after and accommodated were four times more likely to have a mental disorder that those children living with families in the community (41% compared with 9%). For different types of disorder the rates were as follows:
- emotional disorders: 14% compared with 5%
- conduct disorders: 35% compared with 6%
- hyperkinetic disorders: 8% compared with 1%
Again, some young people had more than one type of disorder.
Six per cent of children surveyed were reported to be taking one of 14 types of medication commonly used in the treatment of childhood mental disorders and a fifth diagnosed as having hyperkinetic disorders were taking some form of psycho-stimulant such as Ritalin (Meltzer et al. 2004).
In another Scottish study, Minnis and Del Priore (2001) found that looked after and accommodated children were more likely than children not known to social work services and living with their families, to have some form of attachment disorder. In the past, attachment disorders have been less recognised by health professionals. However, if these issues are not addressed, there are increased risks of placements breaking down because of a child's failure to form secure attachments and implications for the child's future health, wellbeing and ability to form relationships in adulthood (Minnis and Del Priore 2001).
Minnis and Del Priore also commented that the children in the above study were predominantly white. Whilst this may reflect low rates of ethnic minority looked after children in Scotland, the impact of mental health difficulties on children and families from ethnic minority communities will be just as great as for other groups in society.
Impact of mental health difficulties
McCarthy and colleagues (2003) found that 40% of a sample of children looked after by one English authority were experiencing significant difficulties in three of four key areas: home life, friendships, learning and leisure activities. The authors comment that ' children and young people with multiple adjustment problems are at high risk of developing a range of very significant psychosocial outcomes in later adolescence and early adulthood (p17). There are also implications for those caring for these children and young people.
Studies have found that carers' perceptions of feeling burdened were related to caring for a child reported to be displaying high levels of behavioural problems, such as conduct disorder. Carers have reported that where problems had been identified the symptoms had been present for over a year (McCarthy, Janeway and Geddes 2003). Carers need to be informed of a child's emotional and behavioural problems and supported to help the child. Otherwise, they may feel the child has been misrepresented to them, which has the potential to contribute to breakdown of the placement (Richardson and Joughlin 2000; Wilson, Sinclair and Gibbs 2000).
Foster carers and residential workers require a range of support services while caring for a looked after child with mental health difficulties. They are likely to benefit from specific training and ongoing support in the management of conduct disorders in order to minimise the consequences.
Suicide and deliberate self-harm
The key factors, events or triggers for suicidal thoughts and attempted suicide mentioned previously in the report are often disproportionately present in the lives of looked after and accommodated children and young people (Wade and Smart 2002). The child protection audit undertaken by the Scottish Executive in 2002 found that from 50 deaths of looked after children between 1997 and 2001, 11 were suicides (Scottish Executive 2002b).
A survey of 96 young people in Glasgow looked after away from home reported that 45% of respondents had harmed or self harmed at some point in their lives and a third had asked for help in relation to this behaviour. Females were most likely to deliberately self-harm, especially younger females aged 14 to 15 years. For those who had deliberately self-harmed, there was a clear link between with depression and low self esteem (Scottish Health Feedback 2003).
Oral health
Oral health was highlighted as a neglected area by respondents to a small survey of young people looked after and accommodated (Scottish Health Feedback 2003), with about half of the 96 respondents not having visited a dentist during the last year, 70% of those being male.