4 Factors affecting the health of looked after and accommodated children and young people
For a significant number of looked after and accommodated children, the factors which wider research has shown to be associated with poorer health outcomes are present within the child's original family and environment. Many were born into families from lower socio-economic groups (Bebbington and Miles 1989), exposed to discord likely to heighten the child's stress (Triseliotis et al. 1993) and a significant proportion have become looked after as a result of physical injury, neglect or sexual abuse (Minnis and Del Priore 2001). Thus children who are looked after and accommodated tend to have backgrounds and previous experiences which heighten the risk of poorer than average current and future health and wellbeing.
The factors within a child's family circumstances may mean that they are at considerable risk of missing out on routine health surveillance such as immunisations or regular health care (Ward et al. 2002). Immunisation programmes can offer prevention from diseases which are likely to have long term consequences for children whose health, as Ward and colleagues (2002) point out, is already weakened by a poor diet or adverse living conditions. It is also indicative of the fact that some children entering the looked after system will require compensatory health care, but as Polnay (2000) comments ' The potential for the care service to compensate for previous deficits rather than simply to provide accommodation until children reach adulthood is not always explicitly understood' (p661).
Once in the care of a local authority, the process of conducting health checks and assessments required through routine medical examinations has not always been satisfactory. In England, there has been no standard format for the content of medical reports, which were often poorly recorded. Furthermore, children and young people did not view the annual medical in a favourable light and refused to be taken out of school to attend their medical assessment undertaken by a practitioner barely known to them (Butler and Payne 1997). In Scotland, the approach taken was different, in light of this experience. The Arrangement to Look After Children (Scotland) Regulations 1996 did require local authorities to arrange medical examinations and written health assessment for all children before a child is placed, or as soon as possible thereafter, but there was no expectation to arrange an annual health assessment. Although this may help avoid an experience that some young people find stigmatising or pointless, it could also mean that both routine checks and the need for compensatory health care are overlooked. A study of nine health districts across England, Scotland and Wales showed that 33% of children in public care did not receive the meningococcal C vaccine compared with 15% of children who were living at home and not known to social work services (Hill, Mather and Goddard 2003).
The number of moves experienced by children looked after away from home impacts on the continuity of their development across all areas of their lives including health (Chambers et al. 2003; Ward et al. 2002). National figures from England show that 16% of looked after children experience three or more placements in any year (Ward et al. 2002). Statistics published by he Scottish Executive showed that in the year ending 31 March 2004, 30% of looked after and accommodated children in Scotland had three or more placements (Scottish Executive looked after children statistics, 2004a). Moving between different homes or units can result in issues being overlooked. Moving, which involves changing health authority, can result in appointments being changed, missed or subject to delay. Not only is information about current health issues lost, but just as important is the potential loss of the family health history (Butler and Payne 1997; Hill 2001).
Hill (2001) identified a number of reasons why an accurate record of the child's family health history is important to a child:
- genetic transmission: inherited conditions may remain unnoticed or not be picked up by carers. A common example given was the sickle cell trait where failure to screen could place the child at risk under anaesthesia. Genetic conditions which do not manifest in childhood or in the carrier may not be important during the years of childhood, but knowledge of these conditions may influence important decisions in adult life
- promoting health through prevention: Hill (2001) cites the example of parental history which highlighted that the birth father suffered from coeliac disease. The carers were then advised to delay introduction of gluten to the infant's diet
- infection risk: this includes the transmission of blood-borne diseases such as HIV and hepatitis. Testing needs to be undertaken to ensure the child is not at risk
- prognosis: emotional and behavioural difficulties in children and the child's learning abilities impact on the ability of the child to maximise educational opportunities. Knowledge of the family history may shed some light on the cause of established or emerging problems
Gathering accurate family history is not necessarily an easy task. Some parents may be deceased, untraceable or refuse consent, but it is key that professionals working with children understand the importance of this information in a child's current and later life.
A number of studies have also identified the absence of accurate up-to-date recording of children's health needs (Butler and Payne 1997; Ward and Skuse 1999; Cleaver and Walker 2002). It seems that social workers do not regard this activity as part of their daily routine and, if they do, regard it as a lower priority than other pressing matters of family conflict or finding the child a home. With a less stable workforce struggling with vacancies and high turnover of staff, it is essential to have an accurate record of the child's life when all else around may be changing.
Changes in placement can also result in changes in school and this, together with higher truancy rates, can mean looked after and accommodated children miss out on routine medical checks and health promotion initiatives within the school. This can include informed discussion on healthy lifestyles, contraception, sexually transmitted diseases, sexual choices and risk-taking behaviours such as misuse of drugs, tobacco and alcohol (Ward et al. 2002). When children and young people entered the care system in England they were ten times more likely than their peers to become excluded from school (Polnay and Ward 2000).
The research would suggest that fewer changes in placement and more stable placements are factors in promoting the health and wellbeing of looked after and accommodated children and young people. More attention to and accurate recording of a child's health history, current health and wellbeing would provide a fuller picture of the child's needs, the strategies required to promote the child's development and the supports needed by those who care for them.