Scottish Government

5 Healthy, active children

Children and young people should enjoy the highest attainable standards of physical and mental health, with access to suitable health care and support for safe and healthy lifestyle choices. Children and young people should be active with opportunities and encouragement to participate in play and recreation, including sport. (Vision for children 2005)

I've got healthier and a lot, lot happier. (Toni)

I have done the John Muir Trust award … Walking, walking about the country and all that. It was hard. I used to complain about it because … I hate walking. I eventually started getting used to it and that. I did not think I would have done it anyway. Just trying to prove a point to myself that I could actually do it. Instead of, like, can't be bothered. I wanted to prove to myself that I could actually do it. (Ian)

132. In responding to the Kerr Report, Building a Health Service Fit for the Future Volume 2 (2005h), the Minister for Health and Community Care set out one of his principal aims:

I also expect the changes that we are making will see the health of our population improve. I want everyone to have the same opportunity to experience improvement. Currently there are stark differences in the healthy life expectancy of different communities across Scotland. This is unacceptable (Scottish Executive 2005g: iv).

133. Key themes of the Kerr report (2005h) fit with implementing the vision for children in Scotland today, for example the commitment to collaboration between the NHS and the voluntary sector, tackling inequalities, access and care designed to deliver the best outcomes and new ways of delivering rural health care. Looked after children and young people often experience poor health care and so we commissioned a research review (Scott and Hill 2006) to identify what is known about promoting healthy and active lifestyles for looked after children and young people. Most of the Scottish studies did not include discussion of looked after children living at home, but we consider that many of the ways of helping young people apply to all looked after children and young people.

134. Improving the health of all Scots is a national priority. In 2003 the Scottish Executive published a national action plan, Improving Health in Scotland - the Challenge (2003c). This is designed to help people change unhealthy behaviours and to promote better health outcomes. The Executive has set targets to reduce smoking and drug misuse, improve oral health in young children, reduce teenage pregnancy and tackle self-harm and suicide. The plan looks at ways of encouraging people to eat a healthier diet and take regular exercise, how to reduce smoking and misuse of alcohol and drugs.

Risks to health

135. Children born into low-income families are much more likely to experience social exclusion, lifestyles which put health at risk, and poorer access to health services. Parents who live in more affluent areas are more likely to take up health promotion advice and child health screening. The pre-school child health surveillance programme (2003a) found that, for example, one in ten children from poorer families miss out on routine health checks six to eight weeks following birth. The proportion rises to one in four by age two, and two in five by the time children reach their pre-school year.

136. A survey conducted in Edinburgh found that black minority ethnic children appeared to suffer from common colds, asthma, sleep disorders and bed wetting to a much greater extent than the general population in Scotland. There were causal factors which affected the children's health, the most significant being racial harassment. Most parents who were interviewed claimed that their children's health problems were related to fear, stress, anxiety and depression. The children were reluctant to go out and play in the open (Bibi, Egan and Lee, 1996). A study of children and young people with complex health care needs (Stalker et al. 2005) found that no information on the ethnicity of the children was recorded in Scotland.

137. The Scottish Executive (2005e) has provided guidance Health for All Children (known as Hall 4) on how best to apply the recommended core programme of child health surveillance, and how to identify and target support for vulnerable children and families. The guidance also recognises the importance of encouraging young people to take responsibility for their own health. The recommendations reflect a move away from universal screening towards a more holistic approach, including health promotion, primary and secondary prevention, and targeting resources to need, especially helping vulnerable families and children. It also recognises the importance of integrated services, which make best use of available skills and resources across agency boundaries. Community Health Partnerships ( CHPs) are now responsible for ensuring that there are effective pathways in place for the provision of health care services to vulnerable children.

CHPs should put in place plans to improve access for young people to primary care services. This could include the use of the internet and mobile phone access to health care advice as well as dedicated young people's clinics (Scottish Executive 2005h: 201).

In some areas of Scotland, health and social care services are now combining their activities through CHPs with the intention of ensuring a more integrated and coherent approach to the identification and delivery of community based services to families.

Looked after children and young people

138. The Residential Care Health Project ( RCHP) was set up in 2000 in recognition that the health of looked after children is the responsibility of a number of agencies. Their report Forgotten Children (2004) concluded that:

From past research and from information gathered in the course of the RCHP it is clear that the primary cause of poor health outcomes for this group of young people is not the state of the child's health on the day they enter the care system. It is rather the history of unmet need prior to being accommodated … These are compounded by the lack of our current health care systems to adapt to the needs of a mobile population, by difficulties of tracking children and young people, and of communication between and within agencies. These issues can only be addressed by a coordinated approach to tracking and intervention, in which all areas of health service provision have a role to play (The Residential Care Health Project 2004:73).

139. Children with disabilities, particularly those which are 'hidden' can be further disadvantaged if their condition is either misunderstood or overlooked when they become looked after away from home. Examples might include some genetic disorders, mild forms of autism and disorders which affect comprehension and learning, or conditions which are found in certain racial groups, e.g. sickle cell anaemia. Parents who may not be able to care for their child are still often experts in their child's health and/or disability and they should be encouraged to contribute as much information as possible.

140. A study of children with complex needs by Stalker et al. (2005) looked at children and young people who spend long periods in health care settings such as hospitals and nursing homes. They found that there was no clear picture of the numbers of children who might fall into this category. For children with a learning disability there was little evidence of procedures for consulting them about their care and treatment. The study found that some service managers and providers in health and social services were confused about the legal status of children and young people in healthcare settings for more than three months.

141. The Children (Scotland) Act 1995 requires NHS boards to notify the local authority of any children who have been living in health care accommodation for more than three months if they had no parental contact or were unlikely to do so. The child does not necessarily become looked after but the authority has a duty to determine whether the child's welfare is being adequately safeguarded. Stalker's study concluded that there is a need for a procedure whereby professionals can identify individuals who may be 'lost' in the system (for more information on this study see further reading section at the end of this chapter).

142. Triseliotis et al. (1996) found in a study of looked after teenagers in Scotland that three quarters of children looked after away from home thought their health was 'good' or 'very good', a view backed up by their carers. Aldgate and McIntosh (2006) found similar patterns amongst children in kinship care, where most carers assessed the physical health of the children they looked after as 'very good' to 'excellent'. Long-term conditions such as asthma had improved with better management and a smoke-free environment.

143. Some studies found that children and young people looked after away from home are vulnerable to drug and alcohol misuse and self-harm. In a study of young people leaving care in Glasgow, Ridley (2001) found that 50% of young people drank alcohol once a week. Meltzer et al. (2004) also found that around a third of young people have tried drugs while in care, and just over two thirds had taken drugs previously.

144. A study of young people leaving foster care in Glasgow (Scottish Health Feedback 2003) found that the young people reported feeling depressed, lacking in self-esteem and there were incidents of self-harming behaviour. Research in Scotland in 2004 (Meltzer et al.) found that 39% of young people in residential care had self-harmed compared to 18% of young people living with their birth parents and 14% of young people in foster care. Another study in Glasgow (Scottish Health Feedback 2001) found that a third of 13 to 17 year olds in residential care had self-harmed and that 10% of young people in residential care use self-harm as a coping strategy when distressed, compared to 1% of young people in the general population. A report published in March 2006, Truth Hurts, which followed a two year inquiry run by the Camelot Foundation and the Mental Health Foundation, uncovered a lack of training for health and education professionals about self-harm.

145. Two small studies which looked at the prevalence of psychiatric disorders amongst looked after children (McCann et al. 1996; Dimigen et al. 1999) found that children in foster care were happier, healthier, eating better, exercising more and drinking alcohol less. They were also less likely to misuse drugs than children in residential care. We need to understand this in the context that young people in residential care are more likely to have had disrupted lives, moved care placements more frequently and some have experienced rejection by adoptive and/or foster parents. We draw attention to the importance of appropriate therapeutic resources to help both the young people and the adults who care for them.

146. In 2005 the Minister for Health and Community Care set up the Children and Young People's Health Support Group ( CYPHSG) and strengthened the role of the Scottish Executive Health Department in setting the child health agenda. All NHS boards and local authorities were asked to draw together their existing planning for children and young people into a single Integrated Children's Services Plan. This describes local improvement objectives and delivery strategies across universal and targeted services for children and young people. The Minister also asked the CYPHSG to produce an Action Framework for Children and Young People's Health Services. The action plan will focus on measurable improvements in health outcomes and health care services.

Mental health and well-being

147. Meltzer et al. (2004) found that children of primary school age who were looked after away from home were more than five times more likely to have mental health problems than children who lived at home. Some of the contributors to Celebrating success (Happer et al. 2006) told us about the emotional pain and distress they had suffered as looked after children:

I became anorexic. I coped with my feelings by not eating. It was my way of saying "stuff you" to everybody. I was very thin and really unwell. (Siobhan)

I suffered from insomnia for years - really bad. (Chris)

I actually tried to commit suicide because I'd had enough. (Thomas)

A framework for promotion, prevention and care

148. A comprehensive assessment of the mental health needs of Scotland's children, known as the SNAP (2003) report, suggests that about 10% (around 125,000 young people), are likely to have mental health problems which interfere with important aspects of their lives, or cause problems with their learning or relationships.

149. The SNAP (2003) report recommended that measures to tackle mental health problems and promote good mental health for children and young people should be located in their communities, schools and families. SNAP recommended that mainstream and specialist services review their combined roles and redesign them in local networks, which provide comprehensive promotion, prevention and care. To implement the recommendations in the SNAP report, the Scottish Executive, with help from the national advisory forum for child health and the child health support group has prepared a framework for child and adolescent mental health services (Scottish Executive 2004a). This aims to help local authorities and NHS boards to gauge how well they are performing, and to plan how mental health services will be provided in future.

The National Programme for Mental Health and Well-being will continue its focus on population health. This is about promoting well-being and resilience and tackling stigma and discrimination to reduce the risk of mental illness … Specifically, we will implement the report on Children and Young People's Mental Health: A Framework for Promotion, Prevention and care, and interim targets will be identified to allow us to track progress by 2008 and 2010 (Scottish Executive 2005g: 44).

150. The Scottish Executive has provided funding for the development of training programmes through the voluntary organisation, Young Minds. This training aims to help frontline staff promote the emotional well-being of young people, and provide appropriate responses where young people are experiencing difficulties. The framework states that NHS mental health services should set up specific arrangements to support children looked after away from home, including those in secure care. The SNAP report recommends that young people, including those who are looked after, must be consulted and involved in any redesign of mental health services for them.

Mental Health (Care and Treatment) (Scotland) Act 2003

151.NHS boards have a duty to provide services which meet the particular needs of children and young people being treated for mental health problems in hospital. Local education authorities must provide the child with proper education if she or he is in hospital for any length of time. Health services must take steps to promote contact with parents and help to sustain the child's relationship with their carer or parent. We were told that many front line health professionals had not received any specific pre- or post registration training on mental health issues particularly in relation to young people and self-harming.

What helps good health outcomes for looked after children?

152. The developments set out below are examples of measures which have been put in place. National care standards (2002) set out what each individual child or young person can expect from the service provider in meeting their needs. The standards include eating well, keeping well - life style, and keeping well - medication. They promote healthy activity and a good diet. The Care Commission inspects all residential homes for children against these standards.

153. Pathways planning (Scottish Executive 2004f) for young people leaving care includes a specific focus on arrangements for health. Pathways materials have been designed to capture young people's views about what they need to make sure they stay healthy. One local authority told us it intended to provide all young people leaving care with a health booklet which contained their full medical history.

154. Many looked after young people find it hard to trust and engage with regular health services. Some NHS boards have set up 'one stop shops' and fast track provision, such as sexual health clinics for young people who may be reluctant to attend local hospital clinics for contraceptive and other advice.

One NHS board has for some years funded 'Sorted on Sex' a clinic aimed at young people housed in the centre of town. The clinic is located in a tenement and has an informal drop in atmosphere. It offers sexual health advice from doctors and nurses who staff clinics twice a week. The young people do not need to make appointments and the service is completely confidential.

155. The Scottish Executive Education Department has made a commitment that schools should be health promoting. In 1999, A Route to Health Promotion was published with the intention to help schools improve their approaches to promoting the health of children and young people. In 2003, HMIE issued How good is our school? Two Health Issues; education about drugs and responsible relationships and sexuality. The Health Promoting School emphasises the importance of partnership working in improving the health of children and young people.

Some looked after children in residential schools are also benefiting from the Scottish Executive's Health Promoting Schools initiative.

A residential school has adopted many aspects of the health promoting school model, making sure both the school's physical environment and its ethos promote good physical and mental health. The school has built good relationships with specialist staff, incorporated health and well-being into the curriculum, fostered strong links with young people's families and home communities, and paid attention to ensuring the health and welfare of staff. This last aspect is important because we know that adults provide crucial role models for young people and can play a part in encouraging healthy lifestyles, reinforcing health education in schools. They can promote physical activity, emotional well-being and healthy diets, helping young people to learn how to shop and cook healthy foods from an early age.

156. Joint working between staff who care for young people and health professionals can help give carers the skills and confidence to provide appropriate care and help for vulnerable young people. For example, health professionals can have a greater impact by working jointly with residential staff to tackle the high incidence of smoking amongst young people in children's homes. This role could be extended to better support foster carers to help young people to stop or not to start smoking. Smoking remains a serious risk to the health of many young people. The change in the law on smoking in public places in Scotland will require all homes to review their approach to smoking.

A city council and partners, with funding from the Changing Children's Services Fund, set up an example of joint working. Mental health specialists worked alongside staff in residential care, seeing young people in their own environments and in everyday situations. The specialists were able to provide advice about promoting good mental health and responding appropriately and sensitively to young people's needs. Together, staff, specialists and young people were able to devise strategies that were effective.

157. Every NHS board area in Scotland should now have a lead clinician with responsibility for child protection. In some parts of the country school nurses may be involved with looked after children and elsewhere community paediatricians may have clinics for looked after children or they may be involved through permanency planning processes for adoption and fostering. Lead clinicians for child protection along with community paediatricians have an important role in working together with school nurses and general practitioners to improve the health of children and young people.

Looked after children nurses

158. Looked after children ( LAC) nurses are part of the community nursing workforce. They have been appointed in many areas to oversee looked after children's health.

They:

• provide initial assessment of children's medical and developmental problems
• put children and young people in touch with other health professionals as needed
• give young people and their carers information and advice about all aspects of health and how to keep healthy
• stimulate interest in the health of looked after children.

159. In some areas, LAC nurses can highlight children's health needs at key decision-making meetings, such as looked after children reviews.

There are particularly strong links between local health services and the local authority in one part of Scotland. The nurse appointed as coordinator for the health of looked after and accommodated children routinely attends meetings where important decisions affecting looked after children are made and where resources are allocated. She also advises children and young people individually, especially those in residential care, on their health needs.

In another area a part-time LAC nurse post has been funded by the Changing Children's Services Fund. There have been positive results both in gathering information about young people's medical histories and arranging immunisations and other follow-up treatment.

Working in partnership with young people and their families

160.Our national health - a plan for action, a plan for change noted that:

We need to talk to young people about their health needs in a language that they understand. And when they respond, we must show we are listening - we will encourage the NHS to work with and listen to young people to make sure that local services are shaped in ways that effectively meet their needs. (Scottish Executive 2000:6)

161. Children and young people can be active, informed participants in assessment of their health needs and should be consulted about their care. The best outcomes for children and young people can be achieved when:

• who can give consent to children receiving treatment for health problems and medical examinations is established immediately a child becomes looked after and this is communicated to all who need to know and recorded accurately
• care plans include attention to health based on accurate and up-to-date information and assessment
• care plans are regularly reviewed with appropriate input from health professionals
• plans state clearly any actions needed, with clarity about who will carry out the tasks, by when, and any contingency plans
• local authority staff carefully consider the health needs (including mental health) of a child or young person when planning any change of their placement
• local authority staff make arrangements with health professionals to ensure continuity of health care, which is recorded in the care plan and the child's case record
• young people have accurate information about their medical history and are supported to take responsibility for their health and healthcare
• specialist services are available in a form and in a timescale which meets the needs of vulnerable young people.

Specialist services for young people who have been sexually abused

162. Some children and young people who are looked after have been sexually abused. Foster carers and residential care staff often want advice and guidance on how best to help them to overcome their experiences.

163. Farmer and Pollock (1998) found in a study in England that sexually abused children were more disadvantaged than other looked after children; they were likely to have experienced other forms of abuse and been in care for longer periods. In addition this group of children and young people were more likely to have severe educational problems, to have experienced rejection and disrupted parenting and to have been seen as troublesome and beyond the control of their carers. In addition the girls were more likely to have become pregnant. Once looked after, a number of other differences emerged. For example, they had more moves in their first six months in care and they showed new behaviour problems.

164. When Farmer and Pollock studied the backgrounds of this group they found that fewer than one in five entered care because of abuse, " so this aspect of their history was easily overlooked" (1998:63). Most worrying was their finding that some social workers did not know about past abuse or minimised the facts to secure placements. During their placements in residential or foster care the young people both faced and presented further risks. A third of the sample (13 young people) was sexually abused, had been involved in prostitution or were vulnerable to sexual exploitation. One in five of the girls became pregnant and a similar proportion alleged sexual assault and rape by a resident or staff member in residential care.

165. Although this study was undertaken in 1998 in England, recent reports in Scotland ( SWIA 2005a and SWIA 2005b) suggest that little progress has been made on understanding and providing appropriate care and help for children who have been sexually abused. These reports found that professionals lacked knowledge and skill in working with sexually abused children and with children and young people who acted in a sexually harmful way to others. There is a shortage of specialist resources for all young people who have been sexually abused or show sexually harmful behaviour.

Active children and young people

166. This chapter has identified the importance for all looked after children and young people of being both healthy and active. Active can mean different things for different young people, for toddlers attending playgroup, for older children belonging to a sports club. Special attention and planning may be required to ensure that disabled children have equal opportunities to participate in out of school activities of their choosing.

A community-based health project

The project's aim is to improve the well-being of looked after young people through physical activity by giving them access to leisure facilities. The project provides leisure passes, clothing allowances, transport costs and, where appropriate, one-to-one support, for young people and, where appropriate, a 'buddy'.

The need for the project

A local study found that some children lacked confidence and self-esteem. Research showed that physical activity reduced anxiety, improved mood and boosted self-confidence but young people also found it difficult to use local leisure facilities because of a lack of the right clothing, transport costs, fees and lack of support.

The people

The project has a multi-agency steering group, with a working group, which meets regularly to monitor the project's work. Two development workers are employed to co-ordinate and manage the project, one for looked after young people under 16 and the other for young people over 16 who are leaving care.

The outcomes

An evaluation of the project showed that those who used the service had improved social skills and increased confidence. One particularly vulnerable young person used the project to go swimming. Here he met a friend who took him to rugby training, following which he joined a local rugby team. The support manager at his school commented on a remarkable difference in his behaviour.

Young people's views

Young people were asked for their views when the project was being designed. They also took part in evaluating themselves and the project.

"I like going to the sauna and for a swim, it's my way to relax and I feel a lot better. It's good that someone comes with me."

"It's good to have a pass and tickets for the bus. I used to go less 'cos I hated asking for the bus fares."

What we can do to keep children healthy and active.

i. Recognise that looked after children and young people can have poorer health than the rest of their peers and make sure that their good health is a priority for them and their carers.

ii. Encourage children and young people to take appropriate responsibility for their own health care.

iii. Record details about a child's health and pass this information quickly to their new carers if a child moves frequently from one placement to another, for whatever reason.

iv. Recognise increased risk of self-harming and know where to get help.

v. Be aware of the increased likelihood that some looked after children and young people may develop mental health problems. Seek medical help at an early stage.

vi. Help children and young people who have experienced sexual abuse by giving them opportunities to talk about their experiences. Recognise that for some young people specialist support may be helpful.

vii. Recognise sexually harmful behaviour and provide the specialist support that may help the child or young person to stop and keep others safe.

viii. Coordinate local services to help looked after children and young people get the best possible health care.

ix. Understand the full implications of a child's disability so they can be as healthy and active as possible.

x. Ensure that looked after children get the opportunity to take part in consultations about health delivery.

Key issues:

• monitoring health outcomes for looked after children up to the age of 21 at a strategic level
• making sure that all health professionals have some mental health input into their pre- and post registration training generally and specifically in relation to young people and self-harm
• putting in place more specialist resources for all children and young people who have been abused, including those who have been sexually abused
• encouraging CHPs to better coordinate local health services for looked after children and young people.

Further reading and websites

The child's world: assessing children in need - a reader editor Jan Howarth published by the Department of Health, the NSSPCC and the University of Sheffield (2003) has useful chapters on The Assessment of Children with Complex Needs, and Young People who Sexually Abuse; implications for assessment

Medical Research Council (2000) Teenage Health: the west of Scotland 11 to 16 Study

Stalker et al. (2005) Care and treatment? Supporting children with complex healthcare needs in healthcare settings York, Joseph Rowntree Foundation

Further information on the study from Kirsten Stalker - kos1@stir.ac.uk

Scottish Executive (2002) Choose Life. A National Strategy and Action Plan to Prevent Suicide in Scotland, Edinburgh, Scottish Executive

NHS Scotland (2004) Promoting the Well-being and Meeting the Mental Health Needs of Children and Young People. A Development Framework for Communities, Agencies and Specialists Involved in Supporting Children, Young People and their Families,NHS Education for Scotland

Residential Care Health Project (2004) Forgotten Children,NHS Lothian

Scottish Executive (2000) Walk the Talk. A guide for practitioners and managers, Edinburgh, Scottish Executive

Self-harm - National Self-harm Network - national charity aims to provide support for people who self-harm and people affected including families and professionals www.nshn.co.uk

Young People and self-harm - web resource for children and young people who self-harm maintained by the National Children's Bureau www.selfharm.org.uk

SCIE research briefing 17: Therapies and approaches for helping children and adolescents who deliberately self-harm www.scie.org.uk/publications/briefings/briefing17/index.asp

Information and web links on suicide prevention www.hebs.com/suicideprevention