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Listen
7 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. In today's society there are concerns about the lifestyles chosen or followed by some of our children and young people. The average Scottish diet remains unhealthy, with childhood obesity on the increase ( NHS Factfile 2003). Recent surveys of Scotland's young population have showed that the awareness and use of legal and illegal drugs is prevalent across the country (McKeganey and Beaton 2001). A sizeable number of our young population struggles with mental health problems which interfere with their daily lives ( SNAP 2003b) as well as dealing with the stresses related to growing up in a society where the structure of our families and communities is changing. Families are separating more, often resulting in new partnerships or remarriage, which pose challenges for the children concerned (Wade and Smart 2002; Jensen and McKee 2003).
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 (Scottish Health Feedback 2003). 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 can load additional pressures on young and vulnerable shoulders.
Health risks and needs
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. This is because some become accommodated, in part, as a result of health issues, while in other cases reasons prompting removal from home (such as child abuse or family tensions) have health components and consequences. The usual arrangements for health monitoring and care may not function so well, especially when there are frequent changes of home and school.
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. Correspondingly, children and young people with severe health problems are considerably over-represented in the looked after and accommodated population. This applies particularly to poor diet and lack of exercise, excessive drug and alcohol use, mental health problems including attempted or completed suicides, and some aspects of sexual behaviour.
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. The presence of a conduct disorder may have implications for the stability of the child's home life and participation within the school environment. Self esteem and self confidence are crucial factors in shaping how young people perceive their own health and build their confidence in order to seek out and access advice from the more sensitive or potentially stigmatising services such as sexual or mental health. It would seem logical that the solutions to health concerns should not be seen as the sole responsibility of one agency, but 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, about how families are supported to care for their child, and about the extent, nature and impact of services on families, children and young people. This is important in its own right, and also because many such children have often been accommodated previously and some are likely to be so in the future. The survey by Meltzer and colleagues (2004) identified that the prevalence of mental health concerns was similar for children and young people who were looked after at home as for those who were looked after and accommodated. 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 may have greater health risks than others. In nearly all areas discussed in this report, males are reportedly more at risk than females; young males are particularly vulnerable with regard to attempting or completing suicides (Choose Life 2000); more have complex mental health needs (Meltzer et al. 2004); and levels of smoking, drinking and drug use are greater (Triseliotis et al. 1995; Griesbach and Currie 2001; Meltzer et al. 2004). Recent reports have also identified the growing mental health needs of black and minority ethnic communities within Scotland. Whilst numbers may be relatively small, the impact of mental health issues on these families will be just as great as for other communities within our society ( NHS Fact File 2003).
A particularly vulnerable group comprises those young adults preparing to leave care and move to (semi-) independent living while still, for the majority, in their teens. The pressures of growing up, deciding whether to finish or continue education, and finding work are challenges in themselves without also finding a home and living independently. This contrasts with the majority of young people in the community, who stay on in education and remain dependent, to varying degrees, upon their families until their mid twenties (Joseph Rowntree Foundation 2002).
Access to appropriate health care
It is not enough to simply identify the health needs of this population. There is also a need to review how services are provided. 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. The reasons include: frequent moves disrupting communication and records; professionals' low level of awareness of the particular circumstances of looked after children; stigma and fears associated with standardised examinations or visits to clinics; and the reluctance of some children and young people to engage with health professionals. Also, social workers and carers have sometimes not given sufficient priority to health matters.
A recent study undertaken by Blower and colleagues (2004) assessed the needs of looked after and accommodated children and concluded that there is also a gap in the delivery of effective interventions to children whose mental health problems are already identified (Blower et al. 2004).
Blower and colleagues (2004) acknowledge that it is uncertain to what extent the findings from one study can be generalised, but their conclusions partly reflect the writings of others who argue for a more flexible approach to mental health issues by health professionals themselves (Dimigen et al. 1999; Minnis and Del Priore 2001; Buston 2002; McCarthy, Janeway and Geddes 2003) and discuss the provision of training in mental health issues for those working directly with young people including carers (Secker, Armstrong and Hill 1999; van Beinum, Martin, Bonnett 2002).
Recent initiatives have begun to consider other 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 been developed. These put the needs and wishes of the young person at the centre, consider more flexible approaches to service delivery and work in partnership with those caring for looked after children.
Initiatives such as Open Door (Van Beinum, Martin and Bonnett 2002), LACES or the Residential Health Care Project (Grant, Ennis and Stuart 2002) provide a more flexible service to looked after and accommodated children and young people. Although different in approach, both projects operated on an outreach basis, taking the services to the young people, who were not expected to attend clinics or surgeries they considered stigmatising or daunting (Grant, Ennis and Stuart 2002). Both approaches supported and trained those working directly with young people to help them deal with difficult behaviours with greater understanding and more confidence. Those involved also acknowledged the need for professionals to work together in a context of mutual respect.
The Residential Health Care Project also took an open-minded approach with the young people in terms of health promotion and various methods were explored including drama, group work, individual work and work involving specialist agencies. There was a need to tailor the work to a particular group or individuals living in the residential unit at any one time. Grant and colleagues (2002) emphasise the value of positive role modelling which can be used to develop the idea of the health promoting unit where staff and young people pull together to make their lifestyles as healthy and enjoyable as possible.
The evaluation of this project concluded that all agencies need to be proactive in nurturing inter-agency links, to encouraging reflective practice and an approach aimed at the continuous improvement of services. Health services need to provide more opportunities for more meaningful health assessments (Grant 2002). In some areas, specialist looked after nurses are increasingly working within school settings, a development which allows young people to access health care and advice in a more routine and non stigmatising way, rather than having to be taken out of class for formal medicals.
While we have seen that for some children, their health may improve once they are looked after, we also know that many looked after children enter the care system with significant health deficits. It is important then, that children's health needs, including their mental health needs, should be addressed as far as possible before this stage. Future customers can be more positive if attention is given to the health needs of a child still living with the family and if effective supports are in place early in a child's life. Starting Well is one of the national health demonstration projects which aims to show that child health in Glasgow can be improved by a programme of activities which both supports families in the period leading up to birth and throughout the first three years of childhood and provides them with access to enhanced community-based resources. Two key components of this project are intensive home-based support and the provision of a strengthened network of community support services for children and families. The project is being evaluated to assess its impact on health outcomes on children.
Many looked after and accommodated children return to the birth home or to live with relatives, or leave care. Often their mental health difficulties and habits, such as smoking, drinking and drug use, were present or established before entering the care system. In order to change or modify behaviours and habits successfully, these issues need to be considered before the child or young person leaves the care of the local authority to a situation where less or no support is provided.
Final comments
Politicians are increasingly aware of the dangers of ignoring the health needs of our young population and there is a policy agenda beginning to address these issues. There is also a greater understanding of the complexities of the health problems of looked after children and how this impacts on children, those who care for them and their communities. The literature recognises that service delivery, particularly in the areas of mental and sexual health, needs to be re-considered and some practice developments have begun to develop these ideas and approaches. Parallels may be drawn with the educational disadvantage of looked after children, which required concerted efforts at individual, local and national levels to instigate organisational, attitudinal and training changes required to ensure that suitable learning support has been made available (Borland et al. 1998; McLean and Gunion 2003). The drive and opportunities are there 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 to parent to the best of our abilities.
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