Overall Outcomes: Linking Starting Points, Outcomes and Support

Previous chapters have explored distinct areas of young people’s lives – housing and life skills, education and employment, social networks, health and well-being – in order to assess how the young people were faring in these respects once they had left care and to identify those factors associated with them doing well or not so well. In this chapter we will take a broader view in an effort to identify factors in young people’s past and current circumstances and experiences that predict or correlate with three measures of final outcome. These measures provide an assessment of a) young people’s general mental health, b) their sense of well-being and c) their progress in relation to housing and work.

Final outcomes measure the change in a person’s welfare and quality of life over time. They are often utilised to assess the component of that change that may be attributed to receipt of a particular service, taking account of wider environmental factors that may be influential and sometimes relative to a comparison group not in receipt of such services. Our approach, however, is more exploratory. In this study, for example, there was no control or comparison group against which to assess service effectiveness nor were there distinct service types between which young people could be allocated. Indeed, the introduction of the CLCA was precisely intended to bring about a convergence in services for care leavers across local authorities through its statutory requirements for needs assessment, pathway planning and the role of personal advisers (Department of Health, 1999a).

Our approach, based on the analysis undertaken in previous chapters, will be to explore the statistical data collected from our sample to consider a number of important questions in relation to these measures of final outcome:

• To identify which groups of young people are more or less likely to attain positive outcomes

• What factors associate with positive or negative changes in their welfare and well-being over the course of the follow-up period

• To consider in what ways, if any, variations in professional support mediate these outcomes.

The final outcome measures

Three measures of final outcome were selected. The first two were standardised measures designed to enable young people to make a broad self-assessment of their mental health and well-being. They were employed as indicators of general quality of life. The third was an ‘in house’ measure, drawing on combined information from young people and their workers, designed to assess how young people were faring in relation to ‘work’ (participation in education, training or employment) and housing. This measure combined the separate ‘career’ and ‘housing’ outcome variables introduced in earlier chapters.

The General Health Questionnaire (GHQ-12) is a standardised instrument that is used to screen for psychiatric distress in community settings. It is designed primarily to detect breaks in normal functioning rather than long-term traits or difficulties and has a focus on detecting symptoms of anxiety and depression (Goldberg and Williams, 1988). The instrument, which includes 12 questions, was replicated with young people at baseline and follow-up to provide an indication of mental health. Higher scores equate to higher levels of anxiety and depression.

Cantril’s ladder forms part of the Lancashire Quality of Life Profile and provides a measure of psychosocial functioning aimed at capturing a person’s current sense of well-being (Huxley et al., 1996). This is a self-completion measure that was incorporated into the young person interviews at baseline and follow-up. It requires young people to place themselves on a ladder where the top rung signifies that ‘things couldn’t be better’ and the bottom rung that ‘things couldn’t be worse’. The score provides a measure of quality of life. The higher the score the better the young person’s sense of well-being is likely to be.

An in house measure (‘workhome’) was also employed. One strength of the GHQ-12 and Cantril’s ladder lies in the fact that they tap into young people’s feelings about their life as a whole. As such, these assessments can be quite independent of the objectives that Government has for these young people and can more readily take account of other priorities that young people may have for their own lives. However, there is also a rationale for providing a more policy related measure of outcome

based on what it is reasonable to expect, as a minimum, for young people on leaving care.

The Quality Protects Initiative prioritised the promotion of social inclusion through housing, economic participation and reduced social isolation for young people leaving care. It set clear objectives for local authorities to maximise the numbers of young people at age 19 who are in suitable accommodation, who are participating in education, training or work and who are still in touch with social services (Department of Health,1999b; Robbins, 2001; Wade, 2003). It would certainly be difficult to argue that a young person was doing particularly well – or that a local authority was acting adequately as a good parent – if they lacked a suitable place to live, sufficient support to help them maintain their home, or if they had been abandoned to long term unemployment.

This context provided one rationale for the ‘workhome’ measure. As noted in previous chapters, the measure does not simply consider where young people were living or what they were doing at baseline and follow-up. The career outcome took into account attendance and progress and the housing outcome was based on its suitability and the young person’s ability to manage their home. The correlation between work and housing at follow-up provided further reassurance that it made sense to combine these into an overall measure (p<0.001; τ .418); that positive progress in one area was associated with progress in the other.1

Method

Linear regression was used to identify factors that were associated with the three final outcome measures after allowing for other possible influences on outcome. In the interests of parsimony, a restricted number of variables were included in each regression analysis. These variables were identified in advance and their selection was informed by prior research findings about factors that may influence outcomes on leaving care and by the emerging findings from this study. A number of support measures were also included – such as preparation support, transition planning, contact intensity with support workers and past carers – to see in what way, if at all, differences in types and levels of support were associated with positive or negative changes in young people’s lives.

1

The housing and careers outcome measures were each rated as ‘good’, ‘fair’ or ‘poor’. The combined variable created a five value ordinal variable for use in multivariate analysis.

In order to ensure thoroughness, the analysis was conducted in two different ways. First, analysis was undertaken for each final outcome using change scores. This provided a sharp focus on factors that correlated with improvement or deterioration over the course of the follow-up period. Second, the analysis was repeated using just the final scores for the three outcome measures at follow-up.2 This approach focused on factors in young people’s past and current experiences that predicted or were associated with final outcome. No significant differences were apparent in the statistical results from these approaches and for simplicity the findings presented below will relate to the second approach, final scores at follow-up.

The analysis was initially undertaken using groups of relevant independent variables to see which were significantly associated with change scores or final outcome.3 A process of backward elimination was undertaken in which the least significant factor was removed until a core number of significant variables remained. Factors that proved to be significant in each group were then included together in a further regression to develop a final model that best predicted the final outcome. This process was repeated for each of the three final outcomes. The findings for the GHQ-12 (mental health), Cantril’s ladder (well-being) and workhome will be presented separately.

Correlations between the final outcomes

Although young people’s feelings about anxiety and depression and about their general sense of well-being may well overlap, the workhome outcome was conceptually distinct. Despite this, they were nevertheless quite closely associated at follow-up. Not surprisingly, the GHQ-12 score was negatively correlated with the well-being score (p<0.001; τ -.377). However, the workhome score was also correlated in an expected direction with both the GHQ-12 score (p=0.001; τ -.281) and the well-being score (p=0.02; τ .179). While the association with well-being was

Further information on this variable – and the checks conducted on it – is provided in Appendix C.

2

Change scores do as they imply. They measure the change that has taken place for each young person, positive or negative, between baseline and follow up. Change scores were calculated for each of the final outcomes. In order to take account of the tendency for regression to the mean, all analyses using change scores and final scores controlled for the young person’s initial scores at baseline.

3

This approach ensured that fewer than 10 variables were included in any regression analysis; an important consideration when analysing relatively small samples. These groups included personal characteristics, aspects of care career, baseline measures (starting points), follow up measures (intermediate outcomes) and measures of professional and informal support. See Appendix C for a complete list of key variables.

weaker, this did suggest that we were, at least in an approximate way, tapping into some broad dimension of ‘doing well’ or ‘not so well’.

However, these also represent important findings in themselves. In Chapter 3, we introduced the idea of a virtuous circle. Where young people were managing well in accommodation that was suitable to their needs and where they were positively engaged in education, training or work at follow-up, there was some evidence that they were also more likely to feel positively about their mental health and well-being. While this is the case to some extent, further analysis pointed to greater complexity. Analysis separating ‘career’ and ‘housing’ outcomes at follow-up showed a moderate correlation between a positive housing outcome and a positive appreciation by young people of their mental health and well-being, and that this was stronger in relation to mental health. In contrast, how they were faring in relation to education and employment ceased to have significance.4

Housing is therefore a critical area for leaving care services. The association that exists between purposeful engagement with education/employment and a positive sense of mental health is therefore likely to be mediated through housing.5 This may reflect a greater ambivalence amongst young people about the type of education or work they were undertaking and the value of this to their lives. As we saw in Chapter 4, young people were often engaged in low level courses or in routine forms of work that may not be expected, in themselves, to contribute greatly to their sense of well- being. However, in tandem with a suitable and reasonably well-managed home, economic participation may contribute to an improvement in young people’s sense of mental well-being.

Leaving care schemes emerged partly in response to the need for improved housing options for care leavers. The development of an appropriate range of supported accommodation options and improved access to independent tenancies with flexible support arrangements has been a major commitment of these schemes, although the supply and quality of accommodation is an enduring concern (Broad, 1998; Broad, 2003). Schemes have also been shown to do quite well in this regard (Biehal et al.,

4

Partial correlations were significant at the following levels. GHQ x housing (controlling for careers) p=0.002; beta= -.323; GHQ x careers (controlling for housing) p=0.503. Cantril’s ladder x housing (controlling for careers) p=0.06; beta= .199; Ladder x careers (controlling for housing) p=0.43.

1995). Our findings demonstrate that this strategy is correct. Providing young people with a secure home base, appropriate to their needs at the time, and sufficient support to help them manage their homes adequately should be a top priority. Although, in itself, it is not a sufficient response to all young people’s needs, it is one from which other benefits are likely to flow. This should be a priority for all local authorities with social services responsibilities, whether or not they have previously invested in specialist leaving care schemes.

The findings presented in Chapter 3 are also optimistic in other respects. How young people fared in relation to housing at follow-up was not greatly affected by events prior to or at the point of leaving care. There was no association between housing outcome at follow-up and differences in young people’s care careers or in relation to their starting points at baseline, except in relation to life skills. Those with poorer skills tended to have a poorer outcome. This is important since it suggests that leaving care services can (and should) make a material difference to young people’s early housing careers. Even periods of homelessness soon after leaving care did not prove fatal, provided remedial help was available to get young people back on to the housing ladder and keep them there. Staying with young people who face initial difficulties can therefore reap rewards. However, more extended periods of instability need to be avoided and particular care needs to be given to the housing and support needs of young disabled people and young people with mental health or emotional and behavioural difficulties, as these were high-risk groups for poor housing outcomes.

Mental health

The GHQ-12 was used to tap into young people’s sense of mental well-being at baseline and follow-up and to trace changes in their perception over the follow-up period. Multivariate analysis pointed to a number of relatively clear findings. However, it is important to remember that factors that do not correlate may be as important as those that do with respect to the messages they generate for policy and practice. We will consider first the findings for each grouping before looking at those factors that proved to be most significantly related to mental well-being in the final model.

5

The career outcome at follow up correlated positively with housing outcome (p<0.001) and with mental health (GHQ p<0.001) but to a much lesser extent with well-being (Cantril’s ladder p=0.08).

The personal characteristics of young people, such as gender and ethnic origin, were not associated with differences in mental health. Nor was there a significant association for young disabled people when compared to young people without a sensory, physical or learning impairment. However, where young people were considered by leaving care workers at baseline to have mental health or emotional and behavioural difficulties, there was a significant negative correlation with GHQ-12 scores at follow-up. The existence of a problem at baseline was predictive of a negative change in young people’s feelings of anxiety and depression during the follow-up period and of a higher GHQ-12 score at follow-up (p<0.01; beta= .297).6

Mental health at follow-up was not greatly influenced by key aspects of young people’s care careers. There was no association with placement movement, length of time continuously looked after nor with age at leaving. However, where young people scored highly for a range of troubles while they were accommodated, this was associated with a higher GHQ-12 score (p=0.02; beta= .236).7

A similar story was apparent for our other baseline indicators.8 The only factor at this stage that predicted a difference in GHQ-12 scores at follow-up was the GHQ-12 score at baseline (p<0.001; beta= .426). However, differences in mental health at follow-up were more closely associated with other aspects of young people’s lives at that time. In other words, how young people felt related more strongly to current rather than past events. Where young people were living in suitable housing at follow-up and were able to cope they were more likely to have a positive sense of mental well-being (p<0.01; beta= -.242). Equally, where they were experiencing troubles (offending or substance misuse) they were less likely to feel positive (p<0.01; beta= .242).

Recent research has tended to find an association between higher levels of contact with professionals and young people experiencing poorer outcomes. In other words,

6

As noted in Chapter 2, this includes a broad definition of mental health issues as defined by workers and covers more than two fifths of the sample (44%). Confidence that it is, however inexactly, tapping into some meaningful aspects of mental health is strengthened by the fact that while these young people were more likely to have a higher GHQ score at baseline, they were not significantly so (p=0.11). This in turn suggests that workers’ judgements were not simply reflecting difficulties at that stage.

7

The care trouble score was a composite variable giving an overall score for a range of potential difficulties – offending, substance misuse, truancy, exclusion, being bullied at school and running away (range 0-9; the higher the score the more acute the difficulties).

8

social workers tend to work more intensively with those in greatest difficulty (for example, Sinclair et al., 2003). This was the case in relation to mental health. None of our measures of support correlated with a positive change in mental well-being and the only significant finding was that more intense contact with a leaving care

worker predicted a worse GHQ-12 score at follow-up (p=0.02; beta= .213).9

Although not always significant, this relationship was apparent for all three final outcomes.

In overall terms, variations in the GHQ-12 score at follow-up appeared to be explained more by the circumstances of young people at that time than they were by past events in their lives, although not exclusively so. The final model identified three independent factors from the above that contributed most to mental health:10

• a higher GHQ-12 score at baseline predicted a higher score at follow-up (p<0.001; beta= .342)

• a positive housing outcome at follow-up correlated with a lower GHQ-12 score (p<0.01; beta= -.252)

• and the existence of troubles at follow-up correlated with a higher GHQ-12 score (p<0.01; beta= .252).

Mental health issues

There is clear evidence that where young people were experiencing symptoms of anxiety and depression at baseline they were predisposed to have similar feelings at follow-up. In itself, this should not be surprising. However, it is difficult for us to explain with any precision. The ‘origins’ of mental health difficulties may have a