Some young people who have been looked after will have needs over and above those of other looked after young people. These needs, whether a physical, sensory or learning disability, physical or mental health difficulties, or problems with drugs or alcohol should be identified and addressed as part of the young person’s care plan whilst looked after and during pathway planning.
Until fairly recently the needs of young people in and leaving care who have health problems and/or disabilities1 have been somewhat neglected in policy, practice and research. In terms of practice, evidence suggests that there have been inconsistencies in the maintenance of health care records and in the provision of general and specialist health care for looked after children (Berridge & Brodie, 1998). A report from the Social Services Inspectorate found poor recording of young people’s health issues, inadequate information on healthy lifestyles for staff and young people, limited evidence of joint strategies for health promotion and insufficient promotion of leisure activities (Department of Health, 1997).
For young disabled care leavers, a recent study reported a lack of planning, abrupt or delayed transitions and inadequate information for and consultation with this group of young people (Rabiee
et al., 2001).
Whilst research into physical health issues is limited, there have been a number of studies, which have addressed mental health difficulties amongst young people with a care background. These studies suggest that young people who have been looked after are more likely to have learning disabilities, emotional and behavioural difficulties and mental health problems than their non-care peers. Indeed, as
1
Koprowska and Stein (2000) point out, some of these issues may well have been brought about by the experiences and conditions that led to the young person entering care in the first place. McCann et al (1996) found that over half (57%) of young people in foster care and 96% of young people in residential care had some form of psychiatric disorder. Similarly, Saunders and Broad (1997) found that 48% of young care leavers in their study had a long term mental illness. Analysis of data from the National Child Development Study which compared the mental health of care leavers to other adults showed a higher incidence of emotional and behavioural problems, psychiatric disorders and a higher risk of depression amongst the care leaver group (Cheung and Buchanan, 1997). Also, recent research into the mental health of looked after children showed that 45% of five to 17 year olds were assessed as having a mental disorder (Meltzer, 2003).
The tendency amongst care leavers towards early parenthood would suggest that there is also a need for information and advice around sexual health. Previous studies have shown that between 20 and 50% of 16 to 19 year old women with a care background were young parents compared to 5% in the same age population generally. Furthermore, half of young parents in one study of care leavers reported an unplanned pregnancy (Garnett, 1992; Biehal et al., 1992; Biehal et al., 1995). As discussed in Chapter 5, a quarter of young people in the current study were pregnant or young parents within a year of leaving care. Almost two-fifths (39%) of these young parents felt that they had not had any support or information about relationships, although most (85%) felt that they had received enough information on safe sex.
In relation to young disabled people, research suggests that they have a greater likelihood of being in care than other young people. The re-analysis of the OPCS disability survey (Gordon et al., 2000) indicated that 6% of all children with disabilities in England & Wales were in care compared with 0.5% of the under eighteen population as a whole. Furthermore, a recent study of disabled care leavers reported that around one quarter of care leavers ‘may be disabled in some way’ (Rabiee et al., 2001).
It is likely that young people with health needs and those with disabilities may face increased disadvantage as they embark upon independent living. For example, previous research has reported a higher incidence of mental disorders amongst those who experience poverty, unemployment, social isolation and poor housing
(Buchanan, 1999; Meltzer et al., 2002). In terms of disability, research suggests that young people with physical or learning impairments are over represented amongst those not participating in education and training and that economic activity is significantly lower amongst disabled people(Tomlinson, 1996). Furthermore, recent research into disabled care leavers found that these young people were often denied suitable housing options because of the lack of appropriate support packages to facilitate independent living (Rabiee et al., 2001).
Health needs over the follow-up
Information on the health needs of young people in the study was collected from young people and their leaving care workers at baseline and follow-up. Although some small differences in opinion occurred, generally there was consensus between the two views.
Disability and general and mental health problems within the study sample were reported earlier in Chapter 2. This suggested that just under a fifth were considered to have a physical, sensory or learning impairment by their leaving care worker. In terms of health, most young people in the study had no problems; in fact almost three in five (59%) were rated highly on a scale of overall health.
There was, however, some evidence of an increase in health problems for young people over the follow-up period. At baseline just under two-fifths (38%) of young people in the study reported having a physical or mental health problem or a disability which affected their daily life, whilst three fifths (61%) reported problems at follow-up. Most notably, more young people reported mental health problems (24% at follow-up compared to 12% at baseline). This was largely reported in terms of stress and depression, although at least four young people had made suicide attempts over the previous nine months. There was also increased reporting of ‘other health’ problems (44% at follow-up compared to 28% at baseline). These included asthma, weight loss, allergies, flu, joint pains and illnesses related to drug or alcohol misuse. Also, more young women had become or were currently pregnant and reported problems, such as morning sickness and miscarriage.
The apparent increase in mental health issues was reflected by the GHQ-12 measure of mental well-being. As discussed in Chapter 1, the GHQ-12 screens for short-term changes in mental health problems such as depression, anxiety, social
dysfunction and somatic symptoms. Whilst it cannot make a clinical diagnosis of long term mental illness it can identify the appearance of disturbing problems, such as psychological distress or poor mental well-being, which may interfere with normal functioning. Young people in the study completed the measure at baseline and again at follow-up. Analysis of the difference in scores over time showed an increase in symptoms for 41% of the sample, indicating deteriorating mental well-being over the follow-up period. Almost a third (30%) of young people remained constant (either good or poor throughout) and a similar proportion (29%) showed lesser symptoms, suggesting an improvement in mental well-being. Previous studies have indicated a threshold score of four for measuring poor mental well-being (e.g. anxiety and depression) on the GHQ-12. Using this threshold score, we found that around a quarter of the young people in our sample were considered to have more serious mental health issues (22% at baseline and 25% at follow-up)2.
It would be difficult to be conclusive as to why health related difficulties amongst the sample had increased over the follow-up. Certainly, the type of problems reported (stress, depression, weight loss, flu, asthma) could be linked to the process of transition from care to independent living and changes in lifestyle or subsequent life events. Indeed, we have seen in previous chapters that a high proportion of young people in the sample had experienced housing mobility, homelessness or unemployment and many were living on limited financial resources over the follow- up, all of which could have an impact on one’s general health.
As the following case study shows, the reality and difficulties of post care living can also trigger past emotional issues:
2
This matches what would be expected in the general adult population (24%) as measured by the GHQ-12 (Goldberg et al, 1997). Unfortunately we were unable to identify any studies which had used the GHQ-12 on a similar age range to that of our sample, which prevented a more appropriate comparison.
Sue entered care at 15 years old and had lived in the same foster placement until she left care to move into a housing association flat at 17. She had achieved a good education with five A-C grade GCSEs but had been unable to find work. Sue had no contact with her birth family because of past trauma, although she reported a good relationship with her boyfriend and his family. Both Sue and her leaving care worker considered her housing to be unsuitable. It was in poor repair with faulty central heating and in an unsafe area.
At baseline, there was no indication of any physical or mental health problems or difficulties with substance misuse. Sue’s only contact with health professionals in the three months prior to baseline was to register with a GP when she moved into her new flat and her overall health was rated highly by her leaving care worker.
At follow-up, however, Sue’s health had deteriorated. She had been on anti-depressants for the past four months and was having regular contact with her GP. She had also been referred to a counsellor and was awaiting an appointment. Sue felt that her poor housing situation, being unemployed and having a limited support network had allowed her to dwell on childhood experiences and the cumulative effect had impacted on her mental health. ‘I was
just a bit lonely and down at the time and since I’ve had this flat I’ve had a lot of time on my own thinking more about not being with my birth family or seeing my little brother and missing things. I suppose it was getting me down a bit’.
Having applied to move to a new flat and take on some voluntary work Sue was feeling optimistic about overcoming her depression ‘things are busy at the moment so I’m not
thinking about it [depression] too much, what with trying to get moved, I’ve got that on my mind’. Her leaving care worker noted at follow-up that ‘Sue has had health problems…. this does limit her as to what she can and can’t do but she’s working on that’. He was supporting
her with emotional issues and was trying to develop her self-esteem and social networks by encouraging her to attend social events and find work.
Health and outcomes
As this young person’s experience suggests, the interplay between health and life outcomes is not straightforward. It may be that a young person’s predisposition to health difficulties can affect their ability to cope with the transition from care to independent living. Conversely, trying to cope with adverse experiences after care, such as poor housing or isolation, can affect a young person’s health and in turn damage their coping strategies.
Evidence from the current study points towards some links between mental health or emotional and behavioural difficulties and poorer outcomes in other life areas for young people leaving care. At follow-up young people with mental health or
emotional and behavioural difficulties were less likely to fare well in relation to housing (p<0.001, n=101) and education and employment (p<0.001, n=101) than were other young people. We also found that young people with a learning disability were more likely to have a poorer housing outcome than other young people
(p=0.007, n=101).
In terms of general well-being, analysis showed a moderate but significant correlation between mental well-being (as measured by the GHQ-12) and general well-being (as measured by Cantril’s ladder) which indicated that those with poor mental health were less positive about their life in general (p<0. 001, τ -.377, n=101).
Support with health
The health needs of looked after children and young people leaving care has increased in profile over recent years. The Department of Health guidance,
Promoting the Health of Looked After Children, sets out a new legislative framework
for local authorities and health bodies in safeguarding and promoting health issues for this group and the QP initiative identifies, as one of its targets for improvements, the number of looked after children receiving dental check-ups and health assessments. Guidance to the CLCA also raises the importance of assessing and monitoring health and promoting healthy lifestyles. It states that such issues should form part of the pathway plan for young people who have ceased to be looked after. However, these aims rely on improvements in identification of need and access to relevant services whilst in care and continued support and access to services after care.
There was some evidence that the focus on health awareness was beginning to be reflected in practice. Leaving care workers reported that health issues had been covered as part of preparation for leaving care for the majority of young people in the study (84%). They also reported that two thirds of young people had received some assessment of health needs as part of their leaving care review and planning process. In addition, workers reported that most young people had been assessed in a range of health promotion areas as part of the preparation process3 (e.g. personal hygiene (71%), diet (74%), sexual health (69%) and relationships and leisure activities (72%)). As discussed in Chapters 2 and 3, over half of the young people in the sample felt that they had received enough information and support in these areas
3
In 15% of cases, the leaving care worker was unaware of whether health or health promotion had been addressed as part of the preparation or leaving care planning process.
and when asked to rate their coping at follow–up most felt they were coping quite well or very well with healthy eating (76%), keeping fit (81%), hobbies and leisure activities (66%) and looking after their physical and sexual health (94%). In many cases leaving care workers took on the responsibility for health promotion, although in two authorities the teams had access to a looked after children’s (LAC) nurse and one had a dedicated health worker, to provide advice and support to care leavers on specific or general health matters. In overall terms however, specific initiatives in these local authorities to promote health, including collaboration with health professionals, were less common than in other development areas, such as housing and education.
Support after care for young people with health difficulties was also evident. This was particularly so for young people with mental health problems and those with emotional and behavioural difficulties. Analysis showed that on average these young people tended to have received more intensive and more holistic support. For example, those young people identified as having emotional and behavioural or mental health difficulties had more contact with their leaving care worker (p=0.023), social work staff (p=0.002) and other professionals (p=0.002) than other young people. They were also more likely to have had support in a wider range of life areas (p=0.026). This confirms findings from earlier chapters that more troubled young people tend to attract more intensive support. However, support did not necessarily come from health specialists and in fact only 13% of those who had mental health issues had been in contact with specialist mental health workers over the follow-up4.
In terms of specific health difficulties, almost three quarters (73%) of those young people who reported problems with their health at follow-up felt that they had received some support with health issues. Young people identified help from health professionals such as their GP, hospital staff, community psychiatric nurses, health visitors and counsellors. A small number of young people were receiving on going support with health problems as part of a supported accommodation package. More generally, support was provided by leaving care workers and ranged from referrals to relevant health professionals and co-ordinating specialist support, to encouragement for young people to attend appointments and check ups. In Ryan’s case, his leaving
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This may well reflect wider difficulties in accessing such services. It also highlights the importance of young people registering and maintaining contact with GPs, as they often
care worker and accommodation worker provided the majority of support with health problems:
Ryan was living in a supported hostel at follow-up. He had a mild learning disability and some general health problems which had required medical attention, including an operation, over the follow-up period. Some of his health problems had been exacerbated by heavy drinking, and Ryan had been encouraged by his ex-foster carers and leaving care worker to seek medical help.
Because Ryan was reluctant to engage with health services, his leaving care worker and accommodation worker took turns to take him to appointments and check-ups and his accommodation worker accompanied him for his operation. Both made sure that health issues were kept on the agenda and tried to address his substance misuse problems.
During the follow-up Ryan took an overdose and was taken to hospital by his accommodation worker. He subsequently refused to attend counselling to address problems with substance misuse and emotional difficulties resulting from childhood experiences. His leaving care worker continues to offer support with these issues, but feels limited in the extent to which he can help, ‘myself and the accommodation worker, basically we’re the people that counselled
him and we are not skilled in that department‘. He felt that Ryan’s unwillingness to engage
with specialist services made it very difficult to access the support he needed.
Some young people, like Ryan, may not be willing to address their specific health problems. A small proportion (7%) of young people who had problems with their health felt that they did not require specific support whilst some, like Danielle, did not feel ready to engage with therapeutic services.
Danielle had been abused as a child and had been offered counselling after taking an overdose at 16. She had initially agreed to see a psychologist, however, after a couple of sessions she felt unable to continue:
They said I was suffering from post-traumatic stress disorder. I still don’t know what they mean but they said when I’m ready for the help they’ll give it to me but I’m not ready for the help cause I do just sit there and go yeah, yeah, whatever and not talk. But then that made me feel uncomfortable because I didn’t want to be horrible to [the counsellor] but it’s a hard thing to