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Five years ago, the Utting report examining the risk of sexual, physical or emotional abuse faced by children in care was published.¹ The study also looked at children's mental health, and found evidence that up to three-quarters had mental health problems. The report recommended that the mental health needs of looked-after children should become a priority. But five years on, there is evidence that this is still not happening.

There are no national figures on the prevalence of mental health problems among children in the care system. But a localised study in Oxfordshire found that 67 per cent of children in the care of the authority had mental health problems, compared with 15 per cent of the general population locally.²


Mental health problems among looked-after children are often difficult to spot. These children often have few people they trust and can confide in, while some may have been through the disruption of multiple placements. Even if a professional realises the child does have mental health problems, they may still have to see a sympathetic GP before being referred to a specialist service.

Assuming they get onto a child and adolescent mental health services (CAMHS) waiting list, a child may have moved to a different foster or residential placement, or even out of care, by the time their appointment comes up. Meanwhile, foster carers without mental health training are left to look after them.

For some children, simply having someone to talk to can help them overcome difficulties. During consultation exercises with young people on aspects of their care experience, the Who Cares? Trust repeatedly heard this request. Jenny Robson, director of development for the trust says: "They want to talk about what has happened to them, why they are in care and what will happen to them. These are very distressing issues."

Robson believes social workers are often valuable sources of support for young people with mental health problems - the trouble is that they don't have the time for direct work with them. "Children often just want the relationship with their social worker strengthened," she says. "For some, that would be an early intervention measure. Not all the young people who need someone to talk to need mental health services."

Wendy McGowan-Griffin is senior development officer for the Promoting Positive Mental Health for Children in Public Care project, run by the National Children's Bureau, which is working with four local authorities and a group of young people to improve access to services and build awareness.

She says the message that mental health is a major issue for looked-after children is filtering through to professionals working with them. But she also highlights two major issues: an urgent need for basic support and training for foster carers and residential care workers; and more co-ordination in CAMHS so there is more integration between those providing general support and specialist workers.

Those children who do require mental health services need a service that acknowledges the additional problems they face. McGowan-Griffin suggests CAMHS should have a team of specialist workers who are aware of the specific difficulties for children in care and who can help them access services. Fostered children face additional problems because CAMHS sometimes won't intervene when a child is in a temporary placement, preferring to wait until they are settled somewhere, by which time it may be too late.

Lack of training is an issue for unqualified staff such as residential care workers and foster carers, too. "They are on the front line in supporting young people with quite serious difficulties. There hasn't been the training put in place to ensure that there's even a basic level of awareness about these issues," says McGowan-Griffin.

Felicity Collier, chief executive of Baaf Adoption and Fostering, says that many new foster and adoptive families simply cannot parent these children unless they are given the help they need. "Without help, placements often break down, inevitably leading to more moves for the child which often results in a further deterioration of the child's mental health."


The impact of the recruitment and retention crisis on looked after children is also under-estimated. Use of agency staff in residential homes and the difficulties in retaining full-time staff mean that staff are often not in a young person's life for very long. "Children need to build up trust and feel secure that the person they are talking to will be around for a while, because you can't sort out these problems in a day," says Robson.

Statistics from the Department of Health show that there were more than 58,900 looked-after children at 31 March 2001. Of these, 38,400 were in foster placements; 6,400 in children's homes including secure units; 3,400 were placed for adoption; 6,900 with their parents; and 3,890 in other placements such as supported hostels or residential schools.

By far the largest proportion, 62 per cent, were being looked after because of abuse or neglect. Family dysfunction was the second largest category, accounting for 10 per cent of children who entered the system. Research shows that abuse leads to children exhibiting behaviour which can lead in some cases to self-harming, severe behavioural problems and depression, says Joanna Richardson, senior development officer for the Focus project at the Royal College of Psychiatrists' research unit.

Both Richardson and Robson suggest that a thorough, early assessment is important. A health assessment is carried out when children come into care, but their mental health needs can sometimes be overlooked. Says Robson: "I suspect that only a few young people are identified as having mental health problems in the initial health assessment. It's terribly difficult to get these children mental health services. There just isn't the capacity to cope with either children in care or children in need generally."

"Preventive and early intervention work is vital," Richardson adds. "But one problem with child mental health is that the evidence-based research for treatment interventions is poor."

For fostering and adoption, it is important to identify the child's needs at the pre-placement stage so that prospective carers are clear what resources they will need, says Jeffrey Coleman, southern region director for Baaf Adoption and Fostering. "Placing a child must not be at the expense of a realistic assessment," he adds.

There are several initiatives which could improve matters, including Quality Protects and a programme of targeted investment in CAMHS. In addition, the national priorities guidance for 1999-2000 sets targets for building up child and adolescent psychiatric services for NHS and social services, and a DoH consultation document recommends that every child should have prompt access to appropriate health services.<sup>3

1</sup> Sir William Utting, People Like Us: the Report of the Review of the Safeguards for Children Living Away from Home, DoH/Welsh Office, 1997

² J McCann et al, Prevalence of Psychiatric Disorders in Young People in the Care System, British Medical Journal, 1996

³ Department of Health, Promoting Health in Looked-After Children, DoH, 1999