Needs to be looked after

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.³

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

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