Doug SimkissAssociate Professor of Child Health

Health issues and looked after children: an overview of the

evidence

Introduction• Health issues for adults who were looked

after children • Health issues for children in care• Health issues of children who then enter

care

Health issues for adults who were looked after children

• Adult health and social outcomes of children who had been in public care: population based study.

• Followed the 1970 British birth cohort and used self reported adult outcomes.

• 3.6% (343 of 9557) had been in public care.

• Viner and Taylor. Pediatrics 2005; 115: 894-9.

Health issues for adults who were looked after children

• Non white children were more likely to have been in care (OR 3.3 [CI 2.1-5.4])

• Men who were looked after as children were: - Less likely to attain high economic status - More likely to be homeless - More likely to have psychological problems - More likely to be in poor general health

Health issues for adults who were looked after children

• Similar associations in women. • Men, but not women, with a history of care

were more likely to be unemployed.• Non white ethnicity was associated with

poorer adult outcomes of being in care

Educational outcomes of looked after children

Statements of SEN

After school outcomes

Introduction• Health issues for adults who were looked

after children • Health issues for children in care• Health issues of children who then enter

care

Health issues for children in care• Looked after children ‘have a higher level of

health, mental health and health promotion needs than others of the same age’

• What is the evidence for this?

Polnay L, Ward H. Promoting the health of looked after children. Government proposals demand leadership and a culture change. BMJ 2000 Mar 11; 320(7236):661-662

Mental health issues

A definitive research study into the mental health issues of looked after children in England.

Assessing mental health needs in looked after children

Immunisation

Hill CM, Mather M, Goddard J. Cross sectional survey of meningococcal C immunisation in children looked after by local authorities and those living at home. BMJ 2003 Feb 15; 326(7385):364-5.

Immunisation• We prospectively assessed whether providing

social services with information on the immunisation status for a cohort of looked after children in the care of an urban unitary authority in England improved uptake rates. The provision of such information did not improve immunisation coverage in these children.

Ashton-Key M, Jorge E. Does providing social services with information and advice on immunisation status of "looked after children" improve uptake? Arch Dis Child 2003 Apr; 88(4):299-301.

Changes in immunisation status of children looked after on 31 March in both 1999 and 2000 (number of children given in bold).

Health issues for children in care

V Rodrigues. Health of children looked after by local authorities. Public Health 2004 Jul; 118(5):370-6.

Health issues of looked after children – physical needs

• Simple issues like;– incomplete immunisations,– asthma,– dental caries,– refractive errors,– scabies,– head lice,– conductive hearing loss

Health issues of looked after children - physical needs

• Complex issues like;– foetal alcohol effects, – vertically transmitted infections – Undiagnosed disability;– Diagnosed disability– Consequences of neglect and abuse– Special Educational Needs

Consequences of abuse‘I cannot express a strong enough concern

that their emotional and psychological needs are not being met. They have numerous physical and medical problems, but the outstanding problem is their obsessive need for food (and drink). They steal, lie and manipulate to obtain food and have to be constantly supervised.’

Consequences of abuse

• Stunted• Growth velocity 0.8cm / year• Palpable liver edge• Heart murmer• Umbilical hernia

Hyperphagic short stature

• Removed from long term foster carer• Growth, 17 cm the following year• Learning difficulties warranting a SSEN• On going emotional issues

NICE PDG - Qualitative review• Identified research on the views,

experiences and preferences of children and young people, their families and carers, about the care system.

• 10 databases searched• Data extracted from 50 studies

Findings of the qualitative review

Findings of the qualitative review

Findings of the qualitative review

Findings of the qualitative review

Full document can be found at http://www.nice.org.uk/nicemedia/live/11879/47416/47416.pdf

Introduction• Health issues for adults who were looked

after children • Health issues for children in care• Health issues of children who then enter

care

Why do children enter public care?

• Bebbington and Miles ‘The background of children who enter local authority care’. BJSW 1989; 349-368.

• Investigated the background of 2165 children admitted to care in England in 13 local authority areas during 1987 and compared with 5407 aged 16 or younger who did not enter care (GHS)

Bebbington and Miles• Child A• Age 5 - 9• No supplemental benefit• 2 parent family• Three or fewer children• White• Owner occupier house• More rooms than people• Odds are 1 in 7,000

• Child B• Age 5 – 9• Supplemental benefit• Single adult household• Four or more children• Mixed ethnic origin• Private rented house• One or more people pre room• Odds are 1 in 10

Bebbington and Miles• ‘The most obscene statistics ever to emerge

from child welfare research in England’• Ryburn, 1993• Having a single parent was the greatest risk

factor for placement, increasing the OR eightfold in the logistic regression analysis model

Hjern and Vinnerljung• In 1997 mother married/cohabiting• Post secondary education• Working• No welfare for 3 years• N = 120,015• <1 in 2000 place in care before 7 year old

• In 1997, single mother• Basic education• Out of work in 1997• Welfare benefits 1996-8• N = 8, 053• 1 in 7 placed in care before 7 years old

Research question

• To investigate, using routine primary care data, whether mother-child pairs with children entering public care have different health service use in the previous 12 months compared to mother-child pairs where children do not enter public care.

• Case control methodology

Conditional logistic regression analysisExposure of interest Cases

n=147Controls n=538

Odds ratio (95% CI) P value

Maternal mental illness 75 (51%) 132 (25%) 2.51 (1.55 – 4.05) <0.001

Maternal drug misuse 7 (5%) 1 (0.2%) 28.8 (2.29 – 363) 0.009

Any non attendance at primary or secondary care

57 (39%) 101 (19%) 2.42 (1.42 – 4.14) 0.001

Child mental illness 34 (23%) 43 (8%) 2.65 (1.42 – 4.96) 0.002

Maternal contraception 41 (28%) 198 (37%) 0.52 (0.31 – 0.87) 0.013

Child admission to hospital 12 (8%) 12 (2%) 3.31 (1.21 – 9.02) 0.019

Socio-economic status quintile

Results – maternal age

What are the challenges?

‘Bring about better outcomes…requires exceptionally high levels of commitment and a culture change. There needs to be both a continuity of policy and a continuity of relationships between looked after young people and their health and social service professionals…’ Polnay and Ward BMJ 11 March 2000

What are the challenges ?

‘What is needed is much earlier intervention with the aim to avoid children developing major social, educational and behavioural problems, combined with innovative, skilled and consistent care for those where early intervention has not been available or successful.’

Polnay, Arch. Dis. Child. April 2000.