The mental health needs of looked after children

1. The mental health needs of looked after children Dr Antonella Ingrassia Consultant Child and Adolescent Psychiatrist Greenwich CAMHS

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3. An outline Part 1. What do we know about the mental health needs of looked after children? Part 2. What happens after leaving care? Part 3. How can lessons from clinical experience and research influence best practice, further research and policy?

4. A preface- the history of alternative care The ‘kindness of strangers’ The first Poor Law (1531) – apprenticeship for children Voluntary care – Children Act 1948 Looked after children - Children Act 1989 Leaving care act 2000 The Foundling Hospital (1857) – boarding out to families

7. 60,900 children were in care on 31 March 2005Care matters White paper 2006 

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9. All lac in oxfordshire at a point in time 134 adolescents (response rate was 66%) 2 stage design- achenbach child behaviour checklist and youth self report questionnairesAll lac in oxfordshire at a point in time 134 adolescents (response rate was 66%) 2 stage design- achenbach child behaviour checklist and youth self report questionnaires

10. Uses the deveraux scale of mental disorders (based on DSM IV criteria)Uses the deveraux scale of mental disorders (based on DSM IV criteria)

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12. Are looked after children different?  Entering care (Sinclair et al 2007) Abuse and neglect 65% of those first in care under 11 Chronic adversities Parental substance misuse and domestic violence in 41% of those first in care under 11 Interaction of biological and environmental factors Chronic adversities related to poor health outcomes 17.7% considered ‘disabled’ by their social worker

13. Are looked after children different? Abuse whilst in care Hobbs et al 1999 (133 children in foster/residential care involved in 158 incidents) Children in care are more likely to be assessed by a paediatrician for suspected abuse (7-8 times FC, 6 times RC) Confirmed cases- 42 physically abused, 76 sexually abused, 15 both FC perpetrators of physical abuse (28) and sexual abuse (22) Retrospective study All suspected cases of child abuse assessed and reported by a paediatrician over a period of 6 years (1990-1995)Retrospective study All suspected cases of child abuse assessed and reported by a paediatrician over a period of 6 years (1990-1995)

14. Are looked after children different? Abuse whilst in care Abuse perpetrated by individuals Institutional abuse Peer abuse Targeting

15. Are looked after children different?  Moves and placement breakdown Minty 1999 - breakdowns between 20 and 50% Sinclair et al 2007 – 17% of the sample had had 6 or more placements Review by Minty on outcomes of long term foster careReview by Minty on outcomes of long term foster care

16. Children “on the edge of care” In and out of care More than one period of care Children in need as a result of abuse or neglect (around 30% will enter care during their childhood)

17. Psychiatric disorder among British children looked after by local authorities: comparison with children living in private households (Ford et al 2007) Comparison between looked after children and children living at home from deprived and non deprived background Data combined from 3 surveys of looked after children (England, Scotland, Wales) ONS sample of children living at home (Meltzer el al 2000) from the child benefit register Age 5-17

18. Measures (Same measure in the 4 surveys) Strengths and difficulties questionnaire (Goodman 1997) Teacher’s report Social worker’s and carer’s report Development and Well Being Assessment (DAWBA- Goodman et al 2000)

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21. Questions (true or false) Research evidence suggests that: 10% of young people who have been in care go on to become young prisoners Looked after children are 10 times more likely to be excluded from school than their peers Of young women leaving care, 25-30% are parents Young people leaving care have a 1 in 10 chance of becoming homeless Studies of care leavers show that: 8% had a long term mental disorder 20% had self harmed since the age of 15

22. Looking at care leavers-mental health (Buchanan 1999) At age 16 less satisfied with their lives 25% had significant levels of maladjustment At age 33 Higher rates of depression than other parental groups National child development study 17000 children born in 1958 in england scotland and wales National child development study 17000 children born in 1958 in england scotland and wales

23. Looking at care leavers-mental health  (Saunders and Broad 1997) 16.6% had a mental disorder 35% had engaged in self harm since the age of 15 60% had felt suicidal 31% had self referred to mental health services (of whom 77% did not find services useful) N= 48, mostly womenN= 48, mostly women

24. Looking at care leavers-social exclusion 50% will be unemployed on leaving care and 20% will be homeless within 2 years of leaving care (Biehal et al 1995, Broad 1998) 26% of all prisoners and 40% of prisoners under 21 (The national prison survey 1991: main findings, 1992) 23 % of adult prisoners and 38 % of young prisoners are care leavers (Department of Health, 1999) 75% have no formal qualifications (Garrett 1992)

25. Looking at care leavers-parenthood On leaving care 1 in 7 young people already have or are expecting a child (Wade et al 2006) On follow up (10 months) this is risen to 26% (35% of females and 15% males) (Wade et al 2006) The children of women who have spent time in care are themselves two and a half times more likely to go into care than their peers (Sergeant 2006) 1 in 7= 14%1 in 7= 14%

26. Looking at care leavers-substance misuse (Wade et al 2006- 106 people and their care leaving workers) Cannabis use- 73% have smoked it, 52% in the last month, 34% report daily smoking One-tenth had used cocaine within the last month 15% have used ecstasy within the month 7 local authorities in england 106 people and their care leaving workers7 local authorities in england 106 people and their care leaving workers

27. The state makes a rotten parent (Sergeant 2006)

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34. The mental health needs of looked after children:everybody’s business