Health issues and looked after
children: an overview of the
evidence
Doug Simkiss
Associate Professor of Child Health
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;
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incomplete immunisations,
asthma,
dental caries,
refractive errors,
scabies,
head lice,
conductive hearing loss
Health issues of looked after children physical needs
• Complex issues like;
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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
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Stunted
Growth velocity 0.8cm / year
Palpable liver edge
Heart murmer
Umbilical hernia
Hyperphagic short stature
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•
•
•
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
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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
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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
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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 analysis
Exposure of interest
Maternal mental illness
Cases
n=147
Controls
n=538
Odds ratio (95% CI) P value
75 (51%)
132 (25%)
2.51 (1.55 – 4.05)
<0.001
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
Maternal drug misuse
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.