The well-being of looked after children
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Wellbeing is a subjective issue, with many attempting to define it. Recent government policies have attempted to create guidelines to improve services; however looked-after children generally have poorer wellbeing than other children. Looked-after children of school age in my area are allocated a named nurse from the school nursing team. The term 'looked-after' refers to children who are subject to care orders and those who are accommodated voluntarily (The Children's Act 1989). The focus of this essay will be on the wellbeing of looked-after children of 14-18 years of age, as this is when children are approaching the end of care - often a time of great disruption to their wellbeing. Furthermore, the wellbeing of looked-after children is particularly vulnerable during the transition period from children's to adult services.
In 2008 there were 59,500 looked-after children in the UK (Department of Health 2009). Evidence shows that a higher percentage of looked-after children will enter the criminal justice system, become teenage parents and have a higher need for Child and Adolescent Mental Health Services (CAMHS), with behaviour and emotional problems being linked to frequency of placement moves and lack of attachment. (House of Commons 2009, Department for Children, Schools and Families 2009, Barnardo's 2006, Department for Education and Skills 2003, Office for National Statistics 2003). To promote the wellbeing of looked-after children extra help from other agencies is required, with the emphasis on holistic assessment. Commissioned Services introduced statutory guidance and named nurses to address this (Open University 2010, Unit 6, page 82-83). It is important as a named nurse that wellbeing is defined and understood in practice. Gough et al (2006, pp4) states "â€¦wellbeing is an umbrella concept, embracing at least 'objective wellbeing' and 'subjective wellbeing'." Ereaut and Whiting (2008) believe that wellbeing is a cultural construct for what people collectively agree makes 'a good life'. The Scottish Government (2011) identifies that a safe and nurturing environment is fundamental to developing into a confident and resilient adult, looked-after children's emotional health is often affected by experiences prior to care entry. Dimigen et al (1999) identified that the level of mental health need in looked-after 11-15 year olds were 55% for boys and 43% for girls compared to 10% for other children aged 5-15. Haywood et al (2008) concur that looked-after children enter care with poorer health than their peers due to the impact of poverty and chaotic lifestyles.
The UNCRC commissioner's guide (2008) recognises the widening gap between rich and poor in the UK, and associated disparities in the children's wellbeing. A UNICEF report (2007) places the UK bottom of 21 industrialised countries for child wellbeing. Forrester (2008) believes that children in care can achieve equal wellbeing to other children, and advocates the European model that entry to care can be beneficial for a child living in deprived circumstances, rather than the UK view of care as a final resort. A study by Helseth (2010) found that quality of life is about a positive self-image, good friends and family - looked-after children often do not have these resources. Graham and Power (2004) state there is evidence that childhood disadvantage is linked to adulthood disadvantage, emphasising the importance of wellbeing during childhood. The Department of Health (2000) considers there are seven dimensions of wellbeing - health, education, identity, emotional and behavioural development, family and social relationships, social presentation, and self-care. To measure child wellbeing, the UK government's Every Child Matters system of five outcomes is used: be healthy; stay safe; enjoy and achieve; make a positive contribution; achieve economic wellbeing (Department for Education and Skills, 2003), which aims to intervene before crisis point is reached (Barker, 2009). The outcomes relate to the 1990 United Nations Convention on the Rights of the Child, and are co-dependent. If children are not achieving any of the five outcomes, then the Framework for Assessment of Children in Need is utilised (DoH 2000). This assessment is based on needs in three domains: Developmental Needs, Parenting Capacity and Family and Environmental Factors (Appendix 1) and contributes towards the Common Assessment Framework (CDWC 2009). The CAF is used across agencies to prevent children having to undergo multiple assessments and to aid sharing of information. In practice this does not always work, as a social worker may emphasise a child's social needs compared to health issues. 30% of looked-after children are placed outside their local authority, which has implications for commissioned health services (Doh2009). This can have a negative effect on wellbeing of children as their needs may not be met due to the lack of joined up services. In practice safeguarding supervision helps to identify children whose wellbeing may be at risk, but cross-county collaboration would help minimise these risks further.
Although looked-after children can achieve all five outcomes on paper, they may not necessarily feel a sense of wellbeing: they may be unhappy, feel different to other children and have upsetting memories (McAuley and Davis 2009, Fleming et al 2005). It has been found that more emphasis may be placed on one outcome depending on an agency's role, creating a disparity in definitions of wellbeing between agencies. Other criticisms of Every Child Matters are that cultural needs, disability, resilience and emotional health are not taken into account (Chand 2008, Sloper et al 2009). Parton (2006) voices concerns that a low mandatory information sharing threshold could compromise confidentiality. Children leaving care have specific needs when it comes to maintaining their wellbeing, having a lasting effect on their adult lives; care leavers are more likely to be unemployed, to become homeless, to spend time in prison and often have trouble forming stable relationships. One in seven young people leaving care are pregnant or are already mothers. They have to learn how to cope financially (Barnardo's 2011). A Panorama documentary (BBC 2011) recently showed care leavers struggling with basic living skills. This is supported by what is seen in practice; many foster carers refuse to allow children assist with preparation and cooking of meals, or ironing in case they may burn themselves. It should be raised with the independent reviewing officer that these skills are beneficial, which should then be recommended formally as part of the care plan. Foster carers now attend mandatory training, and are conscious of health and safety regulations. Often they think they are acting for the good of the child or being nurturing, but in reality they are impeding the child's developing life skills to live independently.
A looked-after child's statutory annual health assessment is at odds with them living as normal a life as possible - other children do not have an annual medical assessment. Fleming et al (2005) identified a low uptake (56%) and few health issues arising from the assessment, questioning its value. Bundle (2001) found that many health assessments were used as a screening exercise rather than a health promotion opportunity. The feeling in practice is that there is a responsibility by the state to ensure that all health appointments and immunisations are up to date - looked-after children generally have a poor history of routine health check-ups at entry to care. Furthermore Coman and Devaney (2011) believe that a good quality holistic assessment is the only way to achieve a meaningful measurement of outcomes for a child. The health assessment also provides an opportunity to support the child with other aspects of health which affects wellbeing such as personal issues and emotional health - issues which a child may normally go to family members with (Hill and Watkins 2003). Health assessments can be a strain on resources in practice - to provide a good quality assessment an hour should be allowed, with the assessment preferably done in the child's home to observe interactions in their home environment. It also provides an opportunity to discuss leaving care, and to ascertain whether the young person is receiving appropriate services and support. This may require acting as an advocate for the looked-after child at their review, to ensure there is an adequate service provision. Therefore, practitioners must keep up to date with government policy, best practice, evidence, multi agency working and services available in their area. The tool used to assess emotional wellbeing is the Strengths and Difficulties Questionnaire (Goodman, 1997), however this can cause frustration when problems identified cannot be addressed due to lack of services (Whyte and Campbell 2008). Healthcare professional have a duty of care to ensure that the young person leaving care knows where to go and how to make appointments for different health services.
Models such as Maslow's Hierarchy of Needs (1943) and Roper,Logan and Tierney's Activities of Daily Living (2000) form the basis of the adult Single Assessment Process (Department of Health 2002), however when holistically assessing children's wellbeing the five outcomes of ECM are used, this can create a situation where as little as a day's difference in age could result the SAP being used rather than ECM to assess a young person's wellbeing. The transition to adult services would benefit from an additional framework for assessment for young people between 18 and 25. To assess the wellbeing of an 18 year old using the same framework as for a 90 year cannot be in the best interests of the young person. To develop and introduce such a framework would be costly and cumbersome; however as the importance of health promotion is increasingly recognised by the government, it would be worthwhile investigating this further. Studies of young people leaving care show that their health concerns are similar to all young people with the additional stressor of learning to live independently. Local studies identify that young people value approachable healthcare professionals, and would prefer to have specific young person-friendly and accessible clinics (National Children's Bureau 2008, Stanley 2002 ).
NICE guidelines (2010) recommend that there is an effective and responsive leaving care service for young people in transition between age 16 and 25. A key leaving care worker can help with the transition however the level of support is varied (Goddard and Barrett 2008). To help a child with the transition leaving care social workers, pathway plans, open door placements and other services should be provided (DoH 2001), but for a young person leaving care many of the domains which contribute towards wellbeing such as housing, income, family relationships, stability and safety are in turmoil and wellbeing suffers greatly as a consequence. Some looked-after children become very emotionally withdrawn leading up to their eighteenth birthday, when they will no longer be a child in care and make the transition to adult services. In 2008 the UK Children's Commissioner's Report found that children felt pressurised to leave care at sixteen, and recommended that no child leaves care before eighteen. Occasionally foster carers allow the child to stay within the family, however in practice when the financial incentive ends, the child has to leave. Resilience has a significant impact on the wellbeing of a child leaving care, resilience is understood as having the capacity to resist or 'bounce back' following adversity and is generally considered to be made up of individual, family and community factors (Glover 2009). Scudder et al (2008) believe that resilient children have belief in their ability to succeed and achieve their personal goals, and that resilience is a dynamic characteristic that can develop over time. Newman and Blackburn (2002) found that children today are less resilient compared to earlier generations, perhaps because of being sheltered from challenging opportunities, however Drapeau et al (2007) state that resilience can be nurtured in children for whom it does not occur naturally. The practitioner should believe in the child's potential and allow them to set the level of intervention. Ahern et al (2008) suggests referring children with low levels of resilience to services such as CAMHS or peer-support groups. In practice, by addressing one problem at a time enables the child to experience and build upon success, rather than setting a huge unobtainable goal and setting the child up to fail.
Wellbeing is believed to include many factors besides health, emphasising the importance of a good quality holistic assessment and appropriate intervention. There are many additional needs for looked-after children, particularly with emotional health, if they are to achieve wellbeing. They are often poorly prepared for independent living when they leave care, and learning life skills should be emphasised during reviews of children approaching the end of care. Upon leaving care, the transition to adult services can be very traumatic and detrimental to wellbeing for looked-after children. As practitioners we should be encouraging looked-after children to prepare for independence and to take responsibility for their own health. To work towards this goal the statutory child in care health assessment should be an exercise in partnership with the child, rather than a professionally led assessment. For a looked-after child to achieve the same level of wellbeing as other children depends on variables such as resilience, attachment and ongoing support which cannot always be provided by the state. There needs to be more research into factors care leavers consider important for their health and wellbeing, which could inform an interim assessment tool between ECM and the SAP providing enhanced transition services for all children.
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