National Clinical Assessment Framework for Children and Young People in Out-of-Home Care (OOHC) - March 2011

B.2.1 Health status of children and young people requiring out-of-home care

Page last updated: 05 December 2011

The available literature widely acknowledges that children and young people in OOHC are a highly vulnerable group with increased physical, mental and social health needs and with limited access to resources.26 They are also more likely to have significant, often unrecognised and unmet health needs, increased rates of developmental difficulties and are less likely to access preventative health services such as immunisation compared with the general population. 27

Assessing each child’s unique health needs should be one of the highest priorities in child welfare agencies.28 In doing so, a child and young person’s own view of their health and wellbeing status and desired outcome must be invited and taken into account wherever possible. The outcomes of each assessment should be shared with the child, inform future assessments, and, where appropriate, inform placement decisions.

The compromised health status of children in OOHC may be a result of previous abuse and neglect and, in addition to suffering abuse and neglect, children within the child protection system have commonly been exposed to other disadvantage within their family such as:

  • parental alcohol and drug abuse;
  • mental health problems;
  • family violence;
  • poor parenting skills;
  • early child bearing;
  • children with health, disability and behavioural problems;
  • adults with histories of being abused or neglected;
  • social isolation; and
  • poverty. 29
Key Learning: Children in OOHC have significantly more health problems compared to children in the general population and therefore warrant additional medical attention.

Physical and developmental health

A study of 122 children published in 2007 demonstrated higher rates of physical, developmental and emotional health problems in children in care compared to children in the general population. Interestingly the study also found that the rates of poor health for Australian children in care were similar to that of children in care in both the United Kingdom and the United States. Specifically, the study reported that 24% of children had incomplete immunisations, 20% had failed a vision screening test, 26% failed their hearing test, 60% required a referral for a formal developmental assessment, 45% of the children aged under 5 years of age had speech delays, 20% of the older children had delayed language skills. Abnormal growth was recorded in 14% of the children and behavioural and emotional health problems were identified in 54%. The report also noted that there were a variety of additional health concerns identified that were similar to that seen in a general paediatric clinic. However, the noticeable difference was that many of the conditions had either been poorly managed or not previously recognised.30

A national survey undertaken by Meltzer and colleagues for the UK Office for National Statistics (ONS)31 found that two thirds of all children entering OOHC had at least one physical health complaint and that these children are more likely than their peers to experience problems including speech and language problems, bedwetting, co-ordination difficulties and eye or sight problems.

Psychosocial health

Children in OOHC experience high rates of developmental and mental health problems. The psychopathology is complex and is currently not well understood, however, research suggests that its origin lies in insecure attachments and the cumulative effects of childhood maltreatment.32

Emotional and behavioural problems are described as the greatest health need of children and young people in care.33 The high prevalence of psychological and mental health problems of children in foster care has also been widely acknowledged.
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The scale of mental health problems among children and young people in care has been described as ‘exceptional for a non clinical population’ and children in residential care have more mental health problems than those in family-type foster care or those in kinship care. Children in care may manifest complex psychopathology, characterised by attachment difficulties, relationship insecurity, problematic sexual behaviour, trauma-related anxiety, conduct problems and defiance, and inattention/hyperactivity as well as less common problems such as self injury, excessive eating and other food maintenance issues.34

Ensuring timely access to professional help for those children most in need is paramount to reducing the burden of disease in the OOHC population.35

One of the main barriers to delivery of mental health services to children and young people in OOHC is the underreporting of mental health problems by foster parents (in 43%-66% of cases). This can be used to argue that when OOHC assessments are included they should be structured ones which can be marked by the professional (such as CBCL) and that regular, focussed mental health assessments should be provided36 by a mental health specialist.

One South Australian based study competed on children 6-17 years of age in OOHC between 2004 and 2006 noted the prevalence of mental health symptoms across all CBCL scales was consistently higher (six to seven times) than for children in the general community.37

In the United States, 70% of children placed for at least a year in alternative care reported moderate to severe mental health problems.38 Another United States study found 84% of a foster care sample had developmental or psychological problems.39

A study of 6,177 children entering the Utah foster care system40 found that 44% had one or more mental health problems (main ones being oppositional defiant disorder, attachment and adjustment disorders and mood disorders), 54% had one or more acute or chronic medical conditions. This was significantly higher than children in the general community and demonstrates not only the importance of having a particular focus on screening for mental health issues but that follow-up is performed by a professional as part of the Heath management plan.

This finding is supported by the Children in Care Study undertaken in New South Wales which found that children in care present with exceptionally poor mental health and social competence when compared to relative normative samples.41 More than half the boys and girls in the study were reported to have clinically significant mental health difficulties. They presented with complex disturbances, including multiple presentations of conduct problems and defiance, attachment disturbance, attention deficit/hyperactivity and trauma related anxiety.42

Studies have also demonstrated a strong correlation between early trauma/abuse and subsequent placement instability which further compromises health outcomes.43, 44
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The ONS Survey confirmed findings of earlier research45, 46 about the high level of mental health need amongst these children, particularly those in residential care. 45% were assessed as having a mental health disorder, rising to 72% of those in residential care. Among 5-10 year olds, 50% of boys and 33% of girls had an identifiable mental health disorder. Among 11-15 year olds, the rates were 55% for boys and 43% for girls. This compares to around 10% of the general population aged 5 to 15.

Clinically significant conduct disorders were the most common among these children (37%), while 12% had emotional health disorders (anxiety and depression) and 7% were hyperactive. Even when compared to children in a community sample from the most deprived socio-economic groups, children in OOHC still showed significantly higher rates of mental health disorders.47

Further analysis of the ONS survey carried out by Tamsin Ford et al48 found that even when children in OOHC were compared to children in a community sample from the most deprived socio-economic groups, they still showed significantly higher rates of mental health disorders. The authors suggest that this is largely due to adverse factors impacting on children prior to entry into care. They also identified significantly higher rates of developmental disorders, such as autism and ADHD, which may have gone previously undiagnosed. Other studies also indicate that behaviour and mental health problems in children, along with a number of other factors in the child and carer, are linked to increased risk of placement breakdown.

A further source of information on the prevalence of emotional and behavioural difficulties among children in OOHC is the Looking After Children longitudinal study of children and young people who remained in care for at least a year.49 This considered the needs of children at the point of first entry into care and identified emotional and behavioural problems from information recorded in case files by social workers and subsequently assessed by psychologists. Using these methods, it was found that 72% of children aged 5 to 15 had a mental health or behavioural problem compared to 45% in the ONS survey. Among children entering OOHC under the age of five (this age group was not included in the ONS survey), nearly one in five showed signs of emotional or behavioural problems.

Key Learning: Children in OOHC present with health problems across three domains - physical, developmental and psychosocial.

Health status of Aboriginal and Torres Strait Islander children and young people in OOHC

Since 2003 the Kari Clinic for Aboriginal and Torres Strait Islander children in Western Sydney has collected and evaluated relevant data relating to the needs and progress of Aboriginal and Torres Strait Islander children and young people entering OOHC. In a formal report of their findings in 2007 the results showed that 53% of children had overdue immunisation status, 43% had had hearing problems, 44% had visual concerns, 61% had speech delays, 34% had fine motor problems, 66% had educational problems and 30% had global developmental delays.50

Although methodologically sound, Australian researchers to date have only identified the need for culturally specific wellbeing assessments for Aboriginal and Torres Strait Islander children, rather than directly investigating what such assessments might look like.
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Studies have indicated that concepts such as attachment and bonding to assess the wellbeing of Aboriginal and Torres Strait Islander children are inconsistent with Aboriginal and Torres Strait Islander values of relatedness and childrearing practices.51 Whilst others have reinforced that wellbeing indicators for Aboriginal and Torres Strait Islander I children should include cultural and spiritual dimensions as well as physical, emotional and social status.52

The CREATE Foundation53 has also advocated for caseworkers and carers to have training on the value of connecting Aboriginal and Torres Strait Islander children and young people to their culture.

Key Learning: Aboriginal and Torres Strait Islander children and young people are over-represented in OOHC statistics and have significantly more health problems compared to other children in OOHC. Consideration should be given to the specific needs of Aboriginal and Torres Strait Islander children and young people in the development of the framework particularly in relation to building cultural connections.

Impacts resulting from the rise of kinship care

One of the primary strengths of kinship care is that children in kinship care (both Aboriginal and Torres Strait Islander and non- Aboriginal and Torres Strait Islander) can benefit from maintaining family, cultural and community connections and, as such, is the fastest growing form of OOHC in Australia .

Research in this area has focused on grandparents providing care for grandchildren. The growing number of grandparents raising grandchildren due to parental substance abuse highlights the need for greater social, financial and service supports.55

Australian research has shown that kinship foster carers are recruited differently from non-relative foster carers, and yet assessment procedures have not been modified to account for the different circumstances.56 Kinship care placements receive less (and in some instances receive no) monitoring, training and support. This is problematic, as kinship carers tend to have higher rates of poverty and disadvantage and tend to require more support than non-relative foster carers.

Key Learning: The Carer is an integral participant in the effective implementation of the Heath management plan. Appropriate training and support should be provided to take account of individual carer’s knowledge, experience and capability.

26 Royal Australasian College of Physicians (2006) Health of Children in “Out-Of-Home” Care - Paediatric Policy
27 Nathanson, D & Tzioumi, (2007), Health need of Australian children in out-of -home care. Journal of Paediatrics and Child Health 43 665-669
28 American Academy of Pediatrics (2002) Health Care of Young Children in Foster Care Pediatrics Vol. 109 p537
29 Royal Australasian College of Physicians (2006) Health of Children in “Out-Of-Home” Care - Paediatric Policy
30 Nathanson, D & Tzioumi, (2007), Health need of Australian children in out-of -home care. Journal of Paediatrics and Child Health 43 665-669
31 Meltzer H., Corbin T., Gatward R., Goodman R. and Ford T. (2003) The mental health of young people looked after by local authorities in England. London: The Stationery Office
32 Royal Australian & New Zealand College of Psychiatrists (June 2009) Position Statement 59: Then mental health care needs of children in out-of-home care. P1
33 Nathanson, D & Tzioumi, (2007), Health needs of Australian children in out-of -home care. Journal of Paediatrics and Child Health 43 665-669
34 Tarren-Sweeney, M, (2008) The mental health of children in out-of-home care. Current Opinion in Psychiatry 21:345-349
35 Royal Australian & New Zealand College of Psychiatrists (2008) The mental healthcare needs of children in out-of-home care: A report from the expert working committee of the Faculty of Child and Adolescent Psychiatry p 38Top of page
36 M, Halfon, N Zepeda A, Inkelas, (2000) Mental Health Services for Children in Foster Care Policy brief 4, UCLA Center for Healthier Children, Families and Communities
37 Sawyer MG, Carbone JA, Searle AK and Robinson P. (2007) The mental health and well-being of children and adolescents in home-based foster care. Med J Aust; 186: 181-184
38 Halfon N, Berkowitz G, Klee L. (1992) Mental health service utilization by children in foster care in California. Pediatrics. Jun;89(6 Pt 2):1238–1244
39 Royal Australasian College of Physicians (2006) Health of Children in “Out-Of-Home” Care - Paediatric Policy
40 Steele J, Buchi K, (2008) Medical and mental health of children entering the Utah foster care system Pediatrics 122; e 703-e709
41 Tarren –Sweeney,M and Hazel,P. (2006) Mental Health of Children in foster and kinship care in New South Wales. Journal of Paediatrics and Child Health, 42. 89-97
42 The Royal Australian and New Zealand College of Psychiatrists (2008) The Mental Health needs of children in out-of-home care; A report from the expert working committee of the Faculty of Child and Adolescent Psychiatry, Melbourne
43 Osborn, A., & Delfabbro, P. H. (2006a). An analysis of the social background and placement history of children with multiple and complex needs in Australian out-of-home care. Communities, Children and Families Australia, 1, 33–42.
44 Osborn, A., & Delfabbro, P. H. (2006b). National comparative study of children and young people with high support needs in Australian out-of-home care. Adelaide: University of Adelaide.
45 Dimigen G., Del Priore C., Butler S. et al (1999) ‘Psychiatric disorder among children at time of entering local authority care: questionnaire survey’, British Medical Journal, 319, 675
46 McCann J., James A., Wilson S. and Dunn G. (1996) ‘Prevalence of psychiatric disorders in young people in the care system’, British Medical Journal 313, 15, 29-30
47 Ford T., Vostanis P., Meltzer H. and Goodman R. (2007) ‘Psychiatric disorder among British children looked after by local authorities: comparison with children living in private households’, British Journal of Psychiatry 190, 319-325
48 Ford, T. et al. (2007) Psychiatric disorder among British children looked after by local authorities: comparison with children living in private households. British Journal of Psychiatry, 190; 319-325.
49 Sempik J., Ward H. and Darker I. (2008) ‘Emotional and behavioural difficulties of children and young people at entry to care’, Clinical Child Psychology and Psychiatry, 13, 2, 221-233
50 Kari Clinic- By Sandra Reynolds, Psychologist, KARI Aboriginal Resources Inc SNAICC News July 2008
51 Yeo, S. S. (2003). Bonding and attachment of Australian Aboriginal children. Child Abuse Review, 12(3), 292–304.
52 McMahon, A., & Reck, L. (2003). Well-being for Indigenous foster children: Alternative considerations for practice research. Children Australia, 28(2), 19–24
53 CREATE Foundation. (2005). Indigenous children and young people in care: Experiences of care and connections with culture. Perth, WA: Author.
54 Mason, J., Falloon, J., Gibbons, L., Spence, N., & Scott, E. (2002). Understanding kinship care. Haymarket, NSW: Association of Children’s Welfare Agencies and University of Western Sydney.
55 Baldock, E., & Petit, C. (2006). Grandparents raising grandchildren because of alcohol and other drugs. Curtin, ACT: Canberra Mothercraft Society.
56 Bromfield, L and Osborn, A (2007) ‘Getting the big picture’: A synopsis and critique of Australian out of-home care research. Child Abuse Prevention Issues No 26 2007 Australian Institute of Family Studies.