And what about the mental health of children and young people in care in the UK ?

By Nancy Mohindra

Date Posted: Sunday, 13 December 2009


Nancy Mohindra graduated in psychology at Universidad Nacional de Colombia. She has worked in England with adolescents who are leaving care and she continues to  psychology studies at post-graduate level in London. Here Nancy examines the mental health services provision for young people in England.


And what about the mental health of children and young people in care in the UK ?

The purpose of this article is to create a picture of the mental health situation of children and young people in care aged between 5 to 15 years old. Why is this important? Because the transition between adolescence and adulthood is riddled with challenges; and to suffer from a mental health condition makes that transition even more complex. If things that go wrong in terms of a young person’s mental health are left unattended even greater problems are stored up for the future. I start with the word ‘and’ because rightly there is concern about the five outcomes –   to be healthy, to be safe, to achieve and enjoy, to make a positive contribution, and to achieve economic wellbeing – that the government hope will be the experience of children in care in England and yet from my experience of working in the care of children and young people service I observed a tendency for workers to steer clear of mental health issues which the children have to deal with. It is as if it is an area which is too technical or threatening to them and yet the children are dealing with these issues all their waking hours.
In order to avoid tedious repetition I have used ‘children and young people in care’ and looked after children and young people’ interchangeably and having the same meaning. The same is true of ‘children’ and ‘young people’.

Health and mental health are multi-dimensional constructs which take into account the human beings and their environment. Physical, mental and spiritual dimensions are affected by aspects such as socio-economic status, education, ethnicity, gender and age, all of them interlinked simultaneously (Marks, Murray, Evans, Willig, Woodall, et al., 2005). Nonetheless, the present analysis is focused on children’s opinions about the mental health services.
The World Health Organization (2008) describes mental health “as a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to their community”. For children and young people to be able to realise their full potential it is necessary to count on reliable adults who can provide them with permanent and consistent support (Bowlby, 1988). In the case of children and young people in care, this fundamental element is riddled with more obstacles, either because of the nature of the care setting or by the way the service is administered. In addition if either or both of these are not right there is a tendency for the child or young person to be transferred from one placement to another making it more difficult to build relationships (Sharpe, 2006).

It would seem that the prevalence of mental health problems in all children in the United Kingdom is increasing. Jo Dixon (2008) found that there has been a general increase in mental health complaints in the whole young population in the United Kingdom over the last 25 years. She reported a twofold increase in behavioural problems and a 70% increase in emotional problems. It seems that society as it is working today is failing to protect young people and consequently may be damaging the health of the adult of tomorrow. Against this background, it is generally recognized that the mental health of children and young people in care is more problematic when compared to the mental health of children and young people living with their own families. Meltzer, Corbin Gatward, Goodman & Ford (2003) found that the prevalence of mental disorders among 5 to 10 years olds was higher for children in care than for children living in their own family homes: 42% versus 8% respectively. Regarding the prevalence of mental disorder among young people (11-15 years old) the researchers found it higher among looked after young people, 49%, compared to 11% for those who live with their own family.  The mental health concerns analysed by Meltzer et al., were emotional disorder, conduct disorder and hyperkinetic disorders. Children looked after by local authorities were categorized by four types of placement: living with their natural parents, living with foster carers, living in residential child care and living independently. According to this study those children living with foster carers showed better mental health.

There does seem to be a powerful link between mental health wellbeing and where children and young people in care live. One of the elements that Dixon found in her study was a positive association between young people’s accommodation and their levels of well-being. Care leavers who perceived their accommodation to be suitable for their needs were more likely to report to cope well with accommodation and viewed their mental health positively. Although, the research showed an important link between material stability and mental health, it was not the only principal element which defined an underlying stability to a placement. Others were suitable and safe “accommodation” which represented protection, a place where friends can come over, a place within a community they knew well, with supportive schools and other facilities which assisted communication and integration.
How to provide mental health services for children and young people in care?

My view is that the health services for children and young people should be organised keeping in mind age, and mental disability of their service-users. All children are particularly sensitive to the stigma associated with receiving treatment for their symptoms and this increases if the young people are in care. Blower, Addo, Hodgson, Lamington, & Towlson (2004) carried out a combined qualitative and quantitative approach to assess the needs for mental health services of looked after children in Lomond & Argyll Primary Care NHS Trust, Scotland. In this study which considered the experience of 48 children and young people whose problems included alcohol abuse, conduct disorder, oppositional disorder, specific phobia, enuresis and ADHD/AD. Their participants expressed that they wanted to establish a distinction between their mental illness and themselves. They felt that being in care and labeling them with a mental health condition worsens their status. They spoke about the dilemma that being in care poses to the way they establish relationships. On one hand they want to be closer to their carers or foster parents, while on the other they want privacy. They felt cared for and protected where their accommodation had health and safety equipment but felt embarrassed when friends saw this. They felt that they had no voice when discussing placements; despite of displaying good behaviour.

Assessment on emotional well-being of children and young people in care would be important, in especial, the aspect related to establishing formal and informal long lasting relationships.


What is the opinion of children and young people about mental health services?

There is a dearth of research in the United Kingdom about the subjective experience of children and young people who have been recipients of mental health services but an interesting study carried out by Ross & Egan (2004) in Dublin, Ireland provides useful indicators of how mental health provision impacts on children. Ross and Egan gathered the perceptions and experiences of thirty children, between 5-15 years attending a child and adolescent outpatient mental health service for the first time in Dublin. They made use of a qualitative approach using a ‘feelings checklist’ which included okay, scared, worried, silly, excited, upset, happy, mixed up, angry sad and curious. And, a narrative ‘cartoon strip’. The most frequently reported feelings among children between 11-15 years were, curious, mixed up, okay, worried and silly. Among the 5-10 years it was found that feelings were more confused mixed, many of them reporting positive and negative feelings at the same time. The Cartoon Strip was used to assess children’s perceptions about the service they were provided. Children and young people developed a story of how their visit had been for them. Four main stages of this story were; coming along to the clinic, waiting for and meeting the clinician, the assessment, and leaving the clinic. Themes found to be associated to these categories were: among the 5-10 years old group it was found that coming along to the clinic was associated to apprehension or why am I here? The themes for the leaving the clinic category were positive, and reassured. Among the 11-15 years old the themes for the first category were apprehensive and hostile; whilst for the last category the themes were positive outcome, “hard, but useful” and feeling better.
It can be concluded from this that when young people and children understand the importance of attending the service and the benefits drawn from it, anxiety is reduced, drop out decreased and therapeutic outcomes improved.


And what about the mental health of children and young people in care in the United Kingdom ?

Although the mental health of children and young people in care in the United Kingdom can seem a gloomy picture, it is important to highlight that “mental health” is now a matter of concern. It is acknowledged as an important element in the development and well-being of children and young people. The recommendations put forward in the National Children and Adolescent Mental Health Service Review chaired by Jo Davison (CAMHS, 2008), emphasised the role that child-centred clinics have in the satisfaction and engagement of the young population with mental health services. Some of the children and young people who participated in the survey expressed that mental health is ‘feeling in control’ or ‘feeling balanced’. Children and young people feel safe when they are taken into consideration in matters which are concern to them. These include learning disorders, sexual, physical, emotional abuse and neglect, difficult temperament, ability to learn from experiences, how to improve good self-esteem, learn problem-solving abilities and social skills.
The message coming from children, parents, health professionals and all related research is a call is for continuous support to parents, carers and anyone involved in the day-to-day contact with children and young people in areas such as child development, the causes and prevention of mental health problems, as well as providing them with tools to strengthen children and young people’s self-esteem. It is my view that the underlying theme of all this is that the emotional wellbeing of children and young people in care will be achieved by high quality assessment and continued relevant help and support based upon the establishment of long-lasting, formal and informal relationships.



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© and Nancy Mohindra  :   December, 2009


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