Dr Emma Sunderland, Dr Liz Jacks and Dr Hannah Zhu
About to start a job in community paediatrics? This article will cover how to perform an initial health assessment for a child or young person who finds themselves ‘in care’.
When a child or young person is removed from their families to go into foster or residential care they are required by law to be offered an initial health assessment (IHA). During your community paediatrics job, you may be asked to contribute to these health assessments. It can feel quite strange doing an assessment on someone who has not chosen to come to you for help with a specific medical problem. You can quickly find yourself lost in the forms and acronyms associated with being ‘in care’. This article aims to help you to navigate the obstacles and perform assessments that make a difference for the children and young people that you see.
Why is this important?
Those in care have higher rates of physical, developmental and mental health problems and worse longer-term outcomes than their peers. Think about the reasons a child or young person may go into care. They are likely to have experienced abuse and neglect, growing up in chaotic households where their health needs were not met. The health assessment provides an opportunity to ensure that issues are identified and addressed, as well as to promote health and wellbeing moving forward.
Performing a health assessment usually involves completing a long form…don’t let it distract you from doing a great job for the young people that you see!
Before getting started it’s important that there is appropriate consent in place for the health assessment. This is usually gained from the birth family by the social worker at the time the child or young person becomes ‘looked after’. It’s rare that consent is withheld; a senior member of the social care team can also provide consent if an appropriate care order is in place. A young person can also provide consent if they have capacity to do this.
Some young people may be told that the health assessment is a ‘compulsory’ part of being ‘in care’ and this can put them off attending. Letting them know in advance what the purpose of the assessment is and that they can “opt out” of any aspects of it at any time can help to reassure them.
Setting the scene
At the start of the appointment there are a number of key things that you need to be sure the child or young person understands.
- The purpose of the assessment – to support them with their health and wellbeing
- That they get to choose who is in the room
- Confidentiality and its limits
- That you will write a report with some recommendations for their health and that this will be shared with their social worker and their GP.
“ If there is something that we talk about today that you don’t want to share then we will respect that unless it was something really serious that could put you or someone else at risk”
Foster carers, social workers and sometimes birth families can provide useful contributions to health assessments and for younger children they are likely to need to be present throughout the assessment. However it is best practice to also assess every child or young person on their own if developmentally appropriate, for part of the assessment, to ensure we have every opportunity to hear their voice, learn what matters to them and allow them to discuss any concerns about their current placement and wellbeing in confidence.
Start with trying to identify if the child or young person has any worries about their mental or physical health. The foster carer or social worker may also have some concerns that they think need to be addressed.
Next, explore the key components of a healthy lifestyle.
- Activites, exercise and hobbies
How is the placement going for the child or young person? Do they have a trusted adult they can go to if they have a problem?
For unaccompanied asylum seeking young people there are a number of specific health risks that relate to their home countries, journey and experiences in the UK. This may include injuries resulting from accidents, assaults or even torture, exposure to infections or incomplete vaccinations.
Remember to ask about vision, hearing and dental reviews. These are things that could have easily been missed in a chaotic household.
Are there any current medical conditions, regular medications, or allergies? Are there any health care appointments coming up or were any missed when they went into care?
The dates of all immunisations should be recorded. This may involve reviewing GP records or calling child health records services. If there are missed immunisations or an incomplete history, recommend a catch up program and explain this to the young person, giving them the opportunity to ask any questions they may have.
This section is essentially a thorough antenatal, birth, family and past medical history. There may be information available from GP held records, the social worker or birth parents.
Many children who are ‘looked after’ will have a history of antenatal exposure to alcohol or illicit drugs. Family history should include not just physical conditions but also any history of mental illness and learning difficulties.
These factors can have significant implications for their future health and development. Through early identification of the risks you can facilitate early intervention if problems arise. This information is also important for the child or young person as they grow older, as well as for prospective adopters.
Social care history
This should be gathered from the social worker and will include any history of abuse or neglect. It is important to consider the impact of your questions on the child or young person and avoid asking probing questions that may be traumatic for them when not absolutely necessary to your assessment of their health. It may be helpful to obtain this history from the social worker alone, without the child present.
Impact of contact
Many children and young people will have ongoing contact with their birth families. This can be a difficult experience to navigate and bring up lots of confusing emotions for children and young people. Try to understand what they think about the contact arrangements. Foster carers and social workers may have their own views about this which may well provide a valuable insight but this is not a substitute for hearing the child or young person’s voice.
Emotional and behavioural development
Children and young people who are ‘looked after’ have much higher rates of mental health problems than their peers. Your earlier questions about sleep, diet, friendships and feelings may help direct you to areas you may want to explore further. Issues with behaviour are a primary cause of placement breakdown. By identifying problems early and providing timely support you can help prevent a cycle of destabilising moves that can have a hugely detrimental effect on the young person.
For all children, this will include thinking about danger awareness, risks and road safety.
For older children, this will involve the inevitable questions about self harm, sexual health and substance misuse. Consider whether the young person’s social media use could also be placing them at risk. Think about whether the young person could be at risk of gang based violence or exploitation. When a young person becomes looked after they are often at a crisis point, on the background of long standing difficulties with their families. They are extremely vulnerable to sexual or criminal exploitation and may not be able to recognise when this is occurring.
It can be helpful to explain to the young person why you’re asking these questions and to make it clear that you’re not there to judge.
“Sex and relationships can have a big impact on your health and wellbeing so this is something we ask all young people about. We want to find out whether you feel happy and safe in your relationship and make sure that you know how to access contraception and prevent STIs.”
“Using drugs and alcohol can affect your physical and mental health. We’re not here to lecture you, we just want to help make sure you have accurate information about any substances you’re using and that you know where to find out more or access expert help.”
The young person you see may (understandably) not want to disclose all their risk behaviours to you but you can still signpost them to local services who can provide them with appropriate support, such as a young persons sexual health clinic or substance misuse services.
For younger children a developmental history and assessment will help to identify any needs in this area.
- Gross motor
- Fine motor
- Speech, language and communication
- Self care and social
- Play and learning
Pay particular attention to how the child interacts with you and with their carer. Children who have experienced inconsistent care may display behaviours that could indicate a problem with attachment such as being overly familiar to those they meet or indifferent to their carers. Think about their experience before coming in to care and how this could have impacted on different aspects of their development. You should conclude whether development in each of these areas is within the expected range. If it is not think about why this might be and what services might be required to support their development.
Looked after children and young people have significantly worse educational outcomes than their peers. Their experience of education can have a huge impact on their health and wellbeing throughout their lives. Try to gain an understanding of the child or young person’s likes and dislikes, their aspirations and what are the barriers to their learning. Most children and young people will be supported by the ‘virtual school’. The virtual school usually consists of specialist teachers and therapists who will work with children and young people directly or provide advice and support to their schools to ensure that their educational needs are met.
For older children careful preparation for independence is key to securing their long term health and well being. Can the young person travel independently, are they able to manage money, can they cook for themselves? Ensuring that young people are able to access health services appropriately is also an essential part of the preparation for independence.
This will comprise checking height and weight and calculating body mass index to determine whether the child or young person’s weight is in the healthy range.
You should then perform a full systems examination (including teeth), focusing on areas where you have identified problems in your history.
Remember – not all children and young people who come for an initial health assessment will have had a safeguarding medical assessment. This may be the first time they are examined by a doctor since they have come into care. Be thorough and meticulous in your approach looking for signs of injury and neglect.
This is where your thorough and holistic assessment can really make a difference for the child or young person you’ve seen. Remember that this section will be shared and reviewed as part of regular reviews by children’s social care. Make sure the young person you have seen is aware of this and happy for the information to be shared.
Consider all the unmet health needs and risks that you have identified. What can you do to address them?
- Do they have a health problem that needs further investigation or treatment by their GP or a referral to secondary care?
- Are any chronic diseases being managed well? Do they have all the medications they need?
- Could they benefit from input from specialist psychology services?
- Have they missed any aspects of screening or preventative care such as dental reviews and immunisations?
- Try to think more widely… what services in the wider community could be of benefit to their health and well being?
- How about recommending that the young person’s social worker helps them to find a football club they could play for to ensure they are getting enough exercise.
- Maybe a recommendation that the young person downloads the ‘change for life’ mobile app for ideas for healthy recipes to try at home.
This is your opportunity to promote the health of the child or young person you have seen.
You should discuss your recommendations with the child or young person and try to come up with a plan together.
It is important that all recommendations have a timescale and responsible person identified. Particularly where placements are short term it can be easy for actions to be missed. There is no point doing an assessment if recommendations aren’t followed and failing to follow through can further contribute to mistrust in professionals which can be extremely detrimental for this vulnerable group.
Young people in care value professionals who listen to them, take their views seriously and ‘get things done’. Your assessment can address unmet health needs and empower children, young people and their carers to make positive decisions for their health. By listening, taking them seriously and being a reliable professional that turns words into actions, YOU can set the precedent for future interactions with health services and put young people who’ve experienced lots of challenges on the right track.
- Set the scene – make sure the young person you see is fully informed
- Focus on what the child or young person thinks is important, try to hear their voice
- Think about how the child or young person’s experiences could affect all aspects of their health and well being
- Make sure that they haven’t missed out on key opportunities for preventative care like dental reviews and immunisations
- Work in partnership with the young person to come up with recommendations that address their health needs
CoramBAAF is an organisation for professionals, foster carers and adopters, and anyone else working with or looking after children in or from care. Its website is filled with lots of relevant information regarding health assessments.
Unaccompanied Asylum Seeking Young People
This article provides a useful framework for understanding the health risks unaccompanied asylum seeking children and young people face, giving you the tools you need to perform a holistic assessment.
This website from the team in Kent is full of useful documents, templates, tools and guidance relating to unaccompanied asylum seeking young people. It also has health information for young people in a range of different languages.
This helpful one page summary gives advice on what to do when you have an incomplete immunisation history. For most UK born children you will be able to find out their immunisation status from their GP or by calling local child health services.
This article provides information on how to recognise the signs of sexual exploitation, a really important skill for those working with looked after children and young people.
This article outlines the specific requirements placed on local authorities for the education of looked after children and young people, including the role of the virtual school.
This article provides lots of useful tips for how to approach health promotion without being patronising