BAAF conference report: troubled teens – recognising and responding to the health needs of looked after young people

Vaccination uptake

The first presentation by Dr Peter Barnes, CCP, South Wales, featured a study conducted to compare the uptake of HPV (human papilloma virus) vaccination in girls looked after in three Welsh local authorities. The results were compared with uptake in the same age group of non-LAC in corresponding areas. Out of 208 identified girls, 157 were included. Results showed that 90% of the girls in the general population had been fully vaccinated compared to 83% in the LAC group. These results gave rise to a lively discussion as it might have been expected that looked after populations would have better coverage than the general population. It was suggested that these poor results could be due to the complexities of obtaining consent or to the lack of GPs offering this service for young women who had missed it in school. If a similar pattern was evident across the rest of the UK, then a large number of LAC girls might have potential health consequences. Larger scale studies are needed to further assess findings.

The second presentation, by Cathy Donoghue, Designated Nurse in the London borough of Lambeth, described a teamwork approach to improve the uptake of immunisation for LAC. Cathy presented a response to very poor vaccination data in the borough in 2010. At that time, general uptake of vaccination in the looked after population was only 40% and HPV uptake was 10%. Factors included: large numbers of children placed out of area; parental attitudes; socio-economic variables; poor co-ordination of immunisation services, including access to guidelines and policies; lack of updated records, especially for children out of area; unclear professional lines of responsibility; and attitude towards immunisation.

Improvement strategies included robust appointment systems and opportunistic and outreach immunisation clinics during school holidays. This had boosted general vaccine uptake to 85% and HPV uptake to 95% by July 2014. Another positive factor was that young people felt their health was being taken seriously and that someone cared for them; also immunisations gave them additional opportunity to engage.

Again, this presentation provoked vigorous discussion. The presenters were complimented on their extraordinary achievement with other areas raising similar difficulties, particularly where children placed out of area are concerned.

Mental health

Various studies have ascertained that significant numbers of young people would look for a counselling service online and there followed an interesting presentation by the staff of Xenzone, which provides just such a tool. They explained that a range of online services is offered to 11- to 25-year-olds in areas where it is acknowledged that looked after young people require locally commissioned services that are stable, consistent, confidential and available on their terms. The models of delivery (available on Kooth.com) were outlined including personalised webpages, magazine-style pages, peer support and chat sessions. Individual, confidential, safe and anonymous services are provided to users, free at the point of contact. Commissioning is in the hands of local authorities, 17 of which have taken up these services so far.

The presentation provoked a number of questions from the audience. There is high sensitivity to issues of safeguarding and regular liaison with other services and it was explained that workers within Xenzone are highly experienced and appropriately supervised. It was also clarified that the organisation is non-profit making and is advertised in areas where it is commissioned through targeted marketing. In some cases, there can be a transition from an online to a face-to-face service.

Cecily Engle, School Outreach Therapist for the Anna Freud Centre, presented the next session. Her work engages complex and problematic families with a focus on early intervention to build resilience and prevent escalation of mental health problems and family breakdown. The aim is to treat the context and not just the individual. It was clarified during discussion that this service was not set up to engage LAC because these children have access to other resources. However, the opportunity to highlight ways of picking up children with mental health problems in school was welcomed. It was also seen as positive that this service is accessed in school and not in ‘mental health’ premises that can lead to stigma and reduced engagement.

Sexual health and well-being

To end the morning, Carlene Firmin, Senior Research Fellow at the University of Bedfordshire, delivered a powerful presentation about child sexual exploitation in gangs and groups. Carlene outlined the nature and scale of the problem, emerging trends and challenges and core components to building an effective response. Based on anonymous interviews with young people, she found that while girls highlighted fear, vulnerability and guilt as the cause of repeat exploitation, what surfaced for boys was the expression of power, control and competition with peers. The limited availability of choice and context for consent in exploitative relationships were explored. The majority of victims are reported to be girls aged 10 or above, mostly living at home but including a proportion in care. The perpetrators are mainly males, aged 12 or above. The emerging trends are very complex and create particular problems for services, such as when both victim and perpetrator require a safeguarding response. Relocating a victim prioritises physical safety but may trigger the breakdown of positive relationships. The limitations of current services were exposed with the implication that children can fall through the net. Carlene’s own work has demonstrated that for engagement to take place the environment around the child needs to be made safe – safe space counters external risk. Understanding the social environment that so many young people are having to navigate and providing support for parents and carers are essential components for an appropriate response.

The afternoon session began with a presentation on the work of Brook, a leading charitable organisation offering advice to young people regarding sexual health and well-being. Identification of the signs of sexual exploitation in young people presents challenges for services and an extensively piloted proforma has been developed to assist professionals in picking up the signs. The development of online clinical services has got the potential to deliver Brook services to new areas and more vulnerable young people. There has also been a corresponding increase in staff capacity to assess and understand what services they need. With the growth of online services, the phone line has become redundant. Feedback from young people has been very positive.

The ensuing discussion focused on how quality is assured, difficulties related to the maintenance of confidentiality in safeguarding situations and appropriate staff debriefing.

Supporting care leavers, including young offenders

Next on the agenda, Jo Thompson and Deborah Turley, both nurses for looked after young people in Worcestershire, presented their experience of developing an integrated service to engage, promote health and prepare for transition to adult services in their locality. This highly relevant session brought into focus some pitfalls such as perhaps being overly ambitious and unrealistic in planning against a historical lack of provision for this 16+ age group, but also the rewards in terms of better engagement with young people and increasing numbers of health assessments successfully achieved. The need to set realistic key performance indicators and engage and involve commissioners throughout was highlighted.

Lin Graham-Ray, another specialist nurse, went on to share her insights into the trials and tribulations of working with young offenders. Many of these young people have experienced school exclusion, learning difficulties, communication problems, mental health disorders and/or longstanding physical complaints, and homelessness, and a significant number have been looked after. Lin described the journey she had to access young people in custody and was able to give an update on active projects for this particular group. The Legal Aid Sentencing and Punishment of Offenders Act in relation to looked after children was outlined together with the implications for health services. Lin presented some moving accounts of young people in custody who had greatly valued her service.

The final presentation by Dr Adele Yeadon, a paediatrician from Leeds, opened with a quotation: ‘Life does not get any easier or forgiving, we get stronger and more resilient.’ She presented her research about resilience in looked after young people in Leeds. A paper-based questionnaire was sent (or given) to 84 12- to 15-year-olds who had been in care for at least 12 months. Thirty-eight questionnaires were returned, predictably confirming the requirements for positive education experience, positive relationships with the primary carer and other adults and strong social networks as key factors for promoting resilience. Areas requiring better opportunities for young people included ways of improving self-esteem, provision of personalised support for care leavers, creation of a care leaver passport and training for foster carers in sexual health education.

Conclusion

Among the key reflections of the day was the familiar emphasis on the importance of listening to young people to ascertain their views and feelings; it was affirmed that developing services need to be sensitive to the views of young people but also consistent and safe. The complexities of developing services for young people living in a digital age were strongly highlighted. Difficulties faced by children placed out of area were also raised in a number of discussions. The poster sessions appeared to be warmly received although delegates were overheard saying that they had not had time to see them. All in all, this was a successful conference on a theme that is likely to become even more pressing in the years to come.