Prepared by Jenny Marshall & Graham Vimpani Primary Health and Community Partnerships Branch

1. Children in statutory out-of-home care: what do the case files tell us about their health status? Prepared by Jenny Marshall & Graham VimpaniPrimary Health and Community Partnerships Branch NSW Department of Health October 2010

2. Background • 4,830 children and young people entered care in NSW in 2008/09 • Over 16,524 children and young people are currently in out-of-home care in NSW • 65.3% in statutory care, 34.4% in supported care • 56% were in the care of relatives, parents or kin, with or without a Court order • 44% were in foster care with a non-related person or in another care arrangement e.g. residential care or supported accommodation • High prevalence of health care needs in children entering out of home care (OOHC) • Kari clinic and Sydney Children’s Hospital studies • KTS has committed to health assessment of children within one month of entering OOHC

3. Research Questions • What is the Health status and health care prior to entry into OOHC? • How many children are currently assessed when they enter OOHC? • What Health and/or developmental assessments have occurred since entering care and what domains of health and development are covered by this assessment? • What are the outcomes following these assessments (by way of diagnosis, referral and treatment) and have these outcomes been actioned?

4. Methods

5. Children’s Guardian Case File audit 2008-9, 2009-10 • The Audit collected data from case files on a representative sample of children and young people in out-of-home care on either interim or final orders. • Small advisory committee established • Recommendations of professional colleges etc noted • The two phase sample of 3448 included 816 children who were placed within 15 months of the Audit date • Audit included 51 designated agencies which were providing court ordered out-of-home care over the period of the Audit • 49 non-government agencies, • Ageing, Disability and Home Care and • Community Services

6. Methods • Sample was drawn for each agency using iSix Sigma methodology • PricewaterhouseCoopers engaged to assist with CS sample • 2 phase study covering all CS regions and NGOs • Health problem considered to exist if mentioned on file • Some additional health questions added in 2010 (Phase 2b)

7. Results

8. Results – age groups

9. Results – Indigenous status

10. Results – by AHS

11. Key questions • Did the child or young person have a pre-existing recognised health and or developmental problem for which they were receiving treatment prior to entering care? • Don’t know • Is the child or young person’s key health information recorded on the files – less often recorded for children in kinship care • Medical history - 37.5% • Family medical history -12.1% • Medicare number - 90.3% • Medical problems – 39.5% • Asthma, Diabetes, Epilepsy, Severe allergies – 13.1% • Dental problems – 31.8% • Mental or behavioural problems - 38.6% • Hospital of birth? – Don’t know

12. Blue book and immunisation • Blue book record in 2.9% • Up-to-date immunisation status recorded in 61.6% of children under 8 years

13. What health care providers have been identified for this child or young person? • 62.6% had GP details (44.1% kinship v 69.0% foster) • 39.1% of children over 2 had dentists’ details • 54.6% had other health professionals listed on file and 44.3% had their details – more specific details in phase 2b • Not known if in public or private system • 33.8% in Phase 2b had paediatricians’ details recorded • AMS mentioned in 64.4% of Aboriginal children’s files with their contact details mentioned in 30.4% • Apparent poorer recording of details for children in kinship care

14. Has a health and/or developmental assessment been conducted? • Of the 816 files examined in which the child or young person had been placed within the past 15 months, 22.1% (or 178 children) had an initial health assessment within 60 days (previous CS standard) • Higher in younger children • Higher in foster children (27.7% v 16.4%) • Higher in Indigenous children (24.4% v 20.5%) • AHS variability (SW 12.1% - SESI 39.2%)

15. What details are available about the content and comprehensiveness of health assessments in the 22.1% who had them? • 55.6% included a medical history of the child • 16.9% included a medical history of the family • 47.8% included a immunisation register check • 93.3% included a physical examination • 40.3% (children 2 years and over) included dental health • 65.2% included a developmental assessment • 47.7% included a visual check • 47.2% included a hearing check • 43.3% included a mental health/behavioural assessment • 66.7% included screening for pathological conditions.

16. What details are available about the content and comprehensiveness of health assessments in the 22.1% who had them? • Higher proportions of Aboriginal children and young people had physical examination, immunisation register check, vision and hearing checks but a lower proportion had a developmental and mental health/behavioural assessments

17. Who did the health assessments in Phase 3?

18. Outcomes • If referrals were recommended in the health and/or developmental assessment/s: Who were the referrals to? Were the referrals to public or private providers? What, if any, action has occurred? • No information • If any ongoing treatment has been considered necessary, has this occurred and has continuity of care been maintained? • No information

19. Outcomes – current care plans • 70.9% had current care plan (target 100%) • k 60.1%; f 74.5% • 59.9% had a current care plan that addressed and/or reviewing health issues (k 46.2%; f 64.4%) • 41.3% had a current care plan that addressed dental issues (k 26.1% ;f 46.5%) • 61.8% had a current care plan that reviewed behavioural issues (k 46.4%;f 66.6%) • 52.7% had a current care plan that included a report on psychological or psychiatric well being (k 34.6%; f 57.7%)

20. Summary and conclusions • The Children’s Guardian has observed there is minimal information on the health status of children on their files prior to assumption of care yet there is significant information about the parenting capacity of their birth parents. • The case files suggest a relatively low baseline of children or young persons entering care receiving initial health assessments (at around 20% of those eligible); • The case files are not showing universal coverage at this time in important areas of primary health care (Medicare, GPs, dental care, immunisation, Blue Book); • The case files are showing a relatively low rate of children and young persons in care with recorded personal medical histories and family medical histories;

21. Summary and conclusions • The case files suggest that only some and not all Aboriginal children in care are linked to Aboriginal Medical Services; • Health issues are not being routinely addressed in Community Services’ care plans for children and young people in out of home care; • 44.3% had contact details of other professionals recorded. The highest proportions were for paediatricians, psychologists and speech pathologists • Children and young persons in OOHC had lower proportions with mental health or behavioural problems than in many other studies (CBCL scores in clinical range in over half, compared with 38.6% in this study) • Unclear whether the lower rates of recorded behaviour problems for children in kinship care represents real difference or inconsistencies in documentation

22. Summary and conclusions • Will comprehensive health assessments result in children and young people in care receiving the ongoing treatment they need? • Consistent approach to recording data on health needs by agencies • Development of a template jointly between CS, NGOs and Health • Data collection system should record outcomes of health assessments and follow up reviews • Longitudinal data through the pathways of care study will be helpful. • Action-Research Strategy to examine processes and outcomes of new approach to Health Assessment in NSW

23. Summary and conclusions • Do health interventions initiated at the time of entering statutory care improve the medium and long-term health and wellbeing outcomes of these vulnerable children and young people. • We need to know whether some of the health and wellbeing problems of children arising from their earlier experiences of disadvantage, trauma and neglect are so entrenched by the time they enter care that significant improvements at this late stage are difficult to achieve. • Earlier identification of health and developmental issues and effective intervention at the time risk of significant harm has been first substantiated may be required. • Tarren Sweeney (2006) has shown improved outcomes in younger children where interval between maltreatment and placement in OOHC is shorter • Collaborative work between CS and Health

24. Acknowledgements • Kerryn Boland and other staff of the Children’s Guardian’s office for access to work done as part of the file audit of children in OOHC • Staff in the Mental Health and Drug & Alcohol office, NSW Department of Health • Margo Barr, epidemiologist, NSW Health currently on secondment to Community Services • Members of the OOHC Research Advisory Committee, NSW Health

25. The End