Improving the health of Australian children entering out-of-home care

Decisions to remove children from their biological parents are never taken lightly. Such decisions are reinforced by the growing body of evidence of the adverse short- and long-term outcomes of child maltreatment,1 which are increasingly seen to be mediated through the effects of abuse on early brain development.

Given the prevalence of physical, developmental and psychosocial morbidity in this population, most clinicians would agree that every Australian child and young person taken into the protection of out-of-home care following abuse or neglect should receive a comprehensive assessment of their physical, developmental, psychosocial and mental health needs. To maximise each young Australian’s chance of achieving optimum health after abuse or neglect, the first national out-of-home care standards, introduced from 1 July 2011, challenge state and territory governments to work more closely with doctors to reach and maintain new health assessment and treatment goals.2

At 30 June 2010, 35 895 Australians aged 0–17 years lived in out-of-home care.3 Of these, 12 002 had entered care during the previous financial year. The health status of these children has become a matter of increasing concern in Australia over the past decade. A recent study of 122 children attending a specialist clinic for children in out-of-home care found that only 3% had no recognised health issues.4 Health issues ranged from the relatively simple, such as uncertainty about immunisation status, to the complex, such as the developmental, emotional and behavioural problems that are often the sequelae of earlier trauma or poor attachment. Professional medical colleges5,6 and research studies of children in out-of-home care7 have each pointed to an increased risk of poor short- and long-term physical and mental health outcomes.

Most Australian jurisdictions expect the child protection system to ensure the conduct of health checks of children entering out-of-home care. In reality, practice has not always met the expectation. Recent audits in two states suggested that less than 25% of children receive comprehensive assessment in a timely way or have acceptable health records and health care management plans in place.8,9 Even when health needs are identified, many young people in out-of-home care do not have these needs met. Current practice will need to change substantially in most Australian states and territories if the new standards are to be met within the next 3 years.

We face significant challenges in improving the management of the health of children and young people in out-of-home care.

The first, overarching hurdle lies in replicating the work of vigilant, emotionally attached parents who steer most Australian children successfully through the sea of the Australian health care system. Health professionals rely on parents to provide medical histories, monitor wellbeing, locate appropriate health services, explain health concerns, consent to assessment and treatment, and monitor outcomes. When children and young people are dislocated from this parental relationship, there is a high risk that understanding about the individual child’s health needs, health history and continuity of health care may be lost, despite the dedication and best efforts of carers and case managers.

Second, health service providers face their own challenges. Although initial assessments of health status addressing immunisation, vision and hearing can be straightforward, determining which children need more comprehensive assessments and require multidisciplinary input is far more complex. Which triage tools are the most appropriate? Once problems have been identified and included in a care plan, who should take on the case management role to ensure that they are addressed in a timely and ongoing way? Should this be a health professional or staff employed by welfare departments, or the non-government organisations providing out-of-home care? And then, who will advocate for additional service provision to meet the needs identified?

Incompatible information technology and records management systems, along with medicolegal issues, can make the transfer of health information between health professionals and child welfare agencies highly problematic,10 notwithstanding that legislative changes in some states now support information exchange in circumstances related to the safety, welfare or wellbeing of a child.

Finally, given that entry into care usually occurs some years after maltreatment is first identified, should more effort be made to assess the health status of children in contact with the statutory child protection system earlier? Effective interventions offered at this time may not only prevent the later transition into care but radically improve the long-term health and wellbeing outcomes of children and young people who have been maltreated.