The mental health needs of children in care or at risk of entering care

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) recognises that children (a), tamariki and rangatahi in care, or at risk of entering care, are a highly vulnerable group who require access to multidisciplinary supports and services. This Position Statement identifies broad principles that should guide governments, agencies, and services in meeting the mental health care needs of children in care. ‘In Care’ refers to services provided to children/tamariki up to the age of 18 who cannot live with their immediate family/whānau, includes kinship care, foster care and residential care.

This Position Statement should be read in conjunction with the RANZCP’s Professional Practice Guideline 15: The role of the child and adolescent psychiatrist, which informs psychiatrists, other medical and health professionals, service providers, governments, and communities in Australia and New Zealand about the role of child and adolescent psychiatrists, and how they can best meet the mental health needs of young people and their families/whānau.

Key messages

• Children in care are a vulnerable group, commonly presenting with complex health and mental health needs relating to early adversity such as social disadvantage, parental substance use and intergenerational trauma.
• Children in care require early access to comprehensive, multidisciplinary assessment and intervention to prevent further trauma (including by the service system). This approach supports children in care to reach their full psychosocial, emotional, physical and educational potential.
• Children in care living in rural and remote areas increasingly face developmental vulnerability, which is compounded by limited access to services and early intervention.[1]
• Governments and services should focus on strategies for prevention, early identification and non-institutional, culturally appropriate support for children who are in care or at risk of entering care. 
• Multidisciplinary teams, which should include a psychiatrist, should provide assessments (including cultural assessments) and ongoing support that is evidence-based, trauma-informed and coordinated across agencies. 
• Assessments and assistance, including service systems, should ensure they do not retraumatise children, and should be culturally safe and use a strengths-based, child-focused approach.  
• Aboriginal and Torres Strait Islander children, tamariki Māori, and children from culturally and linguistically diverse communities have specific, additional relational contexts and needs, such as the need for access to a wider range of services.
• The cultural safety needs of children in care should be well understood, recognised and supported by relevant policies and care practices. This applies across clinical settings, and also at community, regional, and wider societal levels. 
• Legislation should clearly establish who has responsibility for making medical decisions for a child and ensure children in the care system have a role in making decisions about their own care, as appropriate to their level of developmental maturity.
• Services and care pathways should be child-focused and work alongside the family and whānau (b). 
• More support needs to be dedicated to young people in care aged 16 years and over and are likely to be ill-prepared for the transition to independence when they leave the care system.
  
  

Definitions

‘Care’ encompasses a series of services provided to children/tamariki up to the age of 18 who cannot live with their immediate family/whānau, includes kinship care, foster care and residential care.

‘Child’/‘te tamaiti’/‘children’/‘tamariki’ is defined as people aged 0–17 years, including youth. However, the needs of children in care may extend beyond age 17, especially as youth/rangatahi are transitioning out of care (those aged 18–25 years).  

Background

In Australia at the end of June 2019, approximately 44,900 children were in out-of-home care.[2] In New Zealand in December 2020, there were approximately 5,613 children in the care and protection system.[3] New Zealand has over 1 in 100 children living in institutional care – one of the highest rates in the world.[4]

A disproportionate number of Aboriginal, Torres Strait Islander children and rangatahi and tamariki Māori live in care, compared with other population groups. This difference has been attributed to discriminatory practices and systems, both historical and current.[5, 6] In 2018, Aboriginal and Torres Strait Islander children were 10.2 times more likely to be in care than non-indigenous children, more than ever before.[5] In New Zealand in 2019, 69% of the children in Oranga Tamariki care identified as Māori.[7]

Other groups overrepresented in the care system include young people with disabilities, culturally and linguistically diverse children, and children of care leavers. [8] Children with one or more of these vulnerabilities need ready access to services that meet their unique needs.

Children in care experience a higher rate of mental and physical health conditions than children who are not in care.[9] They are a vulnerable group, having often experienced trauma and other risk factors such as poverty and parental alcohol and other drug problems.[9] These early experiences are detrimental to neurodevelopment, which can then impact their physical, emotional, educational and social outcomes.[10] They also have higher rates of suicidal ideation and suicide attempts than children who are not in care.[11] Health and psychosocial interventions should be implemented as early as possible to ensure that further trauma is prevented for children in care, and it is important that these interventions are trauma-informed as well as culturally safe.[10, 12]

Service systems should recognise the capacity to retraumatise those seeking help. In Australia, the Aboriginal and Torres Strait Islander Healing Foundation emphasises the importance of providing trauma-informed, strengths-based approach to care that is based on an understanding of an Aboriginal world view and the pervasive trauma of colonisation, while creating opportunities for those affected by trauma to build a sense of control and empowerment.[10]

In New Zealand, the context of Te Tiriti o Waitangi (the Treaty of Waitangi) and Māori as tāngata whenua should be considered, as well as the historical and ongoing intergenerational trauma experienced by Māori. Te Tiriti reaffirms the tino rangatiratanga (sovereignty) of Māori and determines the Crown’s responsibilities to ensure equity. Further to this, there is a legislated requirement under s7AA of the Oranga Tamariki Act 1989 for the Oranga Tamariki chief executive to ‘recognise and provide a practical commitment to the principles of the Treaty of Waitangi’.[13] As noted in He Pāharakeke, He Rito Whakakīkinga Whāruarua, there have been consistent breaches of tino rangatiratanga in the care and protection system, which has further contributed to inequities for Māori.[14]

It is important to recognise the significance of developing and maintaining connections with family, whānau, community and culture for all children in care, and especially for Aboriginal and Torres Strait Islander children and tamariki Māori.[15] The care system should be designed to strengthen these connections. This may require system redesign led by Aboriginal and Torres Strait Islander people and Māori. Attempts should be made to place these children in kinship care to keep these connections and, where kinship care is not possible, placement within the child’s wider community (or hapū or iwi for tamariki Māori). An Aboriginal and Torres Strait Islander or other Māori carer should be next considered.[16] Where these types of care are not possible, carers must be provided with appropriate training and information on developing and maintaining connections to family, whānau, culture and community.[17]

Children in rural and remote areas are more likely to be developmentally vulnerable.[1] Children in remote areas are four times as likely as those in major cities to be the subject of substantiated cases of abuse or neglect, and twice as likely to be in care.[18] It is crucial that barriers to accessing appropriate care services for children in rural and remote areas are recognised and addressed.[18] 

Current issues

Current deficiencies in Australia’s and New Zealand’s care systems vary across their diverse jurisdictions. There is commonly a lack of targeted and effective prevention and early intervention programs, as well as a lack of integration and constructive liaison between health, social and education systems. This fragmentation limits consistency and continuity in health care and access to health records.[19, 20] The quality and safety of care for children are also impacted by other systemic issues, including the growing demand on the care system and corresponding resourcing issues, the increasing number of children and families with complex needs, placement instability, and vulnerability of young people leaving care.[20]

These system gaps are recognised in frameworks and standards in both Australia and New Zealand. In Australia, the National Framework for Protecting Australia’s Children 2009–2020 and associated National Standards for Out-of-Home Care establish standards for the out-of-home care system.[21, 22] In New Zealand, the National Care Standards set out requirements for care.[23]  These frameworks aim to ensure that young people in care can access safe, high-quality care and the right services at the right time. However, more work is needed to bridge the gaps between these children’s needs and the services provided. In New Zealand, this is particularly evident in the Waitangi Tribunal’s findings in He Pāharakeke, He Rito Whakakīkinga Whāruarua.[14]

There is a need for further research examining effective preventative and targeted interventions for children in care or at risk of entering care, and to develop evidence-based recommendations for strategies, service design and delivery. Our capacity to address the mental health needs of this group of children is constrained by our limited current knowledge of evidence-based practices. We especially need to recognise and better understand the importance of culture and the impacts of intergenerational trauma on Aboriginal and Torres Strait Islander children and tamariki Māori, and the needs of children experiencing severe mental health conditions. These evidence gaps are likely due, in part, to significant ethical, cultural and complex considerations associated with conducting research with this vulnerable group. Improvements in services must be informed by evidence, best practice, and evaluation based on Australian and New Zealand research and data.

The RANZCP supports building funded research opportunities into services’ governance and accountability arrangements and recommends that opportunities for research should be offered as part of employment within services. It is also essential that children and their families/whānau are involved in as many aspects of research as possible, as they can provide valuable input at every stage.

Role of the psychiatrist

The role of a psychiatrist, across all jurisdictions and contexts, is to use their specialist skills and medical expertise to achieve the highest quality of care for young people, in partnership with their family/whānau or carers. To do this, psychiatrists undertake a range of communication, collaboration and advocacy roles, recognising the complexity of individual clinical presentations.

The CanMEDS Physician Competency Framework clearly defines the broad role of the child and adolescent psychiatrist, including in working with children in care.[24] This framework assists in describing a child and adolescent’s unique competencies within a broad multidisciplinary team as  medical expert, communicator and collaborator, leader, scholar/professional and health advocate. Within this framework, a psychiatrist conducts a thorough psychiatric assessment and provide treatment based on available, up-to-date evidence, while also allowing for full exploration of the child’s developmental, relational and cultural identity by applying an integrated biopsychosocial model of mental health. If appropriate, psychiatrists should flag co-existing issues that may need to be addressed and facilitate eligibility assessment, preparation, and referral for treatment. Psychiatrists should maintain a collaborative, multidisciplinary approach to supporting children in care, and be aware of the ethical and legal dilemmas associated with this vulnerable group. It is important that psychiatrists are aware of the policies and practices within the jurisdiction in which they work.

Principles of a system for children in care

Children in care, or at risk of entering care, should have priority access to an integrated, comprehensive care system built on the following principles:

• Service providers should focus on prevention, early identification and support strategies for children at risk of neglect due to parental mental, physical or social incapacity, or other factors.
• Mental health clinicians working with children in care, or at risk of care, should guide protective services. 
• Health care should be provided by a multidisciplinary team, which includes:
  • child and adolescent psychiatrists who are available and accessible to provide clinical expertise, supervision and leadership and to facilitate collaborative and coordinated care of children
  • primary care or coordinating medical practitioners to ensure that the child’s care is continuous and comprehensive
  • specific culturally informed care for rangitahi and tamariki Māori in consultation with their whānau members.
• Assessments and interventions should be:
  • comprehensive and multidisciplinary, incorporating mental health and developmental and cultural assessments as well as ongoing interventions that involve cultural assessments, document risks and protective factors, and address all major domains of the child’s life (e.g., carers, birth family/whānau, peers, school)
  • evidence-based, ethical and trauma-informed, to maximise the potential for recovery and minimise the risk of re-traumatisation. These approaches emphasise and enhance strengths or activities to promote the child’s development, and may include cultural models, psychological therapies and/or medication to reduce symptoms and improve functioning.
• For the Aboriginal and Torres Strait Islander child or tamariki Māori, services should be based on the advice of Aboriginal or Torres Strait Islander Elders/Kaumātua to ensure children/tamariki have access to their culture throughout their interaction with the service system. Recovery should occur within the context of relationships within communities and family/whānau.
• For rangatahi and tamariki Māori, services should recognise the tino rangatiratanga of whānau, hapū and iwi Māori, and provide whānau-centred care. Services should enable whānau participation in decisions and provide support to the whānau as a whole.
• Support services should be flexible and adaptable to children’s different needs, able to provide the optimal care setting for the individual child among the different options within the care and protection system (e.g. welfare secure residences and welfare care and protection residences, non-kin foster placements, NGO-supported solo placements).
• Care environments should implement clear safeguarding policies and procedures to avoid further trauma to children in these settings.[25] These should involve adequate assessment, monitoring and credentialing of carers, as well as adequate support and remuneration for carers, and continual assessment of the care provided.
• The care system and associated legislation should clearly define who has the ultimate responsibility for making decisions for the child, including decisions about medical treatment. Children in the care system should have a role in making decisions about their own care, as appropriate to their level of developmental maturity.
• The care system should encourage appropriate information sharing, inter-agency collaboration and care planning between relevant parties involved in the care of the child, including appropriately trained psychiatrists, other health professionals, government departments and caregivers.
• Education and training programs on how to care should be available for carers, including developmentally appropriate information for young carers.

Recommendations

To meet the mental health needs of children in care or at risk of entering care, the RANZCP recommends:

• Improving recognition of and responses to the complex needs of many children in care within mainstream health and mental health services, to enable timely access to high-quality care and support for this vulnerable population.
• Ensuring timely access for children in care to coordinated, evidence-based, trauma-informed and culturally appropriate care via a multidisciplinary team that includes a child and adolescent psychiatrist, whose roles are as defined in the CanMEDS Physician Competency Framework.[24]
• Improving understanding and recognition of intergenerational trauma and/or the importance of culture, and these impacts on the mental health of Aboriginal and Torres Strait Islander children, rangitahi and tamariki Māori, and culturally and linguistically diverse children. 
• Recognising that service systems have the capacity to retraumatise children in care and should be trauma-informed to ensure safety. This may include acknowledging unconscious or implicit biases and providing training for clinicians to reduce racism and discrimination.
• Increasing collaboration between care and protection agencies at local and government levels, as guided by the best interests of children in care and their need for stability, security and comprehensive input. 
• Increasing investment in support for the research and development of targeted preventative interventions for infants, young children and their carers, and in training and support for the workforce that provides specialised services for children in care, including child and adolescent psychiatrists.
• Increasing investment to build psychiatry workforce including more opportunities for advanced training in psychiatry for children and adolescents. 
• Improving awareness of the vulnerability of young people in care aged 16 years and over, who often transition into adulthood without the resources or supports needed for adult life. Research into their needs should be conducted and effective services for this group should be expanded.
  
  

Further information and guidance

Identification and early in life intervention of mental illness in infants and children, Royal Australian and New Zealand College of Psychiatrists 
Cultural safety, Royal Australian and New Zealand College of Psychiatrists 
Trauma-informed practice, Royal Australian and New Zealand College of Psychiatrists

Footnotes

(a) For the purpose of this position statement the term ‘children’ refers to both children and adolescents.The World Health Organization defines adolescence as the phase of life between childhood and adulthood, from ages 10 to 19.

(b) Whānau’ (pronunciation: fa:no) - A Māori word that can be used to describe an extended family group spanning three to four generations. The whānau continues to form the basic unit of Māori society (Rāwiri Taonui)

Responsible committee: Faculty of Child and Adolescent Psychiatry 

References

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2. Australian Institute of Health and Welfare. Child protection Australia 2018–19. Child welfare series no. 72. Cat. no. CWS 74. Canberra: AIHW; 2020. Available from: https://www.aihw.gov.au/reports/child-protection/child-protection-australia-2018-19.
3. Oranga Tamarki Ministry for Children. Safety of Children in Care: Biannual Report July to December 2020 New Zealand: New Zealand Government; 2020 [Available from: https://www.orangatamariki.govt.nz/assets/Uploads/About-us/Performance-and-monitoring/safety-of-children-in-care/2019-20/Safety-Of-Children-in-Care-biannual-report-July-to-December-2020.pdf.
4. Manfred Nowak. United Nations Global Study on Children Deprived of Liberty 2019 Available from: https://www.chr.up.ac.za/images/publications/UN_Global_Study/United%20Nations%20Global%20Study%20on%20Children%20Deprived%20of%20Liberty%202019.pdf.
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6. Office of the Children’s Commissioner. Te Kuku O Te Manawa – Ka puta te riri, ka momori te ngākau, ka heke ngā roimata mo tōku pēpi. Wellington, New Zealand: Office of the Children’s Commissioner; 2020. Available from: https://www.occ.org.nz/assets/Uploads/TKTM-JUNE2020-Final-print.pdf.
7. Office of the Minister for Children. Enhancing the wellbeing of Tamariki and Rangatahi Māori: Setting measurable outcomes and developing strategic partnerships New Zealand: New Zealand Government; 2019 [Available from: https://orangatamariki.govt.nz/assets/Uploads/About-us/Report-and-releases/Cabinet-papers/Enhancing-the-wellbeing-of-tamariki-Maori/Cabinet-paper-Enhancing-the-Wellbeing-of-Tamariki-and-Rangatahi-Maori.pdf.
8. Royal Commission into Institutional Responses to Child Sexual Abuse. Final Report: Contemporary out-of-home care. Canberra: Commonwealth of Australia; 2017. Available from: https://www.childabuseroyalcommission.gov.au/final-report.
9. Turney K, Wildeman C. Mental and physical health of children in foster care. Pediatrics. 2016;138(5):e20161118.
10. Wall L, Higgins D, Hunter C. Trauma-informed care in child/family welfare services. CFCA paper no. 37 2016. Melbourne: Australian Institute of Family Studies; 2016. Available from: https://aifs.gov.au/cfca/sites/default/files/publication-documents/cfca37-trauma-informed-practice.pdf.
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13. Children, Young Persons, and Their Families (Oranga Tamariki) Legislation Act 2017, (2017).
14. Waitangi Tribunal. He Pāharakeke, He Rito Whakakīkinga Whāruarua. Wellington: The Waitangi Tribunal; 2021. Available from: https://forms.justice.govt.nz/search/Documents/WT/wt_DOC_171027305/He%20Paharakeke%20W.pdf.
15. Office of the Children's Commissioner, Oranga Tamariki—Ministry for Children. What makes a good life? Follow-up report: views of children and young people in care on wellbeing. Wellington, New Zealand: Office of the Children's Commissioner; 2019. Available from: https://www.occ.org.nz/assets/Uploads/20191104-OCC-OT-What-Makes-a-Good-Life-Follow-up-Report-FINAL2.pdf.
16. SNAICC. Understanding and applying the Aboriginal and Torres Strait Islander Child Placement Principle: SNAICC; 2017 [cited 2021 October]. Available from: https://www.snaicc.org.au/understanding-applying-aboriginal-torres-strait-islander-child-placement-principle/.
17. Kaiwai H, Allport T, Herd R, Mane J, Ford K, Leahy H, et al. Ko Te Wā Whakawhiti: it's time for change. A Māori Inquiry into Oranga Tamariki - Report: Whānau Ora Commissioning Agency; 2020. Available from: https://apo.org.au/sites/default/files/resource-files/2020-02/apo-nid274231_1.pdf.
18. Arefadib N, Moore T. Reporting the health and development of children in rural and remote Australia. Parkville, Victoria: The Centre for Community Child Health at the Royal Children’s Hospital and the Murdoch Children’s Research Institute; 2017. Available from: https://www.rch.org.au/uploadedFiles/Main/Content/ccchdev/CCCH-Reporting-the-Health-and-Development-of-Children--in-Rural-and-Remote-Aus-September-2017.pdf.
19. Royal Australasian College of Physicians. Health of Children in "Out-of-home" Care. Sydney: Royal Australasian College of Physicians 2006. Available from: https://www.racp.edu.au/docs/default-source/advocacy-library/health-of-children-in-out-of-home-care.pdf.
20. Russell Research Aotearoa. Care continuum – overseas jurisdictions: evidence brief. Wellington, New Zealand: Oranga Tamariki Evidence Centre; 2018. Available from: https://www.orangatamariki.govt.nz/assets/Uploads/About-us/Research/Latest-research/Care-continuum-overseas-jurisdictions-evidence-brief/Care-Continuum-Overseas-Jurisdictions-Evidence-Brief.pdf.
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22. Department of Families Housing Community Services and Indigenous Affairs, National Framework Implementation Working Group. An outline of National Standards for Out-of-Home Care. Australia: Commonwealth of Australia; 2011. Available from: https://www.dss.gov.au/sites/default/files/documents/pac_national_standard.pdf.
23. Oranga Tamariki (National Care Standards and Related Matters) Regulations 2018 (LI 2018/111). New Zealand legislation. Available at: https://www.legislation.govt.nz/regulation/public/2018/0111/latest/LMS56030.html.
24. Frank JR, Snell L, Sherbino J, Editors. Physician Competency Framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015. Available from: https://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e.
25. Faculty of Public Health, Royal College of General Practitioners, Royal College of Nursing, Royal College of Paediatrics and Child Health, Royal College of Psychiatrists, Royal Pharmaceutical Society, et al. Healthcare standards for children and young people in secure settings: Royal College of Paediatrics and Child Health; 2019. Available from: https://www.rcpch.ac.uk/sites/default/files/2019-09/RCPCH_Healthcare%20Standards%20for%20Children%20and%20Young%20People%201.2%20updated%202019-09.pdf. 

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.