There are currently over 43,000 children living in OHC in Australia of whom the vast majority reside in home-based care, either foster care or relative/kinship care. It has been estimated that 3124 young people aged 15–17 years were discharged from OHC in 2013–14 (Australian Institute of Health and Welfare, 2015).
Leaving care is formally defined as the cessation of legal responsibility by the state for young people living in OHC at 18 years or younger. In practice, however, leaving care is a major life event, and a process that involves transitioning from dependence on state accommodation and supports to self-sufficiency (Cashmore & Mendes, Reference Cashmore, Mendes and Smith2015). Care leavers are not a homogeneous group, and have varied backgrounds and experiences in terms of the type and extent of abuse or neglect, the age they enter care, their cultural and ethnic backgrounds, their in-care experiences, their developmental stage and needs when exiting care, and the quantity and quality of supports available to them.
Traumatic circumstances before entering into care and experiences such as instability, disrupted attachments and sexual abuse while in OHC can adversely influence a young person's mental health. Additionally, the loneliness and isolation experienced in leaving care plus the stresses associated with the abrupt shift to living independently can potentially trigger or exacerbate underlying mental health problems (Broad, Reference Broad2005; Mendes, Johnson, & Moslehuddin, Reference Mendes, Johnson and Moslehuddin2011; Stein, Reference Stein2012). The risk of mental health problems and the emergence of mental illness in the OHC population seems to be notably higher than in the general community (CREATE Foundation, 2012; Department of Health, 2011).
The consequences of unaddressed mental health support needs can lead to care leavers being at greater risk of addictions and offending as well as negatively impacting on their education, employment and accommodation outcomes. They may be vulnerable to depression, self-harm and even suicide (Broad, Reference Broad2005; Lamont, Harland, Atkinson, & White, Reference Lamont, Harland, Atkinson and White2009).
Current state and federal policies provide little specific mental health assistance to care leavers beyond 18 years of age. The Commonwealth government introduced national OHC standards in December 2010 requiring the development of a detailed support plan covering key areas such as housing, health and financial security for all young people transitioning from OHC. The standards specifically refer to the need to provide additional services to better address the mental health needs of children and young people in and transitioning from OHC (Department of Families, Housing, Community Services & Indigenous Affairs, 2010), however, these mental health supports are only prescribed up to 18 years of age.
Additionally, the state of Victoria legislated via the Children, Youth and Families Act 2005 for the provision of leaving care and after-care services for young people up to 21 years of age. The Children, Youth and Families Act 2005 appears to oblige the government to assist care leavers with finances, housing, education and training, employment, legal advice, access to health and community services, and counselling and support depending on the assessed level of need and to consider the specific needs of Aboriginal young people. However, these supports are discretionary not mandatory, and key mental health services may not be available post 18 years of age (Mendes, Snow, & Baidawi, Reference Mendes, Snow and Baidawi2014).
The Victorian government has discussed in its five year plan (State Government Victoria, 2014) the possibility of extending supports beyond 21 years of age, but no firm commitments have been announced. An evaluation of the Springboard program, which assists young people aged 16–20 years who are currently living in or have recently left residential care, indicated that 53% of Springboard clients have mental health problems (Baldry, Trofimovs, Brown, Brackertz, & Fotheringham, Reference Baldry, Trofimovs, Brown, Brackertz and Fotheringham2015). The Springboard program, however, prioritises education, employment and training rather than health issues.
A group of health and welfare organisations headed by Orygen, the National Centre of Excellence in Youth Mental Health, are currently undertaking an assessment of the mental health needs of young people aged 12–17 years in OHC. This five year study, called the Ripple Project, does not, however, extend to care leavers, and no findings are available to date.
In this study, we define mental health as the psychological and emotional wellbeing of an individual who is able to develop their potential, work productively and creatively, build strong and productive relationships with others and contribute to their community (World Health Organisation, 2014). We use a broad definition of mental health problems to include psychiatric diagnoses as well as other mental health, emotional and behavioural issues which may not necessarily meet the diagnostic criteria for a specific disorder. This holistic notion of mental health is consistent with the Victorian Chief Psychiatrist's Guideline (Department of Health, 2011) which recommends that mental health supports for young people in OHC should not be restricted to those formally diagnosed with mental illnesses.
Existing Literature on the Mental Health Needs of Young People in and Transitioning From Out-of-home Care
International research suggests that mental health problems are more prevalent amongst young people in or transitioning from OHC (Baidawi, Mendes, & Snow, Reference Baidawi, Mendes and Snow2014; Cousins, Taggard, & Milner, Reference Cousins, Taggaret and Milner2010; Goodman & Goodman, Reference Goodman and Goodman2012). For example, Tarren-Sweeney and Hazell (Reference Tarren-Sweeney and Hazell2006) examined the mental health status of 347 children in foster and kinship care in New South Wales. They found that participants had exceptionally poor mental health, with more than half of the children reported as having psychiatric disturbances. These results are particularly concerning as the sample only included young children aged between four to nine years.
A study of 364 children from four Australian States in care with a history of placement instability found evidence of high levels of psycho-social disorders including clinical anxiety and depression (Osborn, Delfabbro, & Barber, Reference Osborn, Delfabbro and Barber2008). Similar alarming trends were found in a United Kingdom (UK) study by Minnis, Everett, Pelosi, Dunn and Knapp (Reference Minnis, Everett, Pelosi, Dunn and Knapp2006) that investigated the mental health of children aged 5 to 16 years who were residing in foster care. Through interviews with 182 children as well as their foster carers, teachers and biological family members, the study found that 60 to 70% of the children revealed mental health problems.
It is important to note that the aforementioned studies mostly exclude young people living in residential care who have generally experienced an even higher prevalence of poor mental health than those in foster care. This is demonstrated by another UK study (McCann, James, Wilson, & Dunn, Reference McCann, James, Wilson and Dunn1996) which explored the mental health of 134 adolescents aged between 13 and 17 years. The study found that 96% of young people living in residential care had some form of psychiatric disorder, compared with 57% of those living in foster care. In addition, the study showed a higher level of psychiatric disorders among those living in residential and foster care compared with adolescents living with their own families. Consistent with these findings, a British epidemiological study (Ford, Vostanis, Meltzer, & Goodman, Reference Ford, Vostanis, Meltzer and Goodman2007) found that children living in OHC had significantly higher prevalence of having at least one psychiatric diagnosis (46%) compared with children not living in care (only 15%).
The greater prevalence of mental health problems within OHC and leaving care populations appears to arise from a combination of pre-care and in-care experiences as well as poor transitional supports (Broad, Reference Broad2005). Children in OHC often come from highly disadvantaged and dysfunctional family settings that include experiences of family violence and mental health issues as well as substance abuse. The traumatic effects of physical, emotional and sexual abuse and neglect prior to entering care may predispose children in OHC to experience emotional and psychological disturbances as well as developmental delay (Avery & Freundlich, Reference Avery and Freundlich2009; Bruhn, Reference Bruhn2004; Gillberg & Soderstrom, Reference Gillberg and Soderstrom2003).
For example, a longitudinal study of 375 participants conducted by United States (US) researchers Silverman, Reinherz and Giaconia (Reference Silverman, Reinherz and Giaconia1996) examined the relationship between childhood and adolescent physical and sexual abuse and psychological functioning in adulthood. It was found that compared to their non-abused counterparts, abused participants demonstrated significant impairments in functioning, including more anxiety, psychiatric disorders and emotional-behavioural problems. Approximately 80% of the abused participants met criteria for at least one psychiatric disorder. There is also evidence indicating that children experiencing abuse and neglect, particularly in their early years when there are significant issues with attachment, have a high incidence of subsequent mental health problems (Crawford, Reference Crawford2006). Furthermore, emerging trauma neurobiology research demonstrates that exposure to chronic stress, abuse and neglect at a young age impacts on brain development, which could place this population at a greater vulnerability of developing mental health problems (Barton, Gonzalez, & Tomlinson, Reference Barton, Gonzalez and Tomlinson2012).
In addition to their negative pre-care experiences and removal from their biological family, children in OHC may be exposed to unstable and unpredictable living environments. Attachment insecurities and disturbances can arise through experiences such as loss of contact with their biological family and separation from their siblings. John Bowlby's attachment theory demonstrates the need for infants to bond with their primary care giver. It is suggested that the ability to trust and relate to others is established in early childhood through the infant and primary care giver relationship (Bowlby, Reference Bowlby1988), but this relationship may be compromised for young people in OHC (Barton et al., Reference Barton, Gonzalez and Tomlinson2012). Furthermore, multiple placement breakdowns and constant school changes are also a common occurrence, adding to their experience of relationship disruption and loss.
A South Australian study by Delfabbro, Barber and Cooper (Reference Delfabbro, Barber and Cooper2002) of 235 children aged 4 to 17 years who were placed in OHC found that approximately a fifth of young children who were referred to new placements had previously lived in six to nine placements, and a quarter had lived in ten or more placements. These changes require young people to familiarise themselves with new people, routines and surroundings, and may elicit feelings of rejection and insecurity for children in OHC. Instability may lead to the development of mental health issues.
An association between placement instability and poor wellbeing is demonstrated in Rubin, O’Reilly, Luan and Localio's (Reference Rubin, O’Reilly, Luan and Localio2007) study of 729 children residing in foster care in the USA. Their findings highlight that children who failed to achieve placement stability were estimated to have 36% to 63% increased risk of behaviour problems compared to children who achieved stability in foster care. It was concluded that placement instability for children in foster care has a significant adverse impact on their wellbeing. In contrast, there is some evidence that young people living in kinship care display better mental health functioning than those in foster and residential care (Richardson & Gleeson, Reference Richardson and Gleeson2012).
The transition period from OHC to independent living is a vulnerable time for young people, with international research indicating high rates of mental health problems for this population (Broad, Reference Broad2005; Dixon, Reference Dixon2008). On the one hand, a young person's predisposition to mental health difficulties can affect their ability to cope with the transition from OHC to independent living. On the other hand, a poor transition from care itself can adversely affect the young person's mental health. For example, accommodation issues as well as isolation from family networks and supports can affect a young person's coping strategies and their mental health (Akister, Owens, & Goodyer, Reference Akister, Owens and Goodyer2010).
A US study by Fowler, Toro and Miles (Reference Fowler, Toro and Miles2011) interviewed 265 young people aged 19 to 23 years in the first two years after leaving care to examine whether the contextual support of housing security, educational achievements and employment attainment influences rates of mental health problems. Using correlation analyses, the authors found that those who were exposed to the most unstable transitions from care also experienced significantly higher mental health problems.
In addition, Dixon, Wade, Byford, Weatherly and Lee's (Reference Dixon, Wade, Byford, Weatherly and Lee2006) English study, explored the outcomes of 106 young people who had left OHC. The study focused on the first 12 to 15 months of young people's transition from care to independent living in regards to their accommodation, carers, physical and mental health, and risk behaviour. Young people were interviewed three months after leaving care and again 12 to 15 months later. Both qualitative and quantitative data was gathered. The study findings indicated that 12% of young people had mental health problems three months after leaving OHC. The majority of young people with mental health problems described episodes of depression. Furthermore, self-harming, eating disorders, anxiety attacks and episodes of paranoia were also reported. In addition, the study found an increase in mental health problems between the first interviews, at which time young people had left OHC for three months, and at the 12 to 15 months follow-up interviews. The percentage of young people self-reporting mental health problems doubled from 12% to 24%. It was suggested that this increase in mental health problems could be linked to adverse post-care experiences such as poor housing and social isolation which had triggered memories of earlier trauma.
Only a small number of Australian leaving care studies have provided specific findings regarding the mental health needs of care leavers. A survey of 60 care leavers in Victoria – consisting of 30 young people who had experienced positive outcomes and 30 young people who had experienced negative outcomes – Raman, Inder and Forbes (Reference Raman, Inder and Forbes2005) found that 50% of care leavers had sought help from mental health professionals in the past six months, a rate approximately seven times the general population. Almost two thirds of the young people had been diagnosed with a form of physical or mental or intellectual disability or illness. A NSW study of 41 young people found that four to five years after leaving care 71% had thought about or acted on suicidal thoughts as reflected in self-harm or deliberate risk-taking behaviour, and nearly half of them had attempted to commit suicide (Cashmore & Paxman, Reference Cashmore and Paxman2007). Moreover, a national survey of care leavers found that 38% had accessed counselling in the previous six months (McDowall, Reference McDowall2009).
A Victorian study of 19 care leavers reported that many of the young people had experienced mild to significant anxiety and/or depression due to traumatic experiences of child abuse and rejection. Some required ongoing medication and specialist support (Mendes et al., Reference Mendes, Johnson and Moslehuddin2011). Another Victorian study of 77 professionals working with care leavers also involved in the youth justice system reported a prevalence of trauma-related mental health issues within the dual order population including forms of depression and anxiety, and in some cases, instances of self-harm and attempted suicide. A further concern was the challenge of accessing mental health assessments, and ongoing specialist adolescent forensic health support services. Additionally, mental health problems were seen to complicate transitions from care, and respondents believed these issues correlated with substance abuse as a form of self-medication (Mendes et al., Reference Mendes, Snow and Baidawi2014).
Care leavers experiencing or at risk of developing mental health problems would arguably have better outcomes if they had better access to therapeutic programs to deal with trauma experienced pre- and in-care, and assistance in dealing with ongoing difficulties. Therapeutic frameworks can help the young person make links between their experience of trauma, feelings and behaviours, thereby addressing unresolved feelings of anger, distress and grief from their childhood impacting on their mental health (McLoughlin & Gonzalez, Reference McLoughlin and Gonzalez2014).
Mental health support services also need to take into account the holistic context of the young people's lives including education, employment, housing and their need for social connections. UK researchers Lamont et al. (Reference Lamont, Harland, Atkinson and White2009) conducted interviews with 35 service providers and 10 care leavers, and reported that assisting care leavers with mental health difficulties to develop friends and relationships, social networking and engaging in activities within the community helped achieve positive outcomes for their mental health.
In summary, local and international evidence suggests a pattern of poor mental health among care leavers. Contributing factors include experiences of poor parenting, the traumatic effects of physical, emotional and sexual abuse and neglect including unresolved loss and grief, one or two parents with a mental illness, and exposure to poverty and deprivation. These existing problems may be exacerbated by systemic barriers to continuity of health care within the OHC system such as multiple placements and limited access to specialised health services, and also by negative after care experiences such as poor housing, social isolation, teenage pregnancy and unemployment (Dixon et al., Reference Dixon, Wade, Byford, Weatherly and Lee2006; Lopez & Allen, Reference Lopez and Allen2007; Scott & Hill, Reference Scott and Hill2006).
Methodology
To date, there have been no Australian studies that specifically researched the mental health support needs of young people transitioning from OHC. Consequently, the aims of this study undertaken for a Social Work honours thesis were to: explore the views of agencies providing services to young people leaving OHC regarding the support needs of young people with or at risk of mental health problems transitioning from OHC to living independently; and to identify practices that will lead to improved outcomes for young people with or at risk of mental health problems transitioning from OHC in Victoria.
Given the lack of existing Australian research on this topic, an exploratory level of design was judged appropriate to generate insights into the mental health support needs of young people transitioning from OHC (Alston & Bowles, Reference Alston and Bowles2003). Qualitative research was utilised in this study in order to generate a deeper understanding of perspectives on this issue. According to Alston and Bowes (Reference Alston and Bowles2003), a qualitative approach aims to “capture the richness and complexity of the lived experience” (p. 207). Furthermore, the limited research in this area meant an absence of specific variables which could be quantitatively explored (Steinberg, Reference Steinberg2004).
Since the study adopted a qualitative approach and the nature of the research question was exploratory, non-probability sampling was identified as a useful strategy to seek information in this new domain. Alston and Bowles (Reference Alston and Bowles2003), however, note that because non-probability sampling does not necessarily represent the population, the generalisability of the results is limited. Nevertheless, trustworthiness can be enhanced by the use of triangulation involving the application of more than one method of data collection (Curtin & Fossey, Reference Curtin and Fossey2007) which in this case involved focus groups and interviews. A purposive sample of professionals working in the OHC sector and/or in youth mental health services in Victoria was chosen as it was believed that these two groups would be able to provide specialised insights into the mental health support needs of care leavers.
The study comprised two groups of participants. Group one focus group participants consisted of 19 professionals (5 male and 14 female) involved in the Victorian Statewide Leaving Care Forum which is hosted quarterly by the Centre for Excellence in Child and Family Welfare. Flyers advertising the research study were emailed via the Leaving Care forum co-coordinator to those on the mailing list. Participants were able to express their interest by emailing the researcher or by joining the focus group on the day. The forum brought together workers from 14 different agencies including OHC, leaving care and mental health service providers both government and non-government. They were mostly urban, but the sample included three participants from rural OHC organisations.
Group two consisted of 11 participants (5 female and 6 male) with a range of work experience including child protection, youth justice, mental health, OHC and leaving care services, and homelessness. One participant was from a rural agency. Participants were identified from the Victorian Statewide Leaving Care Forum, and through recommendations by the honours supervisor. Agencies were either emailed or telephoned inviting professionals to participate in the study and were asked to contact the researcher for further information. Interested participants were subsequently emailed an explanatory statement and the time for an interview was arranged. Eight were interviewed in person, and three by telephone.
A semi-structured interview schedule was used for both the focus groups and the interviews. The questions were informed by the literature review, and examined a range of areas including professional experiences in working with care leavers with mental health concerns, particular challenges for this cohort, factors contributing to poor mental health, specific issues around shifting from children's to adult mental health services, and the strengths and limitations of existing mental health services.
The researcher conducted a thematic analysis of the data by coding it into categories and themes which were then compared and contrasted with findings from the literature (Alston & Bowles, Reference Alston and Bowles2003). The researcher adopted the view that qualitative data analysis can occur simultaneously with the data collection stage. This strategy was adopted as it encouraged the researcher to think analytically after each interview, and the researcher was able to obtain more insights into the emerging issues (Tutty, Rothery, & Grinnell, Reference Tutty, Rothery and Grinnell1996).
Ethics approval to conduct the study was obtained from the Monash University Human Research Ethics Committee. The researcher obtained informed consent from the participants by providing them with an explanatory statement and consent forms. The researcher explained the research in detail, and participants had the opportunity to clarify any aspects of the research in person. This ensured that participants were well informed when they consented to participate. Furthermore, confidentiality was adhered to by avoiding the identification of participants’ names when analysing the data.
The methodology had some limitations. This study was limited to a small sample of mostly OHC, leaving care and mental health service providers in Victoria. It is obviously not representative of all practitioners working in these fields in Victoria, and its findings cannot be generalised. Nevertheless, the study still provides valuable insights into the views of a group of practitioners who have specialist knowledge of the mental health needs of young people transitioning from care, and the changes that are needed to improve existing policies and practices.
Another limitation of the study was not interviewing care leavers as their experiences and perspectives about their mental health support needs would have provided significant insights into current policies and practices. However, it was not possible to locate a relevant sample of young people who had transitioned from OHC within the time constraints of this study.
Results
The results highlighted key factors influencing mental health outcomes for care leavers, current policy and practice challenges for service providers, and potential systemic reforms leading to improved mental health outcomes.
Factors Influencing Mental Health Outcomes for Care Leavers
Pre-care and out-of-home care experiences
The challenges young people experience prior to care as well as in OHC were regarded as having an adverse impact on their mental health. Participants identified these experiences as being traumatic including neglect, violence, abuse and maltreatment pre-care, and the influence of multiple placement breakdowns during care.
“The challenge [for care leavers] is the impact of trauma. . .Early experience of prolonged neglect, abuse or other forms of trauma can impact on a range of behavioural, developmental and mental health issues. So it can contribute to problems with emotional regulation, problems with forming healthy and trusting relationships. It relates to anxiety and post-traumatic stress and also behavioural issues”. Participant 8 (interview)
“Pre-care experiences were inherently extremely traumatic. A lot of these young people, even from infancy and early childhood experience often profound neglect, not being fed, not being cared for, not having their needs met. Also in a family and community situation where there was abuse, whether it was sexual, physical and emotional and often the combination”. Participant 8 (interview)
“. . .Highly vulnerable traumatised young people who have been through incredibly difficult, challenging circumstances from a very early age”. Participant 3 (interview)
“The major issues that come up for young people is a lack of consistency of care. There is a lot of turnover of staff. There's a lack of having one primary carer figure they can develop a healthy attachment relationship with”. Participant 8 (interview)
“If they are bouncing from placement to placement, it is hard for them to ever be stable and address their own [traumatic] experiences”. Participant 11 (interview)
Transition from out-of-home care experience
The participants elaborated on the heightened anxiety experienced by young people when they transition into independence at the arbitrary age of 18. Particular attention was given to the elevated stress of potential homelessness as well as the loss of support when leaving care.
“The natural anxiety anyone would feel in the context of issues they face such as a lack of access to safe, stable, affordable housing when you are coming out of out-of-home care”. Participant 3 (interview)
In addition, workers made the connection between delayed maturity amongst young people in OHC and the challenge involved in their transition to independence. Workers discussed the impact of significant trauma upon the young people's brain development. Low emotional maturity and poor decision making was identified. It was suggested that there is a significant difference between care leavers’ chronological age and their developmental functioning.
“Their developmental journey has been extremely compromised and they are maturely not ready at 18 years of age to be leaving care into independence”. - Participant 7 (interview)
“They don't have the independent living skills, resources or emotional wellbeing to deal with the sudden transition”. - Participant 8 (interview)
Transitioning From OHC Current Policy and Practice Challenges
Crisis driven practice
A common theme in the focus group discussion and interviews was that addressing discrete mental health concerns is often not a priority as the current leaving care practice is mainly crisis driven and focuses on immediate and practical needs such as appropriate accommodation.
“Often they focus on their housing so mental health isn't a priority. Accommodation is pretty much crisis driven. . .and mental health is not addressed”. - Participant (focus group)
“Mental health is by and large something we address as a means of maintenance and not necessarily in crisis all the time. Because of this maintenance it is the first thing that gets discarded. As they are leading into their end of care experience practice becomes crisis driven”. - Participant 7 (interview)
Access to mental health services
Participants commented on the barriers for care leavers accessing mental health services. They identified a gap between the eligibility criteria for child/adolescent and adult mental health services.
“Lots of people who have been in out-of-home care might have problems with their mental health that don't neatly fit the DSM criteria to be diagnosed as a mental illness. The child and adolescent system has always been oriented towards working with mental health problems and difficulty in functioning. Whereas the adult mental health system is unfortunately structured in such a way that it works with adult diagnosable disorders. Particularly when young people have experienced trauma, neglect, disrupted attachments, they may not neatly fit into those categories. So, young people might not get a service from adult mental health services”. - Participant 5 (interview)
“The peak age of onset [of mental health problems] is in the late teens and early 20s and services are not configured to sort that out”. - Participant 1 (interview)
Staffing factors
Participants raised concern about the impact of the high turnover of staff in the OHC sector on young people's mental health. It was argued that these conditions create barriers to maintaining meaningful relationships between workers and young people. One participant commented:
“I might develop a really good relationship with you as my worker but suddenly you have gone and got a job somewhere. So I have to build trust again with this new person and work through that. None of which is going to be good for my mental health or wellbeing”. - Participant 3 (interview)
Furthermore, it was noted that there are no minimal qualification requirements for those working with care leavers.
“Their entry level is not highly qualified and staff remuneration is not always good”. - Participant 3 (interview)
Practices for Improved Mental Health Outcomes
Mental health support needs
Workers discussed the importance of supporting care leavers’ mental health needs as it can significantly impact on whether or not the young people experience a successful transition from care.
“Without that basic wellbeing for a young person they’re not going to be able to get into long term independence living situations. They are not going to be able to feel included and be able to contribute socially, economically and to survive”. - Participant 8 (interview)
“Whether young people have an illness or don't have optimal mental health, it has serious consequences for their ability to learn and their ability to have a job and to feel part of the community, somewhere to live, ability to form a family of themselves. So it is really the functional aspects”. - Participant 1 (interview)
Inter-agency collaborative practice
Participants emphasised the need for agencies to work collaboratively with each other in order to improve the mental health of care leavers. They explained that meeting the mental health support needs of care leavers is not necessarily provided solely by a specific mental health service. Rather, it was suggested that young people should be provided a systemic level of support to address a range of needs including housing, education, employment and stability.
It was also noted that it is important that agencies communicate to ensure that care leavers do not have to provide the same information to multiple agencies.
“The kids are so sick and tired of retelling their story”. - Participant 7 (interview)
“Where [young people] have multiple workers, the workers need to take some responsibilities about communicating amongst one another and not expecting the young person to do that communication”. - Participant 5 (interview)
Outreach services
Participants identified outreach services as an important component in assisting young people to engage with mental health services. Discussion in the focus group focused on outreach services as being especially beneficial for young people with mental health problems who may have issues with getting out and connecting with other people. Outreach services are viewed as providing an opportunity for young people to be engaged in concrete appointments, and become more accustomed to having mental health support while they are living in a familiar environment.
Similarly, participants in individual interviews suggested that there should be more outreach opportunities for care leavers.
“Having an outreach worker come out and see them in their space seems to be a real advantage. However, there is not enough [outreach] programs to cater for everybody”. - Participant 7 (interview)
Training participants and carers
Participants discussed focusing on better support for those working with care leavers with mental health needs. This included providing mental health training and education by mental health professionals for carers, case managers and other service providers (e.g., housing, employment and education).
“Working with the care workers or the case managers and community service organisations with the aim to enable them to feel more confident in discussing topics related to mental health and wellbeing”. - Participant 1 (interview)
“. . .Ensure that workers that are having contact with [care leavers] can provide something that's therapeutic rather than assuming that they always need a direct mental health service”. - Participant 5 (interview)
Positive role of relationships
Participants argued that establishing caring and stable relationships with others was a very important factor in reducing poor mental health outcomes.
“Kids who have experienced trauma and who have been abused and going through an out-of-home care system the most vital thing for them is to assist them in their ability to function and manage through life is actually forming relationships”. - Participant 2 (interview)
In addition, it was noted that care leavers especially experience loneliness and isolation when they make the sudden transition into independence. Participants discussed that young people in care mainly form professional relationships compared to the organic social relationships formed by young people in the general population. When leaving care, relationships with former carers and workers are often lost and young people don't seem to have the social networks to feel supported. Therefore, participants recommended the introduction of mentoring and group work programs that link care leavers with the community, and assist them to develop social networks.
“We have found that group programs can provide people with opportunities to have a different experience, think about themselves in different ways, build different skills and perhaps most importantly build organic social networks”. - Participant 5 (interview)
Extending service support over the age threshold
A reoccurring theme amongst participants was the need to extend the formal supports available to ensure a better transition from care. These included specific mental health services as well as a systemic level of support whereby young people transitioning into independence are supported in finding safe and appropriate accommodation as well as assisted to access education and employment pathways.
“If we allow young people at 18 not to focus on where they will be living at 18 but they could actually focus on having a normal 18th birthday and then have support up until an appropriate age, what you would find more than likely you take away their anxiety of leaving care and you can potentially do a lot of work with that young person because you are not focusing on their leaving care plan”. - Participant 9 (interview)
“I think there should be some kind of case manager until at least 21 and some housing option until 25”. - Participant 8 (interview)
Furthermore, a comparison was made between care leavers and the general population. Whereas most young people have the ability to return home in event of a crisis or even just to return home for extra support and assistance, care leavers do not have this opportunity of gradually transitioning into independence.
“A general person in the community will often go to-and-from their experience of leaving home- they go and they come, they go and they come. You might have a young kid who decides to move out but brings washing back to mum and dad or comes back for a meal. The difficultly for young people leaving care is that this option is not there”. - Participant 2 (interview)
Participants were concerned that many young people are not ready to address their mental health needs when they leave care at the arbitrary age of 18 years or younger. Therefore, workers emphasised the importance of conceptualising transition as a process rather than a single event, giving young people more time and the opportunity to seek out mental health support later on.
“It is about giving young people an opportunity to address issues when they are ready, at a later date and providing a service for them to do that, because we know from our experience they come back”. - Participant 9 (interview)
Discussion
This study examined the mental health support needs of young people transitioning from OHC in Victoria. Many of the findings are mirrored by previous research conducted internationally. For example, one key finding is that traumatic pre-care experiences such as exposure to violence and abuse can contribute to long-term adverse mental health outcomes. Similarly, the connection between traumatic circumstances and mental health problems is well recognised in the existing literature (Gillberg & Soderstrom, Reference Gillberg and Soderstrom2003; Stovall-McClough & Dozier, Reference Stovall-McClough and Dozier2004).
Another key finding is that in-care instability, including high turnover of staff, disrupted attachments and instances of multiple placement breakdowns, can hinder attempts to address these traumatic experiences. This finding builds on previous studies showing that placement breakdown is a common occurrence that can lead to relationship disruption given the challenge of adjusting to new people and routines (Delfabbro et al., Reference Delfabbro, Barber and Cooper2002). Similar to previous research (Rubin et al., Reference Rubin, O’Reilly, Luan and Localio2007), the current study findings suggest that in-care instability presents as a challenge in achieving positive mental health outcomes.
A further key finding is the difficulty that care leavers may experience in accessing specific mental health services. The findings outline a gap between the relatively flexible eligibility criteria used by adolescent mental health services, and the requirement of adult mental health services that care leavers meet a specific diagnostic criteria to be eligible. This finding is addressed by research conducted in the UK (Broad, Reference Broad2005; Lamont et al., Reference Lamont, Harland, Atkinson and White2009) which proposes that service access should focus on early intervention before mental health problems escalate.
The study highlights a dilemma faced by workers – whether to always refer young people to specific mental health services, or alternatively, whether those already working with care leavers can provide therapeutic support. International research suggests the need to provide mental health training and education to those already working with care leavers (Lamont et al., Reference Lamont, Harland, Atkinson and White2009). This was echoed in the current study which found that there should be a focus on ensuring that the workers with whom the young people have existing trusting relationships are provided training by mental health professionals which will enable them to address mental health concerns.
Improvements in young people's mental health were shown in the current study to be fostered by positive relationships and supportive social networks. Consistent with prior research (Lamont et al., Reference Lamont, Harland, Atkinson and White2009), the study findings highlight the importance of young people establishing caring and stable relationships given they tend to experience loneliness and social isolation during the time of transition into independence. This is reinforced by a UK study (Devereux, Callan & Burghart, Reference Devereux, Callan and Burghart2014) which reported that loneliness can exacerbate underlying mental health problems.
The findings establish that heightened anxiety tends to be experienced by care leavers leading up to and during their transition to independence as there is often uncertainty about where they will be living, and formal relationships and OHC supports may end abruptly. Similarly, in the UK context, Dixon and colleagues (Reference Dixon, Wade, Byford, Weatherly and Lee2006) discuss the adverse impact that poor experiences after care, including unstable housing and social isolation, have on care leavers’ mental health.
The results of this study conform with many of the key international research findings concerning best practice models to address the mental health support needs of care leavers. They suggest the following implications for leaving care planning and policy:
(1) It is essential for leaving care systems to provide flexibility in delaying the transition from OHC where necessary, and reflect the maturity and developmental needs of the young person rather than just ending formal supports abruptly at a specific chronological age. Forcing young people to exit care prematurely is likely to exacerbate their mental health issues. Therefore, ensuring a more gradual transition from care is likely to reduce their anxiety about leaving care and so strengthen their mental health. These expectations are reasonable as most young people in the general population remain in their family home well into their twenties (Australian Bureau of Statistics, 2015).
(2) The leaving care framework should be based on ‘continuing care’ from the same agency (Bristow, Cameron, Marshall, & Omerogullari, Reference Bristow, Cameron, Marshall and Omerogullari2012), rather than requiring care leavers to change service providers during their vulnerable transitioning stage. This would enable ongoing mental health support from those agencies and workers with whom the young people already have established relationships.
(3) There should be specialist programs focused on providing training and information regarding mental health issues to carers and others who are currently working with these young people. This would facilitate earlier intervention before an escalation of symptoms and a crisis occurs.
(4) Appropriate mental health services and supports should be available to those who may be displaying less severe or emerging mental health problems. In order to appropriately respond to the mental health concerns for this population, services need to adopt a trauma-informed approach rather than a purely diagnostic approach. Furthermore, there needs to be an expansion of outreach therapeutic care options to improve access to regular mental health support.
(5) An investment in programs which provide the opportunity for care leavers to develop meaningful social connections is necessary in developing positive mental health. These programs should include mentoring and group programs within which care leavers are given the opportunity to create organic social networks. Building strong supportive relationships is key to addressing extreme loneliness and isolation and will impact positively on their mental health.
(6) Greater collaboration and joint planning between agencies is essential, particularly when aiming to meet the mental health support needs of care leavers through a holistic and systematic level of support. Inter-agency collaboration is required to assist with the acquisition of independent living skills, and promoting access to appropriate accommodation, education and employment.
(7) It is important to have accurate post-18 years data on the outcomes for young people transitioning from care with mental health problems to inform policy and practice development.
It would be beneficial for future research to involve direct consultations with care leavers. Such research should ideally examine and compare the experiences of care leavers who have good mental health outcomes with those who continue to have mental health problems a significant time after leaving care. Finally, given that only a few non-urban practitioners were included in the sample, further research needs to examine mental health service availability for care leavers in rural and regional communities.
Conclusion
This study examined the views of a small group of OHC and mental health service providers in Victoria concerning the mental health needs of young people transitioning from care. The findings suggest that a range of pre-care, in-care and transition from care experiences can contribute to poor mental health outcomes. Transitioning from care can be a particularly stressful time for young people given the lack of mandatory assistance for care leavers in Victoria beyond 18 years of age, and the tendency for existing mental health problems to be exacerbated by difficult transitions. The study highlights the need for a range of program, practice and policy reforms to ensure the availability of effective mental health services and supports for care leavers till at least 21 years of age.
