Children become looked after for many reasons: parental abuse or neglect, parental illness or substance misuse, domestic violence, or the death of a parent. What they share is a period of disruption and, in many cases, significant adverse childhood experience before the care placement begins. Understanding the context – what these children have typically been through before the placement – is essential to understanding their health and developmental needs.
For foster carers, adopters, and professionals working with children in care, the challenge is usually not identifying that a child has needs but accessing the right support quickly enough, in a system that is stretched and often fragmented. The entitlements exist; the navigation can be hard.
Healthbooq (healthbooq.com/apps/healthbooq-kids) covers children with additional needs and the families and professionals who support them.
Who Is a Looked After Child
A child is legally "looked after" if they are in the care of their local authority. This includes children on care orders (where the local authority shares parental responsibility), children placed in care under voluntary agreements with their parents (section 20 arrangements), and children on remand or subject to emergency protection orders. In England in 2023, around 82,000 children were in care at any one time – a number that has risen by over 20% in ten years.
The largest group (around 75%) is placed with foster families. The remainder are in residential children's homes, with kinship carers (family members or friends of the family approved as carers), or – for older teenagers – in semi-independent living arrangements. The majority of children in care are aged 10 and over; a significant proportion entered care as teenagers. Around a quarter are under five.
Health Needs in Children in Care
Children in care have substantially higher rates of health problems than the general child population. Physical health needs include untreated dental problems, undetected visual and hearing impairments, and incomplete immunisation histories – often consequences of poor engagement with health services before the placement. Growth problems, reflecting nutritional neglect or chronic stress, are more common than in the general population.
Mental health difficulties affect the majority of looked after children. The Office for National Statistics has found that around half of looked after children have a diagnosable mental disorder, compared with around 10% of children in the general population. The conditions most commonly seen include conduct disorders, emotional disorders (anxiety and depression), PTSD and trauma-related symptoms, attachment difficulties, and ADHD. Many children in care have experienced complex developmental trauma – repeated, early, relational trauma from caregiving figures – which affects development in ways that may not map neatly onto single diagnostic categories.
Neurodevelopmental conditions including ADHD, autism, and learning difficulties are substantially overrepresented in the care population – partly because these conditions may have contributed to family difficulties, and partly because early adversity and chronic stress affect neurodevelopment. Foetal alcohol spectrum disorder (FASD) is significantly more prevalent in children who have been in care than in the general population, and is often undiagnosed.
The Statutory Framework
Looked after children are entitled to specific health provisions under the Children Act 1989 and subsequent guidance. Every looked after child must have an initial health assessment within 20 working days of entering care, and subsequent reviews annually (or six-monthly for children under five). These assessments are coordinated by the Designated Doctor and Designated Nurse for Looked After Children in each local authority area.
The Looked After Child (LAC) review health assessment covers physical health, developmental progress, immunisation history, dental health, emotional and mental health, and education. It produces a health plan that identifies actions and responsibilities.
The child's GP and the virtual school head (every local authority has a virtual school head responsible for the educational attainment of looked after children) are key parts of the support network. Children in care are also entitled to priority access to CAMHS assessments.
Trauma and Attachment
The framing of "trauma-informed care" has become standard in children's services and is particularly important for looked after children. Bessel van der Kolk, whose book The Body Keeps the Score brought trauma neuroscience to a wide audience, and Dan Hughes, who developed Dyadic Developmental Psychotherapy (DDP) specifically for children with developmental trauma and attachment difficulties, have both significantly influenced practice in this area.
DDP, developed by Hughes at the Osteopathic Medical Center in Maine and widely adopted in the UK, works with the parent-child dyad using PACE – Playfulness, Acceptance, Curiosity, and Empathy – to support the development of secure attachment. Kim Golding at the University of Staffordshire has been influential in adapting DDP principles for foster carers and adoptive parents in the UK, producing the Nurturing Attachments programme.
For children with significant early relational trauma, standard therapeutic approaches designed for single-incident trauma or straightforward emotional difficulties may be less effective than trauma-specific and attachment-informed interventions.
Transitions
Transitions are particularly challenging for looked after children – between placements (placement moves are common and each one involves loss), between schools, and at the point of leaving care. "Care leavers" (young people who have left the care system) at age 18-25 are entitled to continuing support from their local authority, including a personal adviser and a pathway plan; they retain priority access to social housing and financial support through the Staying Put arrangement (allowing young people to remain with their foster family to age 21).
Support for Foster Carers and Adopters
The Fostering Network and Action for Children provide information and support for foster carers. Adoption UK is the main support organisation for adoptive families. For children with FASD, the FASD Trust and the work of Susan Astley Hemingway at the University of Washington (who developed the FASD diagnostic criteria) and UK clinicians including Penny Maudlin are relevant resources.
Key Takeaways
There are around 82,000 children looked after by local authorities in England at any one time, with the number rising steadily over the past decade. Children in care have substantially higher rates of physical health problems, mental health difficulties, learning differences, and neurodevelopmental conditions than the general population – reflecting both the adversity that led to care and often inadequate health care prior to entering the system. The Designated Doctor and Nurse for Looked After Children in each area coordinate health assessments; looked after children are entitled to statutory health reviews. Most children in care are placed with foster families; a smaller number are in residential care or kinship care arrangements.
