Primary care needs of young people in residential care
from – https://www.racgp.org.au/afp/2016/october/meeting-the-primary-care-needs-of-young-people-in
Definition of Out-of-Home Care (OOHC)
- Children/young people unable to live safely with family due to:
- Abuse
- Neglect
- Abandonment
- Death/incapacity of parents
- Types of OOHC:
- Kinship care
- Foster care
- Residential care
- Residential care:
- Usually adolescents >12 years
- Group homes with rostered staff
- Often associated with:
- Placement instability
- Complex trauma
- Behavioural issues
- Mental health disorders
- Substance use risks
Key Health Risks in Young People in OOHC
Physical Health
- Poor nutrition
- Obesity
- Dental disease
- Sleep problems
- Asthma
- Poor access to preventative healthcare
- Delayed immunisations
- Sexual health risks:
- Early sexual activity
- STIs
- Unplanned pregnancy
- Sexual exploitation risk
Mental Health
- Very high rates of mental illness
- PTSD
- Anxiety
- Depression
- Substance use disorders
- Self-harm and suicide risk
- Behavioural dysregulation
- Borderline personality disorder traits/features
- Attachment difficulties
- Complex trauma
Developmental / Educational
- Developmental delay
- Learning difficulties
- Autism spectrum disorder
- Speech/language disorders
- School non-attendance
- Frequent school changes
GP Role in OOHC
Core GP Responsibilities
- Identify child/young person is in OOHC
- Build therapeutic relationship
- Provide continuity of care
- Coordinate multidisciplinary care
- Advocate for vulnerable patient
- Monitor physical + mental health longitudinally
- Ensure trauma-informed approach
Trauma-Informed Care Principles
Key Principles
- Safety
- Trustworthiness
- Collaboration
- Empowerment
- Choice
- Non-judgemental communication
Practical GP Strategies
- Warm, calm approach
- Active listening
- Validate experiences
- Avoid coercive language
- Explain confidentiality clearly
- Allow patient control where possible
- Offer choices during consultation
- Be aware examinations may retraumatise
Important Point
- Young people in care may feel:
- Powerless
- Controlled by systems
- Mistrustful of adults/services
National Clinical Assessment Framework (Australia)
Recommended Assessments
Within 30 Days
- Preliminary health assessment
Within 3 Months
- Comprehensive health + developmental assessment
Domains to Assess
- Physical health
- Mental health
- Development
- Psychosocial wellbeing
- Education/vocation
- Sexual health
- Substance use
- Risk/safeguarding
Consultation Framework for GP
1. Establish Safety
- Introduce confidentiality + limits
- Explain mandatory reporting obligations
- Clarify who attends appointment and why
- Ensure young person has opportunity to speak privately
2. Psychosocial Assessment
Use:
- HEEADSSS framework
Assess:
- Home/care placement
- Education/employment
- Eating/body image
- Activities/peer supports
- Drugs/alcohol
- Sexual health/relationships
- Suicide/self-harm
- Safety/exploitation
3. Trauma Screening
Ask sensitively about:
- Abuse history
- Exposure to violence
- Placement instability
- Feeling safe currently
- Sleep/nightmares/hypervigilance
4. Physical Health
- Growth/BMI
- Vision/hearing
- Dental
- Immunisation status
- Chronic diseases
- Medication review
- Sexual/reproductive health
Mental Health Considerations
High-Risk Features
- Self-harm
- Suicidality
- Dissociation
- Aggression
- Substance misuse
- Emotional dysregulation
- School refusal
- Risk-taking behaviour
Management
- Psychological therapies first-line
- Trauma-focused therapy
- Family/carer involvement where appropriate
- Judicious medication use
- Psychiatric referral if:
- Diagnostic uncertainty
- Significant risk
- Severe impairment
- Poor response to treatment
Legal & Consent Issues (Australia)
Confidentiality
Always explain:
- What is confidential
- Limits of confidentiality:
- Risk of harm
- Abuse/disclosure obligations
- Mandatory reporting
Mandatory Reporting
GPs must understand:
- State-specific child protection legislation
- Reporting obligations for:
- Physical abuse
- Sexual abuse
- Neglect
- Significant harm risk
Consent in Minors
Who Can Consent?
Depends on:
- Age
- Capacity
- Guardianship order
- Nature of treatment
Gillick Competence
A young person <18 years may consent independently if they:
- Demonstrate sufficient maturity
- Understand:
- Condition
- Treatment
- Risks/benefits
- Alternatives
- Consequences of refusal
Important
- Being in OOHC does NOT exclude Gillick competence
Mature Minor Doctrine
Definition
- Legal principle recognising some adolescents can make healthcare decisions independently before age 18
Assessment Includes
- Understanding
- Reasoning ability
- Appreciation of consequences
- Voluntariness
- Ability to weigh options
Guardianship Issues in OOHC
Consent may come from:
- Biological parents
- State guardian
- Foster/kinship carer
- Child safety department
Depends on:
- Court order
- Guardianship arrangement
- Jurisdiction
Common Therapeutic Challenges
Barriers to Care
- Multiple placements
- Poor record continuity
- Missed appointments
- Distrust of professionals
- Behavioural dysregulation
- Complex interagency systems
Helpful Strategies
- Consistent GP
- Detailed documentation
- Strong communication with care team
- Flexible appointment systems
- Youth-friendly practice approach
Important Multidisciplinary Team Members
- GP
- Carers
- Child safety officer
- Case manager
- Psychologist
- Psychiatrist
- Paediatrician
- School staff
- Aboriginal health worker
- Youth worker
- Drug and alcohol services
Aboriginal & Torres Strait Islander Considerations
Key Principles
- Culturally safe care
- Avoid stereotyping
- Recognise historical trauma
- Consider intergenerational trauma
- Support cultural identity and connection
- Liaise with Aboriginal Community Controlled Health Services (ACCHS)