Introduction

When an international perspective is taken, Swedish children appear to be in good health, with, specifically, children under the age of 15 having experienced, during the last 20 years, improved health development. A reason for this may be the comprehensive health promotion work conducted in Sweden (National Institute of Public Health 2011a). However, there remain individual health differences among Swedish children (National Institute of Public Health 2011b). From a theoretical perspective this implies that, since children are exposed to different life conditions—depending on, gender, age, ethnicity, neglect and financial situation (James et al. 1998)—a child’s health should be understood from his or her unique life situation. Hence, it is the role of social workers to understand children’s health and well-being from each and every child’s unique perspective (Cederborg 2014).

Child-related social services constitute, in Swedish society, an institutional body that conducts both preventive and supportive work for children in need of health support (Governmental Proposition 2004/05:2; National Board of Health and Welfare 2006a, 2013; The ombudsman for Children in Sweden (BO) 2005). The social services Act (SoL) (2001:453) emphasises that social services are responsible for the promotion of children’s social and physical development (5:1), and should support and protect children whose health and development is at risk of harm in the future (5:1 SoL 2001:453; §§2 and 3; Special provisions for Care of Young People Act (LVU) 1990:52). The National Board of Health and Welfare further highlights that the child’s physical and psychological health should be a principal focus in assessing the potential vulnerabilities and needs of the child. The importance of including and relating to both difficulties and supportive aspects from family members, friends and school, is also of central importance (National Board of Health and Welfare 2006b).

In the social services Act (2001:453) there are, however, few concrete statements about how a social worker should assess children’s health. As health is decisive for children’s development we therefore wanted to explore how social workers take on the assignment to assess children’s health when arguing for their needs.

There seems to be a strong connection between a problematic social situation and problematic health (Bremberg 1998; Eriksson and Lindström 2006; Gironda et al. 2006; National Board of Health and Welfare 2000, 2006a, 2009; National Institute of Public Health 2011b; Park et al. 2009; Robertson et al. 2006; Shaw et al. 2006; Stansfeld 2006; Steptoe 2006; Sundelin 1995). Children’s genetic disposition, such as physiological function (Sarafino 2006), as well as the general socio-economic situation in a particular society (Dahl et al. 2006; Kawachi et al. 2002) can also influence children’s health development. Since health is to be seen as a complex phenomenon influencing children’s and youth’s life situations in multiple ways (Halfon and Hochstein 2002) it can be argued that children involved in social investigations may have a high risk of developing health issues. Such is the case for children who live with parents with drug addiction (Andersson 2001; Grant et al. 2011), or whose parents have physical or psychological illnesses (Monds-Watson et al. 2010), have intellectual disabilities (Azar et al. 2012), or whose parents have physically or sexually abused them (Lindell and Svedin 2004). Children may also live in dysfunctional families (Eriksson 2012; Hollander 2001), have physical or psychological illness themselves (Guglani et al. 2008; Horwitz et al. 2012; McCann et al. 1996), have problems in school (Jonson-Reid et al. 2007; Sundell et al. 2004) or, indeed, be themselves addicted to drugs (Wiklund 2006).

All the same, the connection between health and other aspects in a child’s life cannot be understood unidirectionally. Social aspects can influence health at the same time as ill-health can influence social relations (Lundberg et al. 2008). Physical impairment can, for example, influence psychological well-being (Garralda, 1994; Rangel et al. 2003), while psychological experiences—such as stress—may influence the physical reaction of the body (Ljung and Friberg 2004). This means that various risk factors may cause the same health problem while, concomitantly, various illnesses can be caused by the same risk. Moreover, individual psychological resources can influence how a child copes with ill-health (Heinonen et al. 2009); illness can be mitigated through protective factors such as, for example, social support provided by others. Children’s health development, as well as the explanations of causes and consequences of ill-health, can therefore vary between each and every child. Besides, the effects of measures taken can be difficult to predict, and often one effort may not solve the entire problem (Author forthcoming).

The task of assessing children’s health can be difficult to carry out. Still, social workers have to pay attention to child health, since the arguments that they advance can have important consequences in the securing of support for children’s needs.

Aim

In this study we explore how social workers in Sweden adapt to the task of assessing children’s health. Specifically, we investigate the ways in which children’s health is explained in the context of reaching conclusions about the concrete needs of children, with a particular focus on cases where health concerns were expressed at the point of initiating an investigation.

Method

Data

This study is part of a larger project exploring how social workers focus on children and children’s health in written social investigations. The Head of the social services in a medium-sized town in Sweden permitted us access to written investigations conducted during 2008. We started with data from three out of four districts. Once permission had been granted, a list of all relevant investigations made by social workers in the three districts during 2008 was delivered to the researchers. After which all data from the social services archive were collected. All eligible children, between 0 and 18 years of age, were included, constituting, in total, 272 investigations. Considering this as an appropriate number for analysis, we refrained from analysing material from the fourth district. The children were investigated according to Chapter 11, §§ 1 and 2, of the Swedish Social Service Act (SoL 2001:453) in response to the submission of a report to the social services. Both parent- and child-related reports about the children’s life situation were included. We wanted to focus on those cases in which someone from outside the family had assessed and reported to the social services a child in a vulnerable position. Therefore applications from children and their families, relating to a self-defined need for support, were excluded.

For the purpose of this study investigations were selected in which the reason proffered by social services for conducting an investigation was distinct worries about the child’s health. We focused our qualitative analysis on the final part of the investigations, whereupon social workers argue for their conclusions and decisions. In total, 60 out of 272 investigations fulfilled the inclusion criteria of social workers’ expressed concerns about children’s health. We divided the social workers’ reports about the ill health of children into four different categories: psychological ill-health (39 investigations), physical ill-health (5 investigations), psychological and physical ill-health (7 investigations), and unspecified problems of well-being (9 investigations). One girl was investigated twice, which means that the investigations of immediate interest involved 59 children, 29 girls and 30 boys. When the investigations were conducted, the children were aged 4–17 years, (M = 12, 7 years).

The project was approved by the Regional Ethical Committee in Linköping, Sweden (Dnr 221-08). Details and references to persons and places that might permit identification have been removed. In the excerpts, the child’s name is referred to as X. Names of other persons, places or situations are given an explanatory description in brackets. Expressions that are irrelevant have also been removed. This is denoted with the use of elliptical marks […]. When sentences have been adjusted, in order to make them understandable, care has been taken not to influence the point being made.

Theoretical Standpoint and Analysis Procedure

When analysing data, a social constructionist and discursive analytical approach was used. Both approaches help to contribute to an understanding that the use of language is not a neutral activity. Rather, descriptions, representations and explanations express how things are perceived and should be understood. A principal implication of this approach is that descriptions should be analysed in their situated context (Potter and Wetherell 1995; Taylor 2001; Wetherell and Potter 1992).

In the context of social work, categorisation is used to define behaviour, object, event and persons’ individual traits; social workers help to create meaning about what kind of cases they are working with (Hall et al. 2006; Potter 1996). The writing of assessments by social workers can therefore be seen as a categorisation process in which children are designated as regards who is in need of health support and who is not.

Moreover, language use is to be seen as constitutive of social life and has consequences for how people both act and interact in a certain context (Burr 2003; Potter 1996; Potter and Wetherell 1995). How social workers construct meaning about children’s health can therefore have consequences for what support the clients will receive (Börjesson and Palmblad 2008; Hall et al. 2006).

Inspired by Potter and Wetherell (1987) we inductively searched for key patterns of variation and consistency in the language used in both the contents and structure of the social workers’ accounts. At first, the first author selected the sections of the investigations in which social workers’ argue for their conclusions and proposed decisions. Secondly, once the relevant passages, referring to children’s health, were selected, this author carried out repeated readings of them with the analytic focus on how social workers assess children’s health. During this process she searched for all the ways in which children’s health was explained in the final assessment and conclusions of the investigation. Thirdly, all of the explanations were then discussed between the two first authors, who collaboratively found that the findings could be organised into three themes, sparse information, explanations and signs of psychological problems as well as brief explanations of physical health. All three themes had subthemes that could further contribute to the understanding of how social workers make use of children’s health when arguing for their decisions. Fourthly, the organised themes with many subthemes were then discussed between all three authors. During this collaborative process, some subthemes were rejected and those themes that best could explain the themes found was chosen. This analytical process ended once all three authors agreed upon the validity of the themes and subthemes presented below.

Findings

Our analysis revealed that, even though child-related social services stated that the reason for conducting the studied investigations was a concern over the specific child’s health, there were in actual fact 14 cases in which the child’s health was not commented on at all. We found, therefore, references to children’s health in 46 of the 60 studied cases. These references were mostly described with a few words, giving limited information about how health could influence the child’s unique life situation. Out of the 46 cases 31 were initiated because of a variety of psychological problems, 3 because of physical problems, 5 because of psychological as well as physical problems and 7 because of unspecified health problems. This database can explain why social workers mostly described psychological health problems in their assessments. Furthermore, social workers mostly focused on the children’s problematic health, as opposed to their healthy condition.

There was a difference in how social workers described physical- and psychological health problems. Explanations about psychological problems included reasons and signs of children’s difficulties. Reasons were mostly referred to as parents’ incapacities. Signs of children’s psychological problems were described by their own destructive behaviour. If the child was mentioned as a support receiver then the argument was often related to the parent’s inability to meet the needs of the child. The few cases mentioning children’s physical problems were couched in statements about the need for securing external support outside social services, as well as detailing the parents’ capacity to support their own child. Below is a presentation of the main findings.

Sparse Information

Most of the referrals to children’s health were short and were described with words such as well-being, health, psychological health or physical health, with no further explanation provided.

In a case involving a 12-year-old boy the social worker briefly argued for the child’s need for support with the use of one word alone, well-being. According to the social worker the initial concern raised about the child’s health was that the boy had expressed health problems.

Example 1

Xhad previously been placed in a foster home because of his mother’s addiction. X also said that his father drank a lot before, the last time was three months ago and X also explains that when he was young he was also with his father when he was drunk. Presumably X has gone through quite a lot, which affects his behaviour and well-being today and which he may need support to process or relate to.

Another example of the deployment of a few word descriptions was a case regarding a 17-year-old boy. Here, an initial concern was raised to the boy’s destructive behaviour and psychological problems. With one word and an unspecified description of the type of health problem, the social worker expressed worries for his future health.

Example 2

X cannot break this trend (of criminality and drug addiction) either on his own or with the help of his family, but needs support and protection so as not to risk his health and development. As a consequence, X needs to receive support in an institution.

Explanations and Signs of Psychological Problems

Descriptions of the children’s psychological health were in general more informative than those about physical health. When the social workers explained children’s psychological problems the descriptions tended to concentrate on two different topics: children’s behaviour as signs or symptoms of their problems and children’s health problems as caused by the parents’ insufficiencies. Children’s behaviour was referred to as either being destructive or obsessive. Assessments of the extent to which parents were the cause of their children’s ill-health were mainly related to parent’s destructive lifestyle, parental conflicts or the psychological ill-health of parents. The examples provided below illustrate how these kinds of description can be formulated.

The first example is about an 11-year-old girl, whose school had first reported concerns over the fact that she appeared sad and angry most of the time. This example shows the way in which the girl’s problematic psychological health was explained by her parent’s previous lifestyle. The social worker also referred to her knowledge of general risk factors associated with parents with destructive behaviours, noting that children caught up in such situations can develop negatively. The way in which the child-related social services were to understand the girl’s ill-health was confirmed with reference to the girl’s behaviour. Moreover, the recommended support suited this explanation.

Example 3

[…]During her childhood she lived in an environment where she was exposed to drugs, criminality and psychological illnesses. Children brought up under these circumstances risk becoming addicted to drugs, becoming criminal and developing psychological ill-health themselves. X’s own behaviour—being involved in shop-lifting—and her own conduct, as she always wears her hood up, has to sit on the same chair, bangs her head against the wall, does not want to answer questions, may be a sign that she is developing a psychological illness [… …]. X needs support from the social services. She needs support to process things that have happened in her family while growing up. X also needs support for her psychological health and help to break the “destructive” behaviour she is developing.

Another example concerns a 15-year-old boy, described as being a self-harmer and inclined towards having suicidal thoughts. In the example below the social worker adopts a rather unilateral description of the causes of the boy’s ill-health, related to his parents’ inability to cooperate and communicate. In the report, it is argued that the parents are still unable to stop their unsuitable behaviour. Therefore the social worker recommends that the boy lives outside the family home, in an institution, until relations between mother and father improve.

Example 4

[…]During the last six months, X has also demonstrated a destructive behaviour and said that he does not want to live any longer. The parents express great concern about X’s psychological health and the investigators share their anxiety, since he, on several occasions, has said that he doesn’t have anything to live for […] X describes how he often had to choose sides in his parents’ conflicts and describes it as difficult. This is considered to have confused X emotionally and has had a negative impact on his psychological well-being. […]. Conversations with X show his dissatisfaction with and anger at his parents’ inability to communicate with each other without getting into rows or long discussions. The investigators’ assessment is that X’s problematic well-being in general is caused by his parents’ difficulties in cooperating and their lack of communication […]The staff (at the institution where he lives) believe that X’s parents need to resolve their conflicts before X can move back home. Their opinion is that it is not good for X to be in the home environment: the investigators share their opinion.

Brief Explanations of Physical Health

In the few cases where children were assessed as having physical problems, the social workers most often mentioned, briefly, the health problem, without providing any further explanation as to the causes, but rather focused on consequences. These descriptions were therefore about how the problem was to be solved, often recommending external sources.

The example below concerns an 11 year old boy diagnosed with stomach ache. The social worker briefly mentions the boy’s problems, which have caused his absence from school. The child-related social services should not support him further; instead a medical investigation at the hospital was recommended.

Example 5

X has problems with his stomach and therefore, at times, is not attending school. He shall be investigated at the hospital because of his stomach problems.

Social workers could also transform the original worries for health into a new category, with therefore the recommended support fitting this latter assessment. The following example is about a 16 year old boy for whom the initial concerns regarded his psychological health. But the psychological problem is not addressed at all. Instead the social worker chooses to highlight physical problems in explaining the needs of the child. Responsibility is thus to be taken by the mother.

Example 6

Both the father and the mother have expressed concern for X’s physical health. They believe that X would feel much better if he was more active during his spare time. The mother has already initiated such opportunities.

Discussion

In this study we have explored the ways in which Swedish social workers assess children’s health when evaluating the needs of children for potential support; we have focused on those cases where an investigation was initiated on the basis of an expressed health concern.

Our findings are that social workers limited their assessments of children’s health, using only a few words when mentioning health aspects. When, however, they did pay attention to children’s psychological health, it was mostly carried out with the use of one single explanation for the cause of the health condition. Besides, this explanation fitted the suggested support. In descriptions of psychological health problems signs of ill-health were explained by children’s behaviour. Physical health was only briefly mentioned and the recommendations for child support involved external assistance. Social workers could also change the original worries of the child’s ill-health to another health problem, connecting the latter to the suggested support, without providing any further explanation. This means that social workers could use a simplified explanatory model lacking thorough descriptions of each child’s life situation. This way of limiting assessment, however, can hinder a deeper understanding of causes and consequences and thereby impose limits on specifying the particular support the child needs.

These findings may be related to recommendations and legal requirements that social workers might try to follow. The social services Act (2001:453) emphasises, for example, that social services are responsible for the promotion of children’s social and physical development (5:1) and that they should support and protect children whose health and development are at risk from harm in the future, whether due to circumstances in the home environment (§2 LVU 1990:52) or due to their own destructive behaviour (§3). Other guidelines further emphasise that social workers should include parental capacity in an assessment of children’s need (National Board of Health and Welfare 2006a, b). Since these recommendations highlight the importance of an analysis of both parental influences and children’s own behaviour, this may imply that social workers refrain from other explanations. Another reason for limited descriptions may be that the recommendations are vague and a specific in terms of how development of health should be assessed in relation to other developmental aspects of a child’s life.

The findings from this study indicate that there is a need to further explain how social workers can develop their analyses and assessments, so as to be able to understand children from their perspectives. Firstly, it seems important to encourage social workers to focus on health aspects in order to better support child health needs. The use of a social constructionist and discursive theoretical approach may help to understand that the social workers use of language is not a neutral activity (Potter and Wetherell 1995; Taylor 2001; Wetherell and Potter 1992). Hence, guidelines directed to social workers may have to include recommendations in how to visualize aspects of children’s health as the words used may increase an understanding of children’s life situation, health and needs. Secondly, social work education may have to train students in how to analyse and argue for health aspects in assessment of children’s life situation. In addition, they may also have to be trained in how to understand children from their perspective.

The social workers referrals to parents’ insufficiencies when explaining the causes of ill- health may be meaningful, however, since research suggests that the quality of close relations can be decisive for children’s well-being (Goswami 2012). Parents’ conflicts (Davies and Cummings 1994; English et al. 2003; Fabricius and Luecken 2007), lifestyle (Osborne and Berger 2009) and ill-health (Lagerberg et al. 2008; Turney 2011; Westin 2007) are examples of parental aspects that can negatively influence children’s health development. Arguments about children’s behaviour as a verification of their psychological ill-health can also be of importance, for it can be a sign of their well-being (Hamama and Arazi, 2012). The problem arises when the social workers use the parental misbehaviour or children’s behaviour as a unilateral explanation for ill health as one risk factor can seldom explain problematic health and its possible outcomes. On the contrary, assessing causes requires a more complex analysis of reasons for ill-health, coupled with the fact that possibilities for support can have various complicated connections and remain unique for each and every child (Author forthcoming; Rutter 1990; Rutter and Tylor 2002).

A clarification about what should be included when assessing unhealthy or healthy child development requires an understanding of aspects such as children’s biological preconditions (Bronfenbrenner and Ceci 1994; Meadows 2010), relations to peers (Berntsson and Gustafsson 2000; Berntsson et al. 2001; National Board of Health and Welfare 2013; Östberg 2001), or the precarity of a family’s economic situation (Kawachi et al. 2002)—since all of these factors, as well as others, can influence children’s health. To be able to assess a child’s needs, the social worker must also incorporate individual child specific aspects—like age, gender, ethnicity, social relations as well as the child’s own experiences and opinions of their needs. This requires that social workers understand two central principles: one, that children as social actors can and should have influence over their everyday lives, and two, that each individuated child has unique prerequisites (James and Prout 1997; James et al. 1998; Meadows 2010).

One limitation with this study is that it is based on investigations from one town in Sweden some years ago. This means that the results may not be comparable with findings pertaining to the management of investigations in other domestic or international social authorities. In addition, this study does not reveal the reasons for social workers limited focus on children’s health when arguing for children’s needs. However, the findings indicate that assessments of children’s needs may not involve detailed descriptions of their health with the possible consequence that an important aspects of their life is missing in social services decision about support. This means that a simplified assessments of health aspects may lead to limited understandings of children’s life situations and needs of support.

Therefore, we conclude that social workers need to develop their way of assessing each child’s health and life situation, implying an enhanced understanding of children as social actors in their own lives (James and Prout 1997). It can, indeed, be challenging to assess whether a child’s health is impaired or at risk of harm in the future, however. On the other hand it is child-related social services that have a principal responsibility for children’s well-being. If social workers refrain from thorough and detailed assessments of children’s unique physical- and psychological health there is a risk that the children are not understood from their perspectives and their needs will not be sufficiently met.