At this point in time, the UK has not fully entered a Covid-19 recovery phase and children, young people and families are still facing disruptions to access to routine services and schooling as a result of the pandemic. For example, we are not fully sure of the impact over the long term on children’s health and well-being, because of delayed speech and language development for instance. We have faced some challenges as key experts have been unable to input into this process up until this point for a variety of reasons. It is also important to acknowledge that some indicators and research show disruptions, due to Covid-19 especially, which makes planning at a time of uncertainty particularly challenging. We will review our analyses to ensure they reflect current and future trends as and when new or more reliable information becomes available.

It is in the early years of a child’s life that we lay the building blocks for health, well-being, learning and relationships for the future. When children have a protective, safe, secure and loving environment to grow up in they can flourish and thrive. From pregnancy and through childhood children benefit from a positive and stable home, with healthy and supportive relationships that enable them to become healthy and happy adults. When a child grows up having positive experiences they are more likely to go on to become parents who give their children the same experiences.

The first 1,000 days of a child’s life are from the time the baby is conceived up to their second birthday and this is where the brain does most of its developing and learning for the future.  This means that the things a child experiences during this time will have an effect on them throughout their lives.  When children have a safe and nurturing environment to grow up in they become resilient and more able to cope well with future life events.

Sometimes children experience stressful and traumatic events during their childhoods, such as suffering verbal, mental, sexual and physical abuse or being raised in a household with domestic violence or drug and alcohol abuse, parental separation or having a parent in prison.  These are called Adverse Childhood Experiences (ACE’s) and they are harmful to the development of a child’s brain and can cause many problems later in life such as poor health and anti-social behaviours.

We know that children who experience ACE’s are more likely to experience poor physical and mental health, suffer from harmful diseases, not to do well at school and struggle to form good relationships later in life.

The Welsh Adverse Childhood Experience (ACE) study highlights the correlation between harmful experiences in childhood and poor well-being outcomes in adulthood.20 The study results show that compared to those who experienced no harmful experiences, people who experienced four or more harmful experiences in childhood were:

• four times more likely to experience high-risk drinking in adulthood;
• six times more likely to be a smoker; and
• five times more likely to have low mental well-being.^[1]

Key health stage – conception to birth (day 1 to day 280)

It is vital for women to be healthy at the start of pregnancy. This will significantly impact on the outcome of the pregnancy for both mother and baby. Many health factors in pregnancy are difficult to address once a pregnancy has started; it is more effective for advice and behaviour change to occur before conception. Issues include:

• advice on vitamin D and folic acid supplements prior to conception and for the first 12 weeks of pregnancy to prevent neural tube defects
• importance of abstaining from smoking, alcohol and substance misuse whilst trying to conceive and during pregnancy. Smoking in pregnancy exhibits a strong social class gradient, with mothers from lower socio economic groups being five times more likely to smoke throughout their pregnancy; this contributes to health inequalities among mothers and children. The risks of smoking in pregnancy include miscarriage, perinatal death, prematurity, low birth weight and congenital anomalies in the baby particularly of the heart, face and limb.^[2]
• being a healthy weight before starting a pregnancy. Women who are obese are more than twice as likely to have a stillborn baby, and the risk increases with increasing maternal body mass index. Babies born to obese mothers are less likely to be breastfed, more likely to have congenital anomalies, especially neural tube defects, and to require admission to neonatal units. The prevalence of obesity can be intergenerational, as women who are obese during pregnancy are more likely to have obese children.
• checking rubella immunisation status.
• advice about individual health and genetic conditions; and general advice about when and how to get help as soon as pregnancy starts.

Teenage conception rates are reducing and there has been a steady decrease across England and Wales for some time. Suggested reasons include, the availability of highly effective long-acting contraception, and also changing patterns of young people’s behaviour where some go out less frequently. Pregnancy can be a positive life choice for many teenagers, however if the pregnancy is unplanned it can be associated with negative health outcomes for both mother and baby.  Teenage pregnancy is a risk factor contributing to low birth weight and many other poor long-term health and socio-economic outcomes for mother and baby. Young mothers are more likely to suffer postnatal depression and less likely to complete their education.  Children born to teenage parents are less likely to be breastfed.

In all areas across North Wales, the number of teenage conceptions has been decreasing since 2015. Within Conwy, the teenage conception rate, for females aged 15-17 years, per 1,000 females was 17.8, and in Denbighshire the rate was 23.5 in 2019.  The Wales average was 17.3. Over time, since 2011, there has been a decrease in the rate from 34.2 (Conwy) and 36.6 (Denbighshire).^[3]

These figures should be treated with caution, however, as the numbers involved are very small for some local authorities.

Low birth weight, when a baby is born weighing less than 2,500g is caused by either premature birth or failing to grow in the womb (or a combination of both). There is a clear link between low birth weight and socio economic deprivation. Low birth weight is so strongly connected with poor health and deprivation that it is sometimes used as a general measure of poverty in the community. The biggest risk factor for low birth weights is exposure to tobacco smoke during pregnancy (both maternal smoking and second hand smoke). Other risks are maternal substance misuse, diet, sexual health and low body mass index (BMI).

In 2019, 5.2% of babies born in Denbighshire were born with a low birth weight below 2500g, and 5% in Conwy. The Wales average was 5.9%.^[4]

Key health stage – the two years of life (day 281 to day 1,000)

Major health concerns for the first two years of life are breast feeding, immunisation and maternal mental health.

Breastfeeding protects the health of mothers and babies. Breastfed babies are less likely to have to go to hospital with infections, and are more likely to grow up with a healthy weight and without allergies.

In 2019 to 2020, 34.1% (618 of 1,814 babies born in Conwy and Denbighshire), were exclusively breastfed at 10 days following birth. The Wales average was 49%. While the number of babies being exclusively breastfed at 10 days following birth has increased slightly since the previous year, the proportion remains significant less than the average across Wales.

Immunisation – a proven tool for controlling and eliminating life threatening infectious diseases – is one of the most cost effective health interventions. It is a primary health consideration for the first 1,000 days of a child’s life. Immunisation rates are slightly low in the area compared to the all-Wales figure, but are above the 95% target (the level at which immunisation provides an effective barrier to disease).^[5]

In 2020, 88% of children in Conwy and 89.4% of children in Denbighshire achieved their routine vaccinations by 4 years old (four in one preschool booster (against diphtheria, tetanus, pertussis and polio), Hib/men C booster and two doses of MMR (measles, mumps and rubella). The Wales average was 88%.^[6]  These are not significantly better than rates achieved in 2016 to 2017 (87.6% for Conwy and 86.4% for Denbighshire. The Wales average was 84.6%).

The mental health of the mother has an impact on the child during and after pregnancy. If the mother is stressed or anxious while she is pregnant, the child is more likely to be anxious.^[7] Mental ill health impacts on the ability to provide positive parenting and this is particularly important in the first two years of life when attachments are forming and brain development is most rapid.

The parenting ability of teenage parents can be affected by factors such as conflict within family or with a partner, social exclusion, low self-confidence and self-esteem. These factors can affect the mental wellbeing of the young person. The impact of being a teenage parent can be felt by both the mother and father.

Key health stage – growing up (1,000 and beyond)

Emergency admissions for injury are used as a general indicator of health and health inequality. Injuries are a key cause of death and disability among children and place significant burden on individuals, families, health services and wider society. The 0-4 age group are exceptionally vulnerable to injuries within the home environment.

• The number of emergency hospital admissions for injuries that occur in children aged 0-4 years in Conwy County Borough and Denbighshire is 142 per 10,000 and 177 per 10,000 respectively. The Wales average is 171 per 10,000.^[8]

Dental decay in young children is strongly linked to deprivation and frequently leads to pain and infection necessitating hospitalisation for dental extractions under general anaesthesia. As well as the discomfort of pain and infection, young children can experience loss of sleep, absence from school and low self-esteem.

The data available for tooth decay is still that from 2017; at which time, 1.2% of five year olds in Conwy experienced tooth decay, with 1.5% in Denbighshire (both Denbighshire and the Isle of Anglesey had the highest rates in North Wales). The Wales average was 1.2%.^[9]

Flying Start – a Welsh Government programme targeted at reducing child poverty – has had great success in ensuring children between the ages of 0 to 4 years living in deprived areas are school ready by supporting parents through intensive health visitor service, child care and parenting programmes. In 2017/18 just over 1,000 children benefitted from Flying Start services in Conwy CB and 700 in Denbighshire.^[10].

Information about domestic abuse is available ‘Tackling domestic abuse’.

Being a victim of crime is an adverse childhood experience for any young person that can have longer term effect. The number of children and young people reported as falling victim of crime has steadily increased year on year across all North Wales local authorities. This could be due to a number of reasons including increased ability/ willingness to report; increased number of crimes committed; increase in particular types of crime such as cyber-crime.

Information about childhood exposure to alcohol and substance misuse is available in ‘People make healthy lifestyle choices‘.

Providing high-quality early years and primary education

Two of the key themes of Welsh Government’s early years strategy is the provision of high-quality early education and childcare, and providing effective primary education.^[11]

The early years is defined by Welsh Government as the period of life from pre-birth to the end of Foundation Phase or 0 to 7 years of age. These years are a crucial time for children. Children grow rapidly and both their physical and mental development are affected by the environment in which they find themselves in. The first three years of life are particularly important for healthy development due to the fast rate of neurological growth that occurs during this period.

The provision of appropriate childcare plays a major part in achieving Welsh Government’s aims, particularly in the pre-school years. It also helps parents, both through providing advice and guidance, by demonstrating practical child care skills and through offering the child care support needed to allow parents to take up work opportunities.

Local Authorities have a responsibility to make sure there is sufficient childcare within their local area to meet the needs of working parents.

‘Sufficient childcare’ means childcare that meets the needs of parents in the area who need childcare so that they can:

• Take up or remain in work.
• Undertake education or training which will help them to get work.

In both Conwy and Denbighshire, Childcare Sufficiency Assessments took place in 2017.^[12] Play and Childcare Sufficiency Assessments are undergoing a full review (as at March 2022), and is due to be submitted to Welsh Government in June 2022. We will consider the findings of both assessments when they are published.

School attainment levels for children who have suffered ACE tends to be significantly lower than the population average. Data at the local level is not statistically robust due to small numbers involved, but at an all-Wales level:

• about 54% of children in need in Wales achieve the foundation phase indicator compared to 87 of all children.
• about 55% of children in need in Wales achieve the core subject indicator at key stage 2 (age 11) compared to 88 of all children.
• about 13% of children in need in Wales achieve the core subject indicator at key stage 4 (age 15/16) compared to 55% of all children.

Improving parenting skills

Parenting skills are normally learnt skills from our own experiences growing up as children. If these experiences lack some of the core elements of bringing up children in a safe and nurturing environment it can have a detrimental effect on the child as they grow and so the cycle of inappropriate parenting continues. Those who provide parenting includes mothers, fathers, foster carers, adopted parents, step parents and grandparents.

Provision of parenting support is needed to break cycles of inappropriate parenting and raise parents’ confidence in their skills to raise their children in a positive and nurturing environment. The provision of services and support can also improve parent-child relationships; improve parents’ understanding, attitudes and behaviour and increase parents’ confidence in order to promote the social, physical and emotional well-being of children.

Over the last few years Welsh Government have implemented parenting skills initiatives under the child poverty agenda such as Families First, Flying Start and Communities First. While Flying Start and Communities First have focused on the more deprived areas and have other restrictions such as age for Flying Start, Families First has been open to any family who needed early support to prevent escalation of need to statutory services.

Flying Start provides parenting courses to families who live within the post code areas deemed to be the most deprived in Wales.

Rising numbers of children with disabilities

There is an estimated 11,500 children and young people with a limiting long-term illness in Wales. This is estimated using a survey. It includes those aged under 16 or those aged 16 and 17 who are dependents. A small decrease of between 110-120 children across both counties is projected over the 20-year period from 2020 up to 2040.^[13]

As at 2020 to 2021, Conwy County Borough had 9.3% (school action) of all its learners with special educational needs, rising to 12.7% with a school action plus (highest across Wales). 8.9% had special educational needs with a school action, rising to 11.2% with a school action plus.

0.6% and 1% of learners in Conwy County Borough and Denbighshire respectively had a special educational needs statement. This compares to 2% in Wales (and 2.8% in Wrexham, the highest for North Wales, Conwy had the lowest). ^[14]

Raising a disabled child has a significant impact on the wellbeing of the parents or guardians in addition to the public and volunteer service that provide them with support. This is covered in more detail in ‘Supporting carers’.

Children needing care or support

The North Wales Population Needs Assessment includes data and analysis about children needing care and support. The numbers vary across North Wales and over time with no clear trend. The greatest proportion of the children needing care fall into the age range of 5-15. The primary issues affecting each age group may vary. For example, for 0-5 year olds the issues may be neglect, whereas for teenagers, behaviour may be the symptom of underlying issues at home.

The category of need for children receiving care and support for North Wales is:

• Just over half are due to abuse or neglect (56.5%).
• The next most frequent category is the child’s disability or illness (17.2%), family dysfunction (11.1%) or family in acute stress (8.3%).
• Families may be referred for more than one reason, so this list reflects the main reason recorded.

The proportion of children with up-to-date immunisations and dental checks is lower for North Wales than the national average. The percentage age 10+ with mental health problems is higher than the national average, 19% compared to 14%. Up-to-date child health surveillance checks are just above the Welsh average. The proportion of children with ASD is higher in North Wales at 16%, compared to 12% for Wales.

Data was also collected for the percentage of children aged 10+ with substance misuse problems. This was suppressed as part of the data release for Wrexham due to the small numbers involved being disclosive. The average for Wales was 7%. Proportions ranged from 12% in Flintshire to 3% in Conwy.

The number of children looked after in North Wales has increased by 350 during 2017 to 2021. North Wales has a lower number of children looked after per 100,000 population than the rest of Wales, however there are significant variations across the region, from 795 in Flintshire to 1,304 in Wrexham. Conwy County Borough’s rate stood at 1,015 and Denbighshire’s at 923 in 2021.^[15]

There were around 945 children in foster care in North Wales in 2020. The numbers have increased year on year since 2015. This increase is also the national trend, with numbers increasing across Wales as a whole. The numbers in Conwy County Borough and Denbighshire have fluctuated and no trend can be observed.  For more information, view the full North Wales Population Needs Assessment here.

A wide educational attainment gap exists between looked after pupils and all pupils in Wales, and this attainment gap increases over time. At 31 March 2019, the proportion of Key Stage 2 pupils who were looked after achieving the expected outcome was 18% points less compared to all pupils, which increased to a 27% gap in Key Stage 3, and 37 percentage points in Key Stage 4.^[16]

Children who are looked after are also more likely to report emotional well-being issues. Wales-specific data on mental health issues in young people who are, or have been, looked after are lacking. However, analysis of British children aged 5–17 shows that looked after children are over five times more likely to have a diagnosed mental disorder than non-disadvantaged children. Rates of behavioural disorders among young people who are looked after children are particularly high, at nearly two-fifths (39%).^[17]

The reasons that young people end up being looked after are complex: the relationship between their experiences before and during care, and subsequent well-being outcomes, is also complex. The literature suggests that poorer mental health and well-being outcomes for young people who are, or have been, looked after can be driven by past experience of abuse; neglect and difficult familial relationships; as well as the potential trauma of the process of being taken into care and certain in-care experiences such as frequent or short-notice moves between different placements. ^[18]

Child sexual exploitation

Child sexual exploitation is defined as ‘forcing or enticing a child or young person to take part in sexual activities. They may not necessarily involve a high level of violence and the child may or may not be aware of what is happening. The activities may include physical contact, such as assault by penetration or non-penetrative acts. They may also include non-contact activities, for example:

• involving children in looking at, or in the production of, sexual images
• involving children watching sexual activities
• encouraging children to behave in sexually inappropriate ways
• grooming a child in preparation for abuse (including via the internet)

It is a complex and largely hidden crime. Perpetrators most commonly operate alone, or if in groups remain tightly bonded, and the victims do not necessarily see themselves as such at the time of the offence. Sexual abuse is not solely perpetrated by adult men. Women may also commit acts of sexual abuse, as can other children.

Victims are in the majority female aged 14-17 years. A large proportion of known victims have witnessed prolonged domestic abuse and many have been a victim of domestic violence themselves. Child sexual exploitation is known to be significantly underreported and therefore incidences are likely to be considerably higher than recorded crime figures suggest. Over half of known victims have been subjected to at least one sexual offence previously. There is a correlation between financial hardship and becoming a victim of sexual exploitation. Complex social and demographic factors are known to coalesce and increase vulnerability. Child sexual abuse is relatively unique in that the offending behaviour has always existed but may not have been recognised as such. This recognition has coincided with a number of enabling factors which have greatly increased the capability of offenders to commit crimes.

All agencies involved in child protection agreed that there has been an increase in online and offline CSE over the past two years. This is partly driven by heightened awareness but it is assessed as highly likely that there is a genuine increase in offending.

The continued growth in availability and affordability of internet enabled technologies such as smart phones and tablets are a critical enablers, as is increasing access to social media. The national rise in self-generated indecent images demonstrates the blurred line between what might previously have been considered sexually harmful behaviour and child sexual abuse. The boundaries between social interaction and communication are blurred in the online space and activities such as grooming are increased in scope and scale through online access to victims.  The Office of the Children’s Commissioner identified in 2012 that the “…use of mobile technology and messaging systems is significant in the facilitation, instigation, sustaining of and perpetrators’ engagement in abuse.^[19]” Based on local analysis we know that this judgement is accurate for North Wales.

It is the perception of safeguarding practitioners that the demographic of children with access to smart devices is getting younger, meaning a younger cohort of children may be active and accessible online.

Police analysis of offline offences (those occurring in a physical location) indicate half are associated with public places, such as on the street, pubs, hotels, schools, in cars and in parks. A significant proportion of the remaining offences occur within a dwelling. There is no evidence of a child sexual exploitation street gang culture in North Wales, although risky sub-cultures within schools and other organised youth activities do pose a risk. The majority of offenders are lone males who exhibit no evidence of organisation or the involvement of others.

The harm caused to children by sexual exploitation is extremely broad, from the physical and psychological impact to the less recognised effects of alcohol and substance dependency following abuse. The vulnerability of victims is increased significantly when mental health issues are present.

Victims of child sexual exploitation often have a pre-existing vulnerability that in many cases has already been identified by one or more agencies. The current body of literature consistently cites children in care as being particularly vulnerable (Pearce and Pitts, 2011, Pearce 2009, Creegan 2005, Scott and Skidmore 2006, Coy 2008, Brodie et al, 2011). National estimations of victims who are also children in care ranges between 20% and 35%. From submissions to the Child Sexual Exploitation in Gangs and Groups Inquiry – which specifically provided data on individual children’s care status – 21% of children identified as being sexually exploited were in the care system.

Social media

For many people, including some children, the use of social media such as Facebook, Instagram, Twitter, Whatsapp and Snapchat has become a means of social interaction and connectivity. For young people and adults, it is also increasingly used as a means of accessing news and information, for shopping and as an aid to decision making.

Evidence about the impact of social media, which can be both positive and negative, is conflicted. There are positive impacts associated with friendship and connectiveity, support and information, but there are also concerns around exploitation, self-impact, cyber bullying and the effects on personal well-being.^[20]

In recent times, misinformation, or ‘fake news’, and social media have presented serious challenges to governments, businesses and people themselves. Examples include anti-vax campaigns, electoral tampering, ‘Covid is a hoax’ campaigns. Fake news is designed to undermine trust and confidence in democracy and public institutions. The World Health Organisation has started to refer to this as an ‘infodemic’, where there is “too much information including false or misleading information in digital and physical environments during a disease outbreak.” In relation to the Covid-19 pandemic, the WHO has developed guidelines to ensure successful ‘infodemic management’, which involves ensuring consistent and factual information is disseminated appropriately.^[21]  We do not currently have evidence to fully understand to what extent misinformation is causing people anxiety, or affecting Covid-19 vaccine uptake for example (see ‘emerging threats to health and well-being‘ for further information).

Perhaps this topic will be better understood in the medium term.

[1] Wales Centre for Public Policy (2021). Well-being and equalities briefing.

[2] Executive Director of Public Health annual report 2011

[3] Conception rate per 1,000 females aged 15-17 years, Wales, Betsi Cadwaladr UHB and unitary authorities, 2011 to 2019. Source: ONS

[4] Low birth weight, percentage of birth weight below 2500g, Wales, Betsi Cadwaladr UHB and unitary authorities, 2015 to 2019 Source: PHW Observatory PHOF & StatsWales (WG).

[5] Public Health Wales Public Health Outcomes Framework 20th June 2018

[6] Percentage of children aged 4 years, up to date with routine vaccinations, Wales, Betsi Cadwaladr UHB and unitary authorities, 2020. Source: Public Health Wales

[7] O’Connor TG, Heron J, Golding J, Beveridge M, Glover (2002) Maternal antenatal anxiety and behavioural problems in early childhood Brit J Psychiatry 180, 502-508

[8] Public Health Wales Public Health Outcomes Framework 20th June 2018

[9] Public Health Wales Public Health Outcomes Framework 20th June 2018

[10] Flying Start summary statistics 2017/18, Welsh Government

[11] Building a brighter future: the early years and childcare plan, Welsh Government

[12] Denbighshire Childcare Sufficiency Assessment, Conwy Childcare Sufficiency Assessment

[13] Predicted number of children (0-17) with a limiting long-term illness, 2020 and 2040. Source: Daffodil. For more information, access the North Wales Population Needs Assessment.

[14] Source: Pupil Level Annual School Census summary data by local authority (pupils aged 5 to 15 in primary, middle or secondary schools), table SCHS0334, StatsWales, Welsh Government. Se also the North Wales Population Needs Assessment.

[15] Source: Children Looked after Census. StatsWales, Welsh Government

[16] Wales Centre for Public Policy (2021). Well-being and equalities briefing.

[17] Wales Centre for Public Policy (2021). Well-being and equalities briefing.

[18] Wales Centre for Public Policy (2021). Well-being and equalities briefing.

[19] Office of the Children’s Commissioner: Briefing for the Rt Hon Michael Gove MP, Secretary of State for Education, on the emerging findings of the Office of the Children’s Commissioner’s Inquiry into Child Sexual Exploitation in Gangs and Groups, with a special focus on children in care, July 2012

[20] Wales Centre for Public Policy (2021). Well-being and equalities briefing.

[21] https://www.who.int/health-topics/infodemic#tab=tab_1. Accessed 26 July 2020