Mental Health Services for Vulnerable Children and Young People

Supporting Children who are, or have been, in Foster Care

Michael Tarren-Sweeney, Arlene Vetere, Michael Tarren-Sweeney, Arlene Vetere

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780415632683
• eBook ISBN: 9781136213960
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Health Care Delivery
• Index: Politics & International Relations

More than half of children either in foster care, or adopted from care in the developed world, have a measurable need for mental health services, while up to one quarter present with complex and severe trauma- and attachment-related psychological disorders. This book outlines how services can effectively detect, prevent, and treat mental health difficulties in this vulnerable population.

Responding to increasing evidence that standard child and adolescent mental health services are poorly matched to the mental health service needs of children and young people who have been in foster care, this book provides expert guidance on the design of specialised services. The first part provides an overview of these children's mental health needs, their use of mental health services and what is known about the effectiveness of mental health interventions provided to them. The second part presents some recent innovations in mental health service delivery, concentrating on advances in clinical and developmental assessment and treatment. The final part confronts the challenges for delivering effective mental health services in this area.

This is the definitive international reference for the design of specialised mental health services for children and young people in care and those adopted from care. It is invaluable reading for health and social care professionals working with this population and academics with an interest in child and adolescent mental health from a range of disciplines, including social work, nursing and psychology.

Part I

Overview

1

Establishing the need for mental health services for children and young people in care, and those who are subsequently adopted

Michael Tarren-Sweeney and Arlene Vetere

No other groups of children and young people in the developed world are more socially or developmentally disadvantaged than children and young people who reside in court-ordered alternate care, and those who are subsequently adopted from care. Prior to entering care, they mostly endure profound social adversity, including traumatic abuse and emotional deprivation. By and large, their pre-care adversity exceeds that endured by the much larger group of maltreated children who remain in their parents’ care. Following their entry into care and/or transition to adoption, these groups have to navigate a host of systemically driven assaults on their well-being and felt security. This book seeks to redress some important social and psychological manifestations of their disadvantage, including mental ill-health, emotional distress and behavioural difficulties – by disseminating the best knowledge we have on prevention and treatment of those difficulties for these populations, and by highlighting the present gaps in our knowledge, and the inadequacies of prevailing service models.

The idea for publishing this book came about in 2010, after we had edited a special issue of Clinical Child Psychology and Psychiatry (October, 2010) on the topic of mental health services for children and young people in care and those adopted from care. The special issue generated a lot of interest and discussion, particularly from clinicians working in child welfare, alternate care and adoption fields, and from people working on mental health services policy within health and social care agencies. These populations exert exceptional demands on poorly matched, generic mental health services – a dilemma that most child welfare and child mental health jurisdictions in the developed world are presently struggling with. The response to the special issue supports our belief that the provision of appropriate and sufficient mental health services for these vulnerable populations will remain a key concern for child mental health and social care agencies over the coming decades. To that end, we set out to publish a definitive international reference guide for the design of specialised mental health services for children in care (and those adopted from care) – one that is equally useful for clinicians and clinical leaders, child mental health and social care agencies, government departments and policy makers.

To make this happen, we were fortunate to enlist the assistance of some of the world’s best thinkers in this field of practice and research. Advancing the well-being and psychological development of children in various types of alternate care (and reducing their felt distress) is a vocation shared by each of the book’s contributors. For most contributors, this has been the focus of their life’s work! Importantly, each contributor brings a mix of practitioner experience in working with these children, and considered scholarship. What communicates most forcefully from their contributions to this book is the need for a drastic reappraisal and overhaul of mental health services provided to children in care and those adopted from care.

Children and young people in the care and adoption systems

At any given time, perhaps a million children in the western world either reside in legally mandated alternate care, or have been adopted from such care. A substantially larger population encounters alternate care at some time in their childhood. Children residing in court-ordered care are collectively referred to as looked after children in Britain and Ireland, and as children in out-of-home care in North America and Australasia – although neither term satisfactorily describes the status of children in long-term alternate care. Many jurisdictions witnessed a doubling of the rate of children in care between the mid-90s and mid-2000s, which in 2005 averaged around 5 per 1000 children across western, Anglophone nations (Holzer & Bromfield, 2008). This change continues unabated in Australia, where the rate increased by 26% (from 5.8 to 7.3 per 1000) between 2007 and 2011 (Australian Institute of Health and Welfare, 2012). By comparison, there was a 9% increase (from 6 to 6.6 per 1000) in the number of children in care (including those adopted from care) in Britain over the same four-year period (Department for Education, 2011). These increases are largely accounted for by a corresponding acceleration in the detection of child maltreatment. Variations in national rates of children in care partially reflect the provision of long-term solutions such as return to birth parents, adoption from care and/or special guardianship orders. They also reflect shifting thresholds of concern, particularly as agencies are subjected to public outcries when children who are formally safeguarded by the State die through lack of proper supervision or services.

While there is considerable variation in care systems, most western jurisdictions shifted emphasis from non-family residential care to foster care through the late twentieth century, and more recently to kinship care and adoption from care. Kinship care is partly driven in Australia, New Zealand and Canada by concern for the identity and well-being of large and disproportionate numbers of indigenous children in care (see for example Lock, (1997)). In Britain and North America, adoption from care is the preferred ‘permanent’ outcome for children who are either unable to return to parental care, and for whom there is no suitable kinship placement. In the year ending March 2011, 3050 children in care were adopted in Britain (Department for Education, 2011), constituting a fairly small proportion of those who are eligible for adoption. Furthermore, the annual numbers of British children in care who are placed for adoption, and who are adopted, fell between 2007 and 2011 (Department for Education, 2011). This situation is contrary to public policy and permanency goals, and has prompted a recent government review of adoption in Britain. In Australasia, adoption from care is more difficult to achieve, and is thus uncommon. Any move to formalise the adoption of Australian children from care would invoke resistance because of that country’s history of forcible and unjust removal of aboriginal children (the ‘stolen generation’). Instead, in Australia and New Zealand early-placed children who are not restored to parental care are typically raised in quasi-adoptive foster or kinship placements. A surprisingly large number of early-placed children are retained in long-term care in England as well, as a part of more general permanency policy (Biehal, Ellison, Baker, & Sinclair, 2009; Schofield & Ward, 2008). These children are more likely to endure greater systemic threats to their ‘felt security’ than children adopted from care, such as the realisation of their carers’ lack of custody rights, and the State’s intrusion throughout their childhood (Nutt, 2006). Otherwise these groups have comparable developmental pathways, invoking similar risk for attachment- and trauma-related mental health difficulties.

Developmental underpinnings

Mental health and resilience among children in care, and those who are subsequently adopted, arise from complex, time-sensitive interactions between genotype, prenatal conditions, pre-care and in-care psychosocial conditions and events, and infant neurological development (Rutter, 2000). The social experiences that predicate entry into care represent critical developmental risks for their well-being and mental health. Foremost of these is exposure to psychological trauma, emotional deprivation and other conditions that negate opportunity for secure attachments. Children in care also encounter a number of uncommon developmental events, the most critical being the loss of their biological parents, integration into new families or non-family settings, and (for some at least) unstable placements. Developmental psychopathology models pertaining to maltreated children (Cicchetti, Toth, & Maughan, 2000) and profoundly deprived inter-country adoptees (O’Connor, Bredenkamp, Rutter, & the English and Romanian Adoptees Study Team, 1999) are thus only partially valid for children in care, as there are both commonalities and differences in their experience. Conversely, there is considerable commonality in the developmental pathways of children raised in long-term foster care and children who are subsequently adopted from care.

Risk studies of children in care have identified several predictors of mental health difficulties and other negative outcomes, notably older age at entry into care, placement instability, perceived placement insecurity, and intellectual disability (Delfabbro & Barber, 2003; Tarren-Sweeney, 2008c). Younger age at entry into family-type (i.e. foster and kinship) care appears to be protective for subsequent mental health (Fanshel & Shinn, 1978; Tarren-Sweeney, 2008c), while early placement in residential care is harmful (Johnson, Browne, & Hamilton-Giachritsis, 2006). These findings can be interpreted in terms of ‘cumulative adversity’ and ‘attachment’ models. Whereas a single harmful event may have life-altering developmental consequences for children at large, the impact of individual events is tempered among children exposed to chronic and multiple adversities. A number of researchers have reported that broad indicators of exposure to adversity and to other risk factors account for a greater proportion of the variance in children’s mental health, than exposure to specific types or single instances of harm (Fergusson & Lynskey, 1996; Rutter, 1999). For instance, it has been shown that length of exposure to maltreatment and the number of maltreatment events are stronger predictors than the type of harm encountered by children (Tarren-Sweeney, 2008c; Zeanah, Boris, & Larrieu, 1997). Similarly, among children with multiple genetic vulnerabilities, individual genetic risks account for small proportions of the variance in their mental health (Plomin, DeFries, & McClearn, 1997).

Age at entry into care also has significance in terms of attachment quality, and related emotional and neurological development. Children who are emotionally deprived and/or abused, are likely to develop insecure or disorganised attachments to their caregivers, or worse, manifest attachment disorder behaviours (Howe & Fearnley, 2003; Newman & Mares, 2007; O’Connor & Zeanah, 2003). Such difficulties are in turn moderately correlated with the presence of behavioural and emotional problems (Marcus, 1991). While a number of studies have articulated differences in the attachment behaviours of abused versus neglected children (Crittenden & Ainsworth, 1989), this is an artificial distinction for children in care. In addition to abuse and neglect, other pre-care experiences account for the development of attachment difficulties among such children. Attachment theory would predict that the therapeutic potential of alternate care and adoption should vary according to: 1. the characteristics of children’s attachment systems prior to entering care; and 2. carer sensitivity and ability to provide a ‘secure base’ following entry into care (Bowlby, 1988; Schofield, 2002). Some children are cared for by a succession of strangers for lengthy periods (sometimes extending to weeks or months). Some endure successive losses, both prior to and following entry into care, resulting in grief, confusion and insecurity. For example, a child might reside with her birth mother to age 18 months, then with her grandmother to age 30 months, then back to her mother, and so on. In this scenario, the child resides long enough with her mother, and thence with her grandmother, to become successively attached to each caregiver. But her relationships are rendered insecure upon losing them.

Regardless of prior conditions, the attachment systems of infants who enter foster care are found to be responsive to changes in parenting style (Dozier, Stovall, Albus, & Bates, 2001; Steele, Hodges, Kaniuk, Hillman, & Henderson, 2003). Beyond infancy, there is evidence of linear deterioration in the mental health of children entering foster care at progressively older ages, including increasing interpersonal behaviour problems suggestive of attachment disturbances (Tarren-Sweeney, 2008c). The attachment difficulties of late-placed children are more resistant to therapeutic change in response to markedly improved care. This is partly due to them having more ‘established’ internal representations of self and others. One study found that birth maternal representations of late-placed children are shaped by the extent of maltreatment in their mothers’ care, which in turn influence both their representations of their foster mothers, and their mental health (Milan & Pinderhughes, 2000).

There is emerging evidence felt security is an important component of the psychosocial development and well-being of children and young people in care, and that their felt security is closely linked to perceived placement security. One study found that indicators of placement security independently predicted better mental health among pre-adolescent children in care (Tarren-Sweeney, 2008c), while another found that retrospectively measured ‘felt security’ was associated with positive outcomes for young adults after they left care (Cashmore & Paxman, 2006). Placement instability is a critical risk encountered more often by late-placed children (Tarren-Sweeney, 2008c). Placement breakdown most often occurs when caregivers are confronted by severely disruptive behaviour. But, placement instability accounts for further deterioration in children’s mental health, over and above the difficulties children bring to their placements (Delfabbro & Barber, 2003; Newton, Litrownik, & Landsverk, 2000). This contributes to the spiralling decline in stability and functioning observed among children who endure repeated placement breakdowns. In many respects this pattern constitutes a ‘developmental cascade’ that involves both cumulative and progressive effects (Masten & Cicchetti, 2010), and which at a practical level becomes increasingly more difficult to reverse as successive placement breakdowns occur.

Taken together, these various research findings: support policies that promote permanency for children in long-term care; suggest that the therapeutic potential of foster and kinship care is greater for children placed at earlier ages (Tarren-Sweeney, 2008c); and conversely, that late placement of children with pre-existing attachment and mental health difficulties may have limited therapeutic potential (Delfabbro & Barber, 2003).

The neglect of children’s mental health needs

The challenge of working with maltreated children before they enter care

“The endpoint of chronically experiencing catastrophic states of relational trauma in early life is a progressive impairment of the ability to adjust, take defensive action, or act on one’s own behalf, and a blocking of the capacity to register affect and pain, all critical to survival.”

(Schore, 2010: p.39)

“Interpersonal vi...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Contributors
• Foreword
• Part I: Overview
• Part II: Recent innovations in mental health service delivery
• Part III: Designing specialised mental health services for children in care, and those adopted from care
• Index