Michael Tarren-Sweeney

Mental health of children in foster and kinship care in New South Wales, Australia.

Objectives: To report baseline mental health measures from the Children in Care study, a prospective epidemiological study of children in court‐ordered foster and kinship care in New South Wales, Australia.

The mental health of children in out-of-home care.

Purpose of review To review the scale, symptomatology and determinants of mental health problems of children in alternate care, and to consider the need for specialized knowledge and clinical competence for assessment and treatment of these problems. Recent findings The scale of mental health problems among children in care is exceptional for a nonclinical population, approaching that of clinic-referred children. Children in residential care have more mental health problems than those in family-type foster care, while those in kinship care have fewer problems. Children manifest complex psychopathology, characterized by attachment difficulties, relationship insecurity, sexual behaviour, trauma-related anxiety, conduct problems, defiance, inattention/hyperactivity, and less common problems such as self-injury and food maintenance behaviours. Summary Children in care have complex symptomatology that is not well represented in present classification systems. There is a need for research into the characteristics and meaning of these complex presentations, and some re-appraisal of present taxonomies. Clinicians should consider these difficulties in their entirety, rather than as discrete disorders. It is recommended that assessment and intervention are provided by clinical teams that have specialist knowledge of children in care, and that use an ecological approach to assessment.

Predictors of Problematic Sexual Behavior Among Children With Complex Maltreatment Histories

Exploratory analyses of sexual behavior problems (SBP) were conducted within a larger epidemiological study of 347 preadolescent children in foster and kinship care. SBP was estimated from carergiver-reported scores on the Assessment Checklist for Children. The study simultaneously examined a large number of discrete and cumulative influences on the development of children at high risk for SBP. Most children with SBP had corresponding psychopathology, most notably conduct problems, inattention, and interpersonal behavior problems suggestive of attachment disturbances. Several correlates identified in previous studies were not associated with SBP. High concordance of SBP was found among 52 sibling dyads. Independent predictors of SBP were older age at entry into care, female gender, placement instability, and contact sexual abuse. The findings emphasize the significance of cumulative risk among children exposed to multiple adversities. The findings generated several hypothesized mechanisms involving attachment disturbances.

Children with disruptive behaviours II: Clinical and community service needs

Objective: To assist in health service planning by determining the perceived clinical and community service needs of families resident in the Hunter region who care for a child manifesting disruptive behaviour.

It’s time to re-think mental health services for children in care, and those adopted from care

Much of what is written in this special issue points to the need for a clinical workforce that has much greater knowledge and skills for working with children with a history of alternate care, including those who are subsequently adopted. Standard child clinical conceptualization, assessment methods, and formulations miss the mark for these vulnerable populations in a number of critical ways. The present paper proposes 10 principles to guide the design of mental health services for children in care, and those adopted from care. Effective specialization in child welfare work by clinical child psychologists, psychotherapists and psychiatrists, requires: (i) specialized knowledge and skills; (ii) a shift from traditional clinical practice to a clinical psychosocial-developmental scope of practice; and (iii) a strong advocacy role. To support such specialized practice, service design should be guided by: (iv) a primary—specialist care nexus, that includes universal, comprehensive assessments; (v) a shift from acute care to preventative, long-term engagement and monitoring; (vi) integration within the social care milieu; (vii) a shift from exclusion to active ownership of these client groups; (viii) normalization strategies; and (ix) alignment of services for these client groups. Finally, it is argued that mental health service provision for these children is strengthened by policy that promotes (x) “whole of government” accountability for their mental health needs.

Beginning School With Asthma Independently Predicts Low Achievement in a Prospective Cohort of Children

BACKGROUND Concerns about the achievement of children with asthma and respiratory conditions are especially important in New Zealand, which has one of the worlds highest rates of childhood asthma. The present study evaluated whether entering school with asthma was associated with low achievement after the first year. METHODS A child cohort was recruited to a prospective study at time of first enrollment into randomly selected schools in Christchurch. Parent interviews covered demographics and respiratory status. Physician reports were sought for children with asthma, and all respiratory information was clinically reviewed. The childrens achievement in reading and math was individually assessed at school entry and reassessed after 12 months. Schools reported absences. Intelligence subtests were administered. RESULTS Two hundred ninety-eight children were recruited, including 55 (18.5%) with current asthma. At 1-year follow-up, retention was 93.7%. Children who entered school with asthma were more likely to be ≥ 6 months behind other participants in reading words (P = .023) and books (P = .026), but not in math (P = .167) at the end of the first year of school. Achievement was not related to asthma severity. Entering school with asthma reliably predicted low reading achievement independent of other known covariates of low achievement (high absenteeism, minority status, male gender, single-parent family, poor academic skills at school entry, and low socioeconomic status). CONCLUSIONS Entering school with asthma was a significant predictor of low achievement in reading at 12-month follow-up, independent of asthma severity, high absenteeism, or other covariates of low achievement.

Concordance of mental health impairment and service utilization among children in care.

This paper describes caregiver-reported patterns of mental health service use for 347 pre-adolescent children in foster and kinship care in New South Wales (NSW), Australia. Children’s mean time in care and mean time with their present caregivers were 4.3 and 3.3 years respectively. Forty-four percent of children received individual therapy or counselling, 45% received interventions in the form of clinical guidance for their caregivers, and 31% received both forms of service. Among children scoring in the clinical range on any CBCL sub-scale (N = 191), equivalent rates of mental health service use were 60%, 55% and 41% respectively. Although not directly comparable, these findings describe a higher rate of service use than that reported for children in care elsewhere. While children with more complex and severe difficulties had higher rates of service use, there was no evidence of variable access for treatment of different types of disorder. Predictors of service use are reported and contrasted with previous findings. The paper considers several features of the NSW child welfare, health and education systems that may account for the relatively high rate of service use.

The developmental case for adopting children from care

The October issue of Clinical Child Psychology and Psychiatry begins with a special section of seven articles on children adopted from statutory care and their adoptive families. This editorial sets out some social policy and political context to adoption from care and presents the developmental case for it and other permanent orders. The special section is particularly timely for clinicians working in England. With the Adoption Support Fund (ASF) now being available to adoptive and special guardianship families through local authorities, the English government is looking more closely at the evidence base for ASF-funded therapeutic interventions. This has inevitably provoked discussion about what constitutes evidence-based treatment for a population that includes a sizeable number of children with complex, poorly conceptualised, attachmentand traumarelated disorders (Stock, Spielhofer, & Gieve, 2016; Tarren-Sweeney, 2014). It is also fitting that our journal should honour Professor David Quinton within this special section, so soon after his passing. David pioneered psychosocial research with looked after and adopted children in the United Kingdom through the 1980s and 1990s, before establishing the Hadley Centre for Adoption and Foster Care Studies at Bristol University, with Julie Selwyn. We are grateful for Alan Rushton’s warm tribute to his colleague and friend, written at very short notice. This journal’s readership has varied opportunities for working clinically with children adopted from care. Those of you in the United States, Canada and the United Kingdom will be familiar with the practice of families adopting children from state care. This includes children adopted by unrelated parents; by long-term foster parents; and, in the United States, by grandparents or other relatives. In most other jurisdictions in the developed world, adoption from care is either not sanctioned, or is impractical. A notable exception is the Australian state of New South Wales (NSW), which recently amended legislation to prioritise adoption from care for non-indigenous children above long-term foster care. This was a bold move in a country that holds painful memories of forced and/or secret adoptions of children born to unwed mothers and of the stolen generations of indigenous children. How this unfolds in NSW will be closely watched by the other Australian states. Some jurisdictions that do not allow adoption from care instead have ‘guardianship orders’, which are designed to achieve relational permanence with an alternate family or with kin while retaining a child’s legal connection to their birth parents. The United Kingdom has both adoption and Special Guardianship orders, with the latter mainly being used for permanent care by relatives or the permanent care of older children and young people. Adoption, guardianship and parental responsibility (e.g. custody, residence) orders provide a legal framework for children to grow up in the permanent care of their relatives or family friends, their former foster carers or new adoptive parents, where restoration to their birth parents is not safe or achievable within developmentally critical timeframes. While these orders provide for legal permanence, we should be mindful that their ultimate purpose is to facilitate relational permanence. 670277 CCP0010.1177/1359104516670277Clinical Child Psychology and PsychiatryEditorial research-article2016

Principles for development of multi-disciplinary, mental health learning modules for undergraduate, postgraduate and continuing education.

BACKGROUND People experiencing mental health problems have greater contact with health and welfare professionals in generalist settings than with specialist mental health services. Yet the capacity for generalist professionals to respond effectively to mental health problems is often compromised by inadequate mental health training. The Discipline of Psychiatry at the University of Newcastle developed a series of CD-Rom mental health learning modules for professionals working in non-mental health settings. The paper describes the principles that guided the development of a series and how those principles were applied. DEVELOPMENT PRINCIPLES The following development principles were adopted. The series should: (i) have a multi-disciplinary application; (ii) be adaptable for presentation in multiple educational domains; (iii) be accessible for rural and remote practitioners; (iv) combine structured solutions-focused lessons (directed learning) with elements of problem-based learning; (v) include working problems that are authentic and relevant; and (vi) describe normal, abnormal and cross-cultural manifestations of problems. APPLICATION OF PRINCIPLES The model guided the development of a short course series on professional engagement with people who have personality problems. The learning modules provide generic, multi-disciplinary training for a range of practitioners, including nurses, primary care physicians, social workers, psychologists and magistrates. The modules have been adapted for use in undergraduate medical education, postgraduate programs (in population health, nursing, psychology and drug and alcohol studies) and continuing education. CONCLUSION In contrast to traditional diagnostic-focussed psychiatry training, the model directly addresses the mental health training needs of health and welfare professionals using a multi-disciplinary, problem-based approach.

Children with disruptive behaviours I: service utilization.

Objective: To describe the demographic characteristics and patterns of service utilization in the Hunter region (NSW, Australia) of families caring for a child manifesting disruptive behaviour.