ACWA CONFERENCE WHAT WORKS!?

Evidence based practice in child and family services

ACWA

CCWT

2 September, 2002

How mental health assessment, consultation and treatment can

improve outcomes for children in care

• Annette McInerney

• Department of Psychological Medicine

• The Children’s Hospital at Westmead

Alternate care clinicCentral idea

Comprehensive psychiatric assessment and treatment service for children in out-of-home care

• including children in relative placements

• including ex-ward, transracial & intercountry adoptees

Why? Cont’d

• Most children entering foster care have been severely traumatised and have special medical, psychiatric, educational and social needs that traditional child welfare and foster care services were not designed to address.

Child Welfare League of America, 91 in Rosenfeld et al, 97

But ...

• Foster homes work best for younger children without clinically significant levels of emotional or behavioural disorder.

Barber & Gilbertson, 2001

•

Physical health needs

• Foster children have 3 -7 times as many acute and chronic health conditions, developmental delays, and emotional adjustment problems as other poor children.– Many foster children who receive needed interventions

improve their health, developmental, and emotional status.

– Significant catch up in height and weight in preschool foster children followed for up to 1 year after placement Rosenfeld et al, 97.

Mental health needs• 84%: developmental & emotional problems

– 33% as reported by carers or social workers

• Younger children have gross & fine motor problems

• Children aged 1-5yrs have language abnormalities

• Cognitive problems occur in in 1/3 of under5’s and in 52% of school age children

Mental health needs cont’d

• School children:– emotional– regulatory

• coping and self-help– relational– behavioural abnormalities Rosenfeld et al,

97

Mental health needs cont’d

• Child Behaviour Check List studies– of random 158, some psychological disorder in

nearly half– overall score higher than for comparison group,

indicating more behaviour problems– carer and social worker under-reporting

problems

Mental health needs cont’d• Deficits amongst Romanian-born adoptees

– cognitive – social behaviours & interactive role play– inattention, impulsivity, restless overactivity– quasi-repetitive & stereotyped behaviours

– autistic features– Catch-up over 2 and a half years Rutter et al, 2000

Trauma, neglect &

attachment disruptionThese impact on the developing brain, affecting, at least:

language sense of self

affect regulation sense of others

arousal sense of time

attention & concentration ability to play

judgement ability to learn

self-soothing problem solving

Risk factors for developmental psychopathology• Most poor children do not have severe

psychopathology• Foster children have more than 14 risk

factors for adverse psychological outcomes Thorpe & Swart, 92, in Rosenfeld et al, 97

Referral criteria

• Temporary or permanent court order

• Displaying significant emotional or behavioural problems

• Ongoing development being affected

• At risk of developing significant problems

Desirable criteria•Allocated cases

•Willingness of carers/caseworkers to participate together

Staffing• Child and Family Psychiatrist

• Senior Social worker

• Additional resources– Occupational therapist– Neuropsychologist– Child psychiatry registrar– Redbank and CHW as needed

The primary questions• What is a workable model of mental health

treatment and support for children in care?

• What are the primary mental health needs of this child and the care system in which s/he is living?

Aims• Access to mental health service

• Continuity of care

• Range of assessments

• Normative family focus

• Assist integration and a therapeutic approach to case planning and implementation

Our hypothesis

• Neither the public mental health system (as it is now) nor the private mental health system is in a position to provide the chronic, multifaceted interventions and systemic interventions needed to facilitate the psychosocial recovery of children coming into the alternate care system.

Measurements Achenbach Beck Depression

InventoryConners Social reciprocity scale (Constantino, 98)

SM2 Standardised measures for children and adolescents

Parent SDQ Youth SDQ

HoNOSCA CGAS

FIHS

The first 12 months• Over 40 referrals

• Pre-school to 17 years

• Concurrent consultations to community health, DoCS, NGO’s and PANOC teams

The referred children

• Problems across multiple domains– behavioural problems

– aggressivity

– affect management difficulties

– arousal

– poor self-esteem and sense of self

– attachment difficulties

– substance abuse

– concentration and attention

– learning difficulties

– social skills and peer relationship issues

– depression, despair, suicidality

– language & other cognitive deficits

The referred families

– compulsive caretaking – chronic psychiatric illness – chronic physical illness

• alcoholism, depression, lupus, MDP

– unplanned pregnancy– large sibling group in care – temporary… respite… long-term... full-time– concerned about medication

The referred families cont’d • poor knowledge of ongoing impact of

attachment, trauma and neglect

• poor developmental history information

• unprepared for regression at crises and fall-off in developmental trajectory

• unsupported / unsupervised relative carers

• single carers (sole focus of aggression)

• no therapeutic foster carers

Some children had

no “family"• sudden disruption to previous placement/s

• temporary group home...

• temporary commercial care providers…

• loss of contact with siblings & parents

The referral systems• abuse and neglect in group home care

• languishing in group home care (race)

• multiple workers, current & past

• multiple agencies, current & past

• temporary intensive support…

• suspicious of requests for help

The referral systems cont’d• sudden disruptions and changes in

therapy/counselling services

• poor follow-up of agreed case plans

• multiple indiscriminate referrals

• crisis focus - short-term orientation

• erratic liaison between health, education and child welfare

In spite of the above• A number of families, caseworkers, and case

managers impressed with the quality of their care, commitment and capacity to deliver a good service to children in spite of horrendous difficulties and few supports.

• “It was impressive and rather moving to see this well bonded family unity interacting with much concern for each other, plenty of affection and occasional appropriate discipline from (foster carer)”. (Child Psychiatrist)

Neurological assessments n=16• IQ, academic, language,visual-spatial,

executive, memory

• Most IQ above 75

• Executive and academic abilities most affected– inattention, impulse control, hyperactivity,

inflexibility in managing transitions, hyperarousal, distractibility

Implications• Above IQ criteria for integration aid

• Need for cognitive assessments and for remediation beyond education subcare teacher transitional support

• Role for medication, including weekends

• Impact at transition to high school

• Impact of early adverse circumstances– understimulation, multiple school placements– early stress, ongoing stress

Implications cont’d

• Parental functions are shared and may be fragmented– DoCS caseworker & foster carer/s– DoCS & NGO caseworker & foster carer/s– DoCS & NGO & carers & respite carers– DoCS & NGO & 3-6 group home staff– Commercial care provider

• DoCS & shift workers & intensive support

• Improving outcomes

First Impressions importance of a detailed

attachment and placement history Pilowsky & Kates, 96

• attachment / relationship focus of interventions Hughes, 97

• developmental context of interventions

• assess strengths and weaknesses of foster family

• the foster child is the weakest point in the system, and other stresses may be acted out in this relationship

Improving outcomes

First impressions cont’d• Judicious use of well monitored medication, at least in the short term

• Active strategic interventions in the school setting

• Psychoeducation of carers & workers • Problems are multifaceted and require

multidimensional services• Advocacy

Many co-morbid problems, multiple deficits and chronic difficulties are the most difficult for the health system to handle They are also difficult for

a complex shared parenting system to sustain interventions

• Rosenfeld, A. A. et al. (1997) Foster Care: An Update. J. Am. Acad. Child & Adolesc. Psychiatry, 36:4

• Barber, J. & Gilbertson,…. (2001) Foster Care: The State of the Art. The Australian Centre for Community Services Research: S. A.

• Rutter, M. et al. (2000) Recovery and deficit following profound early deprivation. In P. Selman, (Ed.), Intercountry Adoption: Developments, Trends and Perspectives. B. A. A.F.: London

• Constantino, J. et al. (2000) Reciprocal Social Behaviour in Children With and Without Pervasive Developmental Disorders. Developmental & Behavioural Pediatrics, 21:1

• Pilowsky, D. J. & Kates, W.G. (1996) Foster Children in Acute Crisis: Assessing Critical Aspects of Attachment. J. Am. Acad. Child Adolesc. Psychiatry, 35:8

• Hughes, D. A. (1997) Facilitating Developmental Attachment. The Road to Emotional Recovery and Behavioural Change in Foster and Adopted Children. Jason Aronson: New Jersey

References