The February issue of the Adoption UK magazine, which I’ve guest edited, is themed around the mental health needs of adopted children and their families. In this accompanying piece Jonathan Green, Professor of Child and Adolescent Psychiatry at Manchester University writes about the particular needs of adopted children and how services may better assess and respond to their needs. He argues for comprehensive assessment and a presumption of long term support.
Adopting parents have opened their hearts and homes to what are now often some of the most complex children in our community. When there are problems, they can be often difficult to make sense of and manage. And yet adopting families often find feel a lack of comprehension from services and difficulty finding help. Why should this be? And what’s to be done about it?
The nature of children coming into adoption has profoundly changed over several generations but professional attitudes and service provision have not always caught up, being more influenced by the nature of adoption two or three generations ago when children given up to adoption often due to religious or social pressures. Children now of course tend to come into adoption rather differently, usually in the context of families whose parenting has failed and whose children have been received into care by the local authority. The complex background of these children leads to many potential impacts on their development and mental health, including heritable risks, potential exposure in fetal development to maternal stress or abuse of alcohol or drugs, and after birth, potential exposure to neglect or maltreatment and a variety of care placements before permanency. Each of these areas of difficulty can leave different kinds of marks on the child’s development, ranging from effects on the developing brain and nervous system to effects on relationships and feelings within attachment problems and consequences of trauma. Hence the complex presentations. Professor Julie Selwyn from Bristol found that a quarter of adopting families reported major challenges and complex needs in their children and at least 80% of these reported major mental health problems in the children – and a fifth of families in which the placement was going well still reported mental health problems in their children.
What sort of service do adopting parents deserve? Firstly a service that respects the very particular situation you’re in. The challenge of making and sustaining relationships with children who have often had previously very complex and difficult experiences is really unique. Secondly, help to understand the real nature of your child’s presentation. There is likely to be a complex picture mixing what we think of as “neurodevelopmental” problems such as ADHD and ASD or fetal alcohol syndrome, with problems of attachment, adjustment and response to trauma. It is not surprising that the behaviour and relating of children after all this can at times be perplexing. We tried to understand the extent and complexity of these layered difficulties in an in-depth research study. In the 60 families who volunteered for our study over 70% of the children had experienced maltreatment and neglect and over 50% exposure to prenatal risks; they had been taken into care at a mean age of one year and adopted at a mean age of three years. Two thirds of these children had problems with mental health and development, with a half showing signs of developmental type disorders and over a half with emotional and behavioural difficulties. Often these problems were mixed in together – creating the complex picture. What families need therefore is an assessment process that is efficient and yet skilled enough to be able to sort out different components of the problem and prioritise elements for intervention. There are good interventions for all of these kinds of difficulties, it is a question of carefully selecting which ones to choose and adapting them to the particular situation of adopting families. The problem with selecting interventions without a thorough assessment of this kind is that the wrong kind of intervention may be given for a particular problem; and this matters, particularly with such complex problems, since the wrong kind of treatment will be ineffective and possibly harmful.
What kind of service can deliver this? Not a “free for all” in my view, but instead one that is based on the best research and clinical evidence that we now have. In such a complex area the service needs to have specialist expertise and for that reason should initially be concentrated in coordinated regional networks of excellence linked to research centres. There needs to be excellent coordination between local authority, child mental health, the voluntary and where necessary independent sectors. Child Mental Health Services in general need alerting to the specific needs of families after adoption and we are working on an ‘adoption awareness’ program to be rolled out to them. We need good screening for problems so that families and social workers and others can know when to refer on to more specialist services; and the specialist services themselves need to be coordinated to produce individualised effective treatments. Additional to that there needs to be a recognition that these problems usually endure and that families need support and sustenance through the development of their children; they will not need help all the time but they need to know where they can get it if there is a crisis, so the availability of longer term support is crucial. If families know they have access to such support in a timely way then they will feel much more resilient in managing.
Is it pie in the sky to create such awareness and service integration within the NHS? No. We have done this before with other kinds of problems in child mental health and with good coordination and clear protocols we can do it in this arena. The attention on the needs of adoption of this current time is helping and we are working hard to make this a reality at the moment. The situation I do believe is gradually changing and the focus bought to the problem by the governments work on the adoption support fund has been a real catalyst.