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.
Fantastic article.
My 6 year old son has exactly the complex profile described here, with clear – to us his parents – neurological difficulties affecting behaviours, relationships, and social understanding.
He has sensory processing disorder and we believe he has probably got a cocktail of ASD, FASD and attachment issues. At 3 years old a paediatrician pronounced “classic Aspergers” but refused point blank to take into account his history of probable prenatal substance exposure, neglect, and early trauma. The next paediatrician is focussed on FASD but will not assess for ASD, will not assess for language disorder and is happy for SS to take responsibility for his mental health. She will not assess for anything till he is 7.
Social services meanwhile are only focussed on attachment and know next to nothing about FASD. CAMHS were happy to talk to us about our son for about 6 2hourly sessions but didn’t want to meet him (!).
They are all intent on ploughing their own furrows, not talking to each other, believing their perspective is the only one, and I am left paddling like mad to join up the dots by myself. My son has had no developmental assessments since he was 3.
Meanwhile, all the time I am reading reading reading but am aware that all the strategies and supports I implement myself are disguising and diluting his true needs so that he copes with life and the professionals can sit back happily thinking what good progress he is making!
We need a consistent, specialised, holistic, multi -disciplinary service.
There are a few centres around the country, including Professor Green’s clinic in Manchester, and the Maudsley in London, that will carry out a full assessment, which takes into account poor early care and pre-natal exposure to alcohol and drugs and ASD etc. If you live in England social services can apply to the Adoption Support Fund to pay for such an assessment. I don’t know if that would help move things along for your family, but may be worth considering. Best wishes and thank you for leaving a comment.
Thank you very much for the helpful information above. Does Prof Green’s clinic accept private referrals, then? From GPs, schools or social workers?
Just read your article with great interest, though I appreciate it was published some time ago. We are battling with our local authority to get thorough assessments made of our two adopted children, aged 6 and 4. One of the excuses we have been given is that there are no providers In our area. We have found one organisation that is fairly local to us, but would be interested to learn of others, so that we have some choice, should the local authority finally agree to the assessments. Are you aware of any organisations in Surrey/West Sussex/North Hampshire that can provide thorough assessments? Any leads would be appreciated.
This article is excellent, the maudsley m.h. trust – slam do have a specalist unit dealing with adopted children, however you need to get a referral if you live outside there referral area, which is normally via camhs, and you have to be able to get there. Support is far too limited and there is a complete lack of joined up planning between services. Our child is currently sectioned as the support for us came far too late, the long term costs will far outway the cost of earlier intervention, it has taken us over 7 years to get assistance for our adopted child and now we fear that the damage may not be undone.
It is dreadful that it took 7 years to receive help. There are some green shoots of change, but sadly too late for many children. You are absolutely right of course that early intervention saves money, as well as misery and lost opportunities. I very much hope that your child is now receiving good quality treatment and that some healing can take place. Best wishes and thanks for commenting x
This is such a thoughtful piece by someone who truly gets the complexity of our children, and what they need. I hope everyone listens to him and every word he says. Thank you for sharing.