Getting Assessments Right for Care-experienced Children & Young People

After over 50 years, SLAM’s NHS National Adoption & Fostering Clinic [https://www.nationaladoptionandfosteringclinic.com/] is to close [LinkedIn post here]

The National Adoption & Fostering clinic was pretty much unique in its approach to assessment, being open to assessing just about all and every mental health condition, all under one roof, including but not limited to the issues below:

Trauma & Attachment

Simple & Complex PTSD with varied presentations and comorbidities [i.e., other co-occurring and complicating disorders]
Attachment pathology [RAD/DSED which are rare] and broader attachment issues with the functioning of the attachment relationship [which are more common, especially earlier in the permanency]

Neurodevelopmental issues

ADHD; Autism Spectrum Disorders; Foetal toxins, including alcohol, smoking, valproate etc; Neuropsychological Problems [e.g., executive dysfunction]; Tic Disorders; Epilepsy; Sensory Issues [+/- autism]; Chromosomal Abnormalities & Phenotypes

Emotional (Internalising) issues

Depression (i.e., Mood Disorder), with or without Self-Harm and Suicidal Ideation, alongside the active management of risk including in-patient admission to, and discharge from, specialist services; emerging Personality Disorders
Anxiety disorders including Separation Anxiety Disorder, as well as generalised anxiety [worry], social phobia (shyness) and ‘simple’ phobias etc.

Behaviour

Behavioural Problems and Conduct Disorders – including the recently specified ‘moderators’ of limited prosocial emotions and irritability; Parenting Assessments; Forensic Issues and Risks; Child Sexual Exploitation; Sexually inappropriate and/or harmful or risky behaviours

Educational issues

Specific Learning Disabilities such as dyslexia, dyscalculia etc; Global Learning Disability; problems with language development / understanding.

And a whole host of other non-psychiatric problems such as

Peer relations; social skills; emotional understanding; school and placement issues; toileting [soiling and wetting]; hygiene; feeding/regurgitation/hording/gorging; sleep problems…

The last ones, the non-psychiatric problems, are often more important to children and their families than the traditional, formal mental health diagnoses , but may not get easily identified or treated in some non-specialist adoption & fostering services or diagnosis-led care pathways. And knowing about the range of formal mental health issues alongside these can help you better formulate what to do for a particular child’s priority goals for treatment.

This is the heart of an evidence-based, personalised and collaborative formulation of needs, of course.

It is no good to lump the wide range of presenting issues under simplistic “adversity” signifiers. It is always going to be better to have Individualised & Personalised formulations, leading to appropriate treatments packages, using the evidence base & outcome monitoring as the basis of collaborative working with families & stakeholders.

But this is not terribly new. Or innovative.

The issues were raised by experts over 20 years ago... This great article, the introduction to a special edition about rare disorders in maltreated children, in Child Maltreatment, warned practitioners to be vigilant to the “allure of rare disorders” in children in the care system (Haugaard, 2004, p127), and to summarise said:
While rare disorders may be more commonly found in maltreated children than other children, they are still rare [e.g., 2% compared to 1% would be a big 100% increase, but still rare]
Common disorders are still the most common disorders in maltreated children
Comorbidity is more likely in maltreated children, so don’t let the presence of one disorder, even or especially a rare disorder, mask the possible presence of other ones
It would be just as bad to fail to identify common disorders, as rare ones
So you need to keep an open mind to all and any possibilities

This was emphasised shortly after, also in Child Maltreatment, but by different authors, including some of the good and the great of attachment research. They were specifically addressing the concerning trend at that time of over-identifying attachment issues at the expense of more common disorders in children in the care system [Chaffin et al, 2006]. They make detailed, evidence-based recommendations for assessment and treatment of these young people, and for the assessment recommendations, numbers 5 to 9 [p86] are copied out in full below:

(5) Assessment for attachment problems requires considerable diagnostic knowledge and skill, to accurately recognize attachment problems and to rule out competing diagnoses. Consequently, attachment problems should be diagnosed only by a trained, licensed mental health professional with considerable expertise in child development and differential diagnosis.
(6) Assessment should first consider more common disorders, conditions, and explanations for behavior before considering rarer ones. Assessors and caseworkers should be vigilant about the allure of rare disorders in the child maltreatment field and should be alert to the possibility of misdiagnosis.
*(7) Assessment should include family and care giver factors and should not focus solely on the child.*
(8) Care should be taken to rule out conditions such as autism spectrum disorders, pervasive developmental disorder, childhood schizophrenia, genetic syndromes, or other conditions before making a diagnosis of attachment disorder. If necessary, specialized assessment by professionals familiar with these disorders or syndromes should be considered.
(9) Diagnosis of attachment disorder should never be made simply based on a child’s status as maltreated, as having experienced trauma, as growing up in an institution, as being a foster or adoptive child, or simply because the child has experienced pathogenic care. Assessment should respect the fact that resiliency is common, even in the face of great adversity.

They also said, in common with Haugaard in 2004, “Just as it is important not to miss the presence of an uncommon condition in a child, it also is important not to diagnose an uncommon and dramatic disorder when the diagnosis of a common but less exciting disorder is more appropriate. Although more common diagnoses, such as ADHD, conduct disorder, PTSD, or adjustment disorder, may be less exciting, they should be considered as first line diagnoses before contemplating any rare condition…” [Chaffin et al 2006, p82, italics added] - this describes the allure of exciting and rare disorders.

So, assessment needs to be done by people who have considerable expertise in child development and clinical diagnostic knowledge, alongside the skills to differentially diagnose competently across a wide range of disorders. Assessments must keep in mind those wide range of disorders, and not inadvertently mask heterogeneity by jumping to trendy, ‘exciting’ top-down explanations such as ‘attachment problems’ [or nowadays, also ‘trauma’ and other fashionable, simplistic, explanatory frameworks] to take into account the diversity of possible issues, and to work out which ones are most likely - bearing in mind that common disorders are still more common, of course…

Although it is fairly obvious that this is the right, evidence-based approach, it is expensive to run a service like that compared with a service that doesn’t assess for anything/everything, but instead can skip assessment and offer the same one or two treatments for all ‘kids like that’. Homogenising across diverse needs will always be far cheaper at the point of delivery. Unfortunately, if you are going to keep in mind the probability of heterogeneity and diversity of presentation in care experienced children, you need clinical services with the knowledge and skills to do that. But as that will always be more expensive than pretending everyone has the same issues, the question must be - are these families worth it? I’d say yes, but evidently not.