364 Chapter 42
commoner. Particularly raised is the prevalence of autistic spectrum dis-
orders and ADHD-like syndromes, especially where there has been severe
deprivation. Attachmentdisordersare more prevalent than in the general
population but still uncommon, but insecure attachmentpatternsare
common. For example, one study of late-placed (mean age at removal
from family 7 years old) fostered adolescents found that 0% were securely
attached to their birth fathers, and only 10% to their birth mothers,
compared to 44% and 60% of controls to their fathers and mothers.
Long-term outcomes are poor, both in terms of presence of psychiatric
disorders, and psychosocial functioning. Among children looked after by
local authorities in England, only 12% obtain five or more grades A–C
GCSEs, compared with 56% in the nation as a whole; criminality rates
are 5–10 times higher. In contrast, studies of earlier adopted children
show only a slight increase in psychiatric disorders and good long-term
psychosocial outcomes.
Assessment
Mental health assessment needs to be comprehensive. Several informants
should be asked for information, not, for example, just the current foster
carers. It is important to get the original records and any medical informa-
tion about both birth parents, including their psychiatric history, criminal
records, level of intellectual attainment and education, and drug and alco-
hol history. A thorough physical examination is essential as there are often
visual or hearing deficits that have previously not been uncovered, and not
infrequently dysmorphic syndromes. A thorough psychometric assessment
is essential as specific learning difficulties and intellectual disability are
common. The child or adolescent needs to be spoken to on their own for
some time to get a picture of their own mental state, their understanding
of their own story and their relationship with, or understanding of, their
birth parents and fosterers or prospective adopters. For children looked
after by the local authority, it is important to ensure that a social worker
is present at the assessment, and if possible, a senior manager too. This
is so that the results of the assessment can be put into action with the
understanding and resources of the management.
Issues in deciding placement
The best therapy for a child who cannot live with their birth parents is
a stable placement with loving parent figures who can meet the child’s
needs by providing sensitive and encouraging care and treating them as
somebody really special. From this it follows that:
1 Residential placements to ‘prepare’ a particularly troubled child for
a permanent placement later are not a good idea, although this is
sometimes still practised. This merely prolongs the period of doubt for