Are they mad or bad conference

By Dr Anna Cohen

10th June 2011

This important and timely conference, organised by Leslie Ironside, Consultant Child and Adolescent Psychotherapist and Director of the Centre for Emotional Development, addressed some of the difficulties raised in trying to understand the complex pattern of emotional and developmental difficulties children who have been in care present.  Ensuring that they receive the right kind of help and support depends on how we recognise and interpret these difficulties.  Perhaps the context of this discussion is set by the significantly raised levels of mental ill health in children who have been in care as compared to children in private households.  72% are rated as having a diagnosable psychiatric disorder.  But does a psychiatric diagnosis make sense of the range of difficulties Looked After and adopted children may present with?

Instead, have you used categories such as “developmental” or “complex” trauma, or “attachment difficulties”?  Do you have a worry that Looked After children may be diagnosed with ADHD and prescribed medication when past histories of neglect and abuse have not been taken into account?  Why do many Looked After children have autistic traits, oe “quasi-autism”, and how helpful is this kind of description?  Why do so many children who have been in care have a diagnosis of Conduct Disorder, and form such a high proportion of the criminal justice system?

This conference explored some of these questions, and others.  Perhaps you may wonder whether we really need to assess and diagnose Looked After children using a psychiatric framework?  I think the importance of careful assessment and diagnosis is to ensure that these multiply deprived children and young people receive appropriate therapeutic support.  One theme focussed on by all the speakers concerned the kinds of deficits children who have experienced early neglect and abuse may have.  In addition to emotional and relationship difficulties, they experience very high rates of neurodevelopmental difficulties, and speech and language disorders.  Speakers discussed the impact of genetic inheritance and environment and how these factors interact to create a complex pattern of emotional and neurodevelopmental difficulties.

Gillian Baird, Consultant Developmental Paediatrician at Guy’s and St Thomas Trust,  spoke about the different impact neglect and individual episodes of abuse may have on development.  She discussed Michael Rutter’s studies of Romanian orphans brought up in institutions with little care-giver contact.  Although these children were later adopted into good homes, and there were significant improvements in speech and language, in adolescence they displayed challenging behaviours.  She argued that early neglect has significant effects on brain development, leading to difficulties for example with executive brain function.  She described characteristic difficulties with thinking through experiences and with emotional regulation and impulsivity.  By contrast, she argued, individual episodes of abuse have a less damaging impact on the brain.

Gillian Baird also talked about the fact that Looked After children often appear to have autistic characteristics, but fail to qualify for a diagnosis of autism.  She argued, and the audience agreed, that the description “quasi- autism”  is not a very helpful one.  The DSM-V, which is currently in process of being drawn up, will have a new diagnosis of disinhibited social engagement which may be useful.  It will link difficulties in social interaction with early failures in care giving, neglect and abuse.

Other speakers described alternative ways of understanding the mental health difficulties of Looked After children.  Margaret de Jong, Consultant Child and Adolescent Psychiatrist, discussed the idea of trauma as at the core of these children’s mental health difficulties.  She is Head of the Parenting and Child Service, an assessment and therapuetic service for children with a background of abuse, neglect and trauma, based at Great Ormond Street.  She discussed the fact that many Looked After children have experienced chronic trauma, which impacts on their emotional and cognitive development.  Some people use the term complex or developmental trauma as a kind of short hand.  Unfortunately there are various problems with using this as a formal psychiatric diagnosis and it has been rejected as a diagnostic category in  the new DSM-V.  She also talked about the difficulties of using the diagnosis Reactive Attachment Disorder, which in the DSM-V will be used only in relation to very young children’s attachment styles.

Paul Holmes, Consultant Child and Adolescent Psychiatrist, and founder of the Attachment Project, an inter-agency service for Looked After and adopted children based in Brighton, discussed attachment as a model for understanding these children’s difficulties.  He drew largely on the work of Patricia Crittenden, and also on Peter Fonagy‘s work on the importance of secure attachment for a capacity to understand one‘s own and other people‘s feelings, and to be able to regulate one‘s own emotions.  Attachment is both an aspect of relationships in the external world, but also shapes internalised models of self and relationships.  A child who does not have a secure attachment is unable to develop a sense of trust and know who they are.  He described how we all re-enact these internalised patterns, or internal dramas, in life and in therapy.  Crittenden rejects the concept of disorganised attachment, and instead conceptualises all attachment behaviour as a survival strategy, however contradictory it may appear.   Looked After children, Paul Holmes argued, lack an integrated sense of self, and use different attachment strategies depending on the situation.  This would explain, he suggested, why some Looked After children behave differently at home and at school.  Finally he argued that attachment styles can be influenced by different kinds of relationships or by psychotherapy, which offer a different attachment experience.  I would add that Fonagy and Anthony Bateman have developed a specific kind of therapy - Mentalisation Based Therapy - which aims to develop a greater capacity to understand what is going on in one’s own mind and in other people’s minds for people diagnosed with a borderline personality disorder.  They think that BPD often derives from highly dysfunctional parenting associated with neglect and abuse in which the infant is not able to have an experience of attachment and is therefore unable to develop consistent protective internalized models of self and relationships.

Finally Julie Withecomb, Forensic Child and Adolescent Psychiatrist,  talked about the high numbers of people in the criminal justice system who were Looked After children.  23% of the prison population and 30% of children in custody have been in care.  By age sixteen, one third of Looked After children have been in custody, and two thirds have a conviction by their early twenties.  The more a child is moved in care, the greater the risk of offending behaviour.  She described research which shows that abuse and maltreatment in early childhood causes changes in the neurotransmitters in the brain.  These changes in turn affect the response of the amygdala to stimuli, which affects the understanding of emotions and capacity to regulate them.   These young people need careful assessment and a range of targeted interventions to help them develop the capacity for emotional regulation, executive brain function and social skills.

The overwhelming theme that emerged as a result of this conference was how important it is to ensure that Looked After children and young people are offered detailed multidisciplinary assessment and a package of interventions designed to support them with their various deficits.  For example, they might need Speech and Languge support, a cognitive assessment to assess global or specific Learning Disability, support focussed on difficulties with concentration and impulsivity, as well as therapy to help them with emotional and trauma related anxieties and difficulties with managing their own feelings and forming more rewarding relationships.  In addition, their carers or adoptive parents need support to help them understand and manage the emotional and behavioural difficulties these children may present.  It reinforced the need in all the audiences’ minds for dedicated resources to provide the high level of assessment and intervention these children need.

Dr Anna Cohen
8th July 2011

Child and Adolescent Psychotherapist
Brighton and Hove CAMHS
Sussex Partnership NHS Trust