Looked-after children show high rates of psychiatric disorder of various kinds – this is the accepted view, based on several influential studies. But how true is it?
A frequently cited study of young people in Oxfordshire reported levels of 67 per cent for psychiatric disorder in looked-after children aged 13-17 who had been in local authority accommodation for an average of three years, rising to 96 per cent for those in residential care.1 Of the 67 per cent, prevalent diagnoses were conduct disorder (28 per cent) and major depressive disorder (23 per cent). The study concluded that resources be directed to these complex psychiatric disturbances.
A later study of five to 12 year olds entering care found that one-third of the sample had significant conduct problems while half of the children entering residential care had significant features of depression.2 This study concluded that children entering care have significant disturbance and are not being referred for psychological help.
So the established literature makes a strong case for investment in specialist child and adolescent mental health services.
However, the received wisdom is challenged by an assessment of the mental health needs of looked-after children we carried out recently in Stockport (for details, contact firstname.lastname@example.org). We assessed all looked-after children over seven years old. Carers were asked to complete the Devereux scales of mental disorder, while the children and young people completed the Reynolds depression scale and self-esteem inventory.
As with other studies, carers in our assessment reported relatively high levels of depression and antisocial behaviour in the 13 to 18 year old age group. However, the children and young people themselves did not report high levels of depressive symptoms or of low self-esteem. Only 2 per cent of the 13 to 18 year olds had scores on the Reynolds depression scale that exceeded “the threshold for further assessment” (showed signs of clinical depression). On the self-esteem index, only 5 per cent rated their self-esteem “low” or “very low” compared with norms.
Also, the methods used in the earlier studies beg some questions. The Oxfordshire study does not attend to the relative validity of the carer’s report as opposed to the young person’s self-report. In this study, 88 out of 144 initial questionnaires to carers were returned and used to identify the children and young people most disturbed. Interviews were conducted with 37 “high scorers”. The conclusions appear to be based on an extrapolation from interviews with this sub-sample. We are not told about the degree of consistency between the children’s self-report and the carer’s assessment.
Another recent study showed that higher rates of report of psychiatric disorder may be expected from carers.3 This warrants further investigation and may have implications for the apportionment of resources between social care services and expensive specialist child and adolescent mental health services.
Our findings raise questions about the assumption that looked-after children are in need of specialist psychiatric services, rather than requiring a more mainstreamed and cost-effective range of support services aimed at their needs as distressed children experiencing difficult times.
1J McCann et al, “Prevalence of psychiatric disorders in young people in the care system”, British Medical Journal Vol 313, 1996
2G Dimigen et al, “Psychiatric disorders among children at time of entering local authority care”, British Medical Journal Vol 319, 1999
3J Williams et al, “Case-control study of the health of those looked after by local authorities”, Archives of Disease in Childhood Vol 85, 2001
Susan White is professor of health and social care at the University of Huddersfield and John Stancombe is consultant child psychologist at Trafford Healthcare NHS Trust