Accommodating Complexity: The Need for Evidence-Informed Mental Health Assessments forChildren in Out-of-Home Care.

Abstract

Children in out-of-home care have all experienced adversity, and most have been exposed to maltreatment. Research across many decades has shown that these experiences are important risk factors for mental health problems. However, there is a lack of consensus about how best to formulate and manage the mental health needs of these children. Our own experience, supported by the empirical literature and clinical commentaries, 1 DeJong M. Some reflections on the use of psychiatric diagnosis in the looked after or “in care” child population. Clin Child Psychol Psychiatry. 2010; 15: 589-599https://doi.org/10.1177/1359104510377705 Crossref PubMed Scopus (66) Google Scholar , 2 McGuire R. Halligan S.L. Meiser-Stedman R. Hiller R.M. Differences in the diagnosis and treatment decisions of children in care compared to their peers: an experimental study on post-traumatic stress. Br J Clin Psychol. 2022; https://doi.org/10.1111/bjc.12379 Crossref PubMed Scopus (1) Google Scholar , 3 Grasso D. Boonsiri J. Lipschitz D. et al. Posttraumatic stress disorder: the missed diagnosis. Child Welfare. 2009; 88: 157 PubMed Google Scholar , 4 Frogley C. John M. Denton R. Querstret D. ‘They don’t meet the stereotypes in the boxes…’: foster carers’ and clinicians’ views on the utility of psychometric tools in the mental health assessment of looked after children. Adoption Fostering. 2019; 43: 119-136https://doi.org/10.1177/0308575919841752 Crossref Scopus (2) Google Scholar , 5 Jee S.H. Conn A.M. Szilagyi P.G. Blumkin A. Baldwin C.D. Szilagyi M.A. Identification of social-emotional problems among young children in foster care. J Child Psychol Psychiatry. 2010; 51: 1351-1358https://doi.org/10.1111/j.1469-7610.2010.02315.x Crossref PubMed Scopus (76) Google Scholar suggests that there can be considerable reluctance to using standard assessment protocols and diagnostic frameworks when formulating the needs of this group of young people. Although some children in the welfare system may experience significant emotional distress and functional impairment yet not meet current diagnostic thresholds, multiple reviews have shown that almost half of children in the welfare system do meet criteria for a diagnosable mental health disorder. 6 Bronsard G. Alessandrini M. Fond G. et al. The prevalence of mental disorders among children and adolescents in the child welfare system: a systematic review and meta-analysis. Medicine. 2016; 95https://doi.org/10.1097/MD.0000000000002622 Crossref PubMed Scopus (126) Google Scholar ,7 Engler A.D. Sarpong K.O. Van Horne B.S. Greeley C.S. Keefe R.J. A systematic review of mental health disorders of children in foster care. Trauma Viol Abuse. 2020; 201524838020941197https://doi.org/10.1177/1524838020941197 Crossref Scopus (16) Google Scholar More still may be subsyndromal but may still benefit from assessment and formulation based on current diagnostic frameworks. Thus, we contend that standard diagnostic frameworks should be central to the formulation and management of mental health difficulties for this group of children, as for any child. Of note, both our opinions here and the empirical literature are nearly exclusively derived from work in high-income Western countries. 6 Bronsard G. Alessandrini M. Fond G. et al. The prevalence of mental disorders among children and adolescents in the child welfare system: a systematic review and meta-analysis. Medicine. 2016; 95https://doi.org/10.1097/MD.0000000000002622 Crossref PubMed Scopus (126) Google Scholar ,7 Engler A.D. Sarpong K.O. Van Horne B.S. Greeley C.S. Keefe R.J. A systematic review of mental health disorders of children in foster care. Trauma Viol Abuse. 2020; 201524838020941197https://doi.org/10.1177/1524838020941197 Crossref Scopus (16) Google Scholar Further research across a range of cultures and particularly in lower- and middle-income countries is vital.