Mental health services for children in care: investigation to elicit outcomes of direct and indirect interventions

Abstract

Aims and method The aim of this study was to compare the efficacy of direct therapy and indirect consultation for treating mental health difficulties among looked after children (LAC), and also to identify any demographic or clinical predictor variables for outcomes in this cohort. A retrospective evaluation of mental health outcomes for 104 LAC was conducted. All children received network consultation in combination with or without direct therapeutic work. Outcomes were compared between the groups with and without direct therapeutic intervention. Results Those receiving both treatments displayed significantly greater Strengths and Difficulties Questionnaire (SDQ)-rated improvements than those receiving just consultation. Nonetheless, improvements in scores for the latter group were significant relative to baseline. Treatment duration, younger age at referral and start SDQ were all correlated with positive outcomes, while number of address changes predicted higher start SDQ scores. Clinical implications Despite the retrospective design of this study, its results can be considered as preliminary findings to guide treatment decisions in LAC. Looked after children (LAC) and mental health Irrespective of circumstances, LAC appear to be disproportionately burdened by an array of adversity, disrupted development and problematic relationships. These challenges commonly manifest as attachment-related disorders, emotional difficulties and maladaptive behaviours. Given the particular vulnerability of this population and the urgency required when dealing with insecure attachment, any research involving an untreated control group would be inherently unethical. Quantitative research in this field has therefore remained sparse, with the vast majority of the literature instead opting to assess case studies and qualitative data. The retrospective nature of the present study means it is able to contribute treatment-related outcome data from a relatively large sample of LAC. Although this naturalistic design is limited in terms of fully controlling confounding variables, it avoids the risk of bias from insufficient blinding and ensures that no child misses out on potentially beneficial treatment. A comprehensive meta-analysis conducted by Vasileva and Petermann 1 accumulated data from 22 samples of abused and neglected LAC under 7 years old. Across 11 studies , 38.5% of the 3211 eligible child participants were found to have either motor or cognitive developmental delays; these were consistently more prevalent in children fostered by strangers than in those looked after by kin. Similarly, 39% displayed clinically significant internalising or externalising problems, and only 35% of LAC met criteria for secure attachment. The findings of Tarren-Sweeney 2 indicate that when mental illness goes untreated during these early years, a child's social and emotional development may be jeopardised, and the possibility of a secure attachment appears to reduce with each placement breakdown. Children that entered care at a later age and were exposed to maltreatment were found to score significantly higher on both the Child Behaviour Checklist and the Assessment Checklist for Children, whereas having a permanent placement was highlighted as an important protective factor. Given the cross-sectional design, however, it was difficult to infer causation, and it is equally possible that children with better mental health are more manageable and thus less at risk of having placements break down. Attachment security appears to be a crucial factor mediating the mental health outcomes of children placed in foster care. Both internalising problems and frequency of mental illness diagnoses diminished significantly for girls removed from institutional care into foster care, but not for boys, in a sample of Romanian children aged 3 and below. 3 Subsequent analysis using the strange situation test 4 revealed that the demonstrated improvements in mental