Transcript Assessing the health and wellbeing needs of children

Assessing the health and
wellbeing needs of children
entering out of home care –
necessary and sufficient?
Professor Graham Vimpani
Clinical Chair,
Kaleidoscope Children’s Health Network
Head of Discipline of Paediatrics and Child
Health,
University of Newcastle
What’s all the fuss about?
“Is it worth the effort and expense that
would be needed to improve health
needs assessment and health service
access for children and young people
living in out-of-home care, especially
when most kids in foster care seem
healthy enough on a day to day basis,
and can just be taken to a doctor if they
feel sick?”
Overview
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The case for comprehensive health
assessments on entering care
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What is happening in Australia now?
Does it make a difference to health and
wellbeing outcomes?
Is it sufficient?
What about the carers’ needs?
Effective intervention has lifelong benefits
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The role of epigenetics
Why children enter OOHC
What is the health status of
children entering care?
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“The majority of children in care are in
good physical health and display
improvements in psychological
functioning over time” (Osborn & Bromfield, AIFS
2007)
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Mental health problem 18%; disability
20%; intellectual disability 14% (Vic govt
audit)
What is the health status of
children entering care?
South Australian study
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61% (N=326 aged 6-17 yrs) in clinical range for behaviour problems
(Sawyer et al, 2007)
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54% needed clinical help but only 24% got it
Proportion with clinical scores on CBCL externalising scale 6-7 times
higher than general community
NSW Study
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53% girls and 57% boys (N=347 aged 4-9 yrs) had at least one scale
of CBCL in clinical range (Tarren Sweeney & Hazell, 2006)
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“The only non-clinical populations of children likely to have poorer
relationship and behavioural functioning … are those in institutional care or
late adoptees following residential care”
Kari clinic (Aboriginal and Torres Strait Islander SSW)
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Language delays or disorder in 63%
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Oral health problems in 37%
Sydney Children’s Hospital Clinic Results
 94 children
 Age range: 3m to 14yrs
 48% (45) were under 5yrs
 43% girls, 57% boys
 Time in care ranged from 1 week to 5 years
 45 children were in their first placement
Health Problems - 1
 97% had 1 or more health issues (medical,
developmental, emotional and/or behavioural
problems)
 Immunisations – 53% up to date
 Vision –
18% (16/87) failed screen and referred
» 8 Squint
» 7 Poor Visual Acuity
» 1 Floater
12 pre-existing eye conditions
Health Problems - 2
 Development
– 69% of under 5s failed screen
– 2 autistic behaviours
 Speech
– 51% of under 5s speech delay
 Growth
– Failure to thrive - 2
– Small stature – 7
– Overweight - 3
Health Problems - 3
 Infections - 14
– Respiratory – URTI, ear
– Skin –impetigo, infected eczema, warts, fungal
 Skin - 17
– Eczema
– Scars
– Nappy rash
– Impetigo
– ?Psoriasis
Health Problems -6
 Behavioural and Emotional health
– Most significant issue in 54%
 Significant mental health issues - 7
– 2 boys depressed
– 1 boy with suicidal thoughts
– 3 children with significant grief and loss issues
requiring counselling
– 3 children with symptoms of Post Traumatic
Stress Disorder
– 1 boy with gender identity issues
Implications of SCH study
 More than 50% - perhaps 70% - of children and young
people will require a secondary level assessment
because of developmental and behavioural problems
 A smaller proportion may require further assessment
because of physical conditions
The case for comprehensive
assessments
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DoCS – Health MOU on Children in OOHC (NSW)
(2006)
Royal Australian College of Physicians policy (2006)
Royal Australian and New Zealand College of
Psychiatrists (Faculty of Child and Adolescent
Psychiatry) (2008)
Wood Special Commission of Inquiry (NSW) (2008)
Keep them Safe (NSW) (2009)
Development of Draft National Standards for children
in Out of Home care (FaHCSIA – 2010)
NSW Standards for Statutory Out of Home care
(updated 2010)
DoCS – Health MOU
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(NSW, 2006)
Identifying referral points in each Area Health
Service for community health, drug and
alcohol services, and mental health services
Specialist medical, psychiatric and other
health assessment services
Specialised medical and mental health
services, including secure in-patient
psychiatric acute care appropriate for children
and young persons
Specialist sexual offender services for children
and young persons who sexually offend.
DoCS (NSW) procedures prior
to Keep them Safe
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All children and young persons should undergo a health,
developmental and mental health/behavioural assessment
within 60 days of entering care.
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The child/young person’s case worker is responsible for arranging these
assessments which are carried out by a range of medical and allied health
professionals
The physical health/medical component of the assessment should
include the following:
1.
2.
3.
4.
5.
6.
completion of a medical history profile of the child and family to
understand the health conditions of parents or siblings which may impact
on the child’s health, welfare and well-being
immunisation register check
physical examination that checks for growth delay (eg careful
measure of weight, height and head circumference) and signs of
malnutrition
screening for visual and hearing deficits
screening for signs of pathological conditions that need further
investigation (e.g. foetal alcohol syndrome, fragile X syndrome, physical
abnormalities that may be related to past abuse)
dental health screening
DoCS (NSW) procedures prior
to Keep them Safe
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A developmental assessment component should
also be done which covers domains such as general
cognitive functioning, language and communication,
gross and fine motor functioning and socialisation
The mental health/behaviour assessment may
be deferred
It is the responsibility on the caseworker to obtain
the child or young person’s personal health record
(Blue Book), from the parents
RACP proposals
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Ensuring that physical, developmental and mental health
assessments are performed on all children who enter out-ofhome care within 30 days;
Encouraging ongoing monitoring of needs by identified health
care co-ordinators;
Ensuring appropriate timely access to therapeutic services;
Developing a transferable health record system;
Improving training and support for foster carers;
Coordinating a health care centred approach between all
agencies involved with this group of children, including
Community Services and Education;
Encouraging governments to adequately fund the
implementation of the suggested recommendations; and,
Collecting aggregated data and ensuring evaluation of
programs.
Components of comprehensive
health care assessment (RACP) 1
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General health assessment including
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a health history of the child and family
physical examination
growth assessment
vision, hearing and dental screening
immunisation register check.
The health assessment information must be
documented to ensure easy access for medical
professionals
Undertaken by paediatrician, GP, nurse practitioner or
Aboriginal Health worker
Components of comprehensive
health care assessment (RACP) 2
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Developmental assessment incorporating
standardised screening tools
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e.g. Ages and Stages or Brigance, as an adjunct to
clinical assessment,
access to formalised assessment.
Local systems must be developed to fast
track therapeutic developmental services to
children with identified deficits.
Systems need to be established for liaison
with Education representatives
Components of comprehensive
health care assessment (RACP) 3
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Mental health screening using accessible and
validated tools
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e.g. Strengths and Difficulties Questionnaire, or
Achenbach Child Behaviour Checklist (CBCL).
Infants and toddlers must be assessed for
attachment disorders (sic)
Local systems must be developed to provide a
therapeutic response to identified needs.
Development of an individualised
health plan - RACP
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Based on results of comprehensive
assessment and in conjunction with
CPS:
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Identifying a health coordinator for each
child;
Promoting a follow-up health review to
occur within three months of assessment
and subsequently at least on an annual
basis.
Ensuring equitable health care
- RACP
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Working with CPS, Education, Health to:
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Develop local systems to ensure that this group of children is
not disadvantaged in their receipt of health care services
compared to their peers;
Promote the use of fast tracking therapeutic services, given
the often, small window of opportunity available due to
transient care placements; and,
Ensure that such services are provided for all health needs
and in particular mental health needs, utilising both public
and private therapeutic services as required
Data collection - RACP
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Governments be encouraged to develop and resource
permanent and easily transferable health records
which will be accessible to future health providers
and available to parents and carers:
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Using electronic health records linked to Community Services
files;
Ensuring these are stored in a safe manner while at the
same time allowing them to facilitate health communication;
Recording information that includes a patient hand-held
record containing past history, relevant family history, health
assessment information, treatments and interventions;
Evaluating the health needs of children placed in out-ofhome care and aggregating this data to monitor and identify
the effective interventions.
Improved access to health
records of birth parents - RACP
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That the College assist Community Services workers
to have access to health records of birth parents in a
fashion which is consistent with privacy legislation
by:
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Developing a proforma to enable these workers to collect a
satisfactory health history from parents
engage with parents over consent for health treatment of
their child at the point of entry into care; and,
Entering into discussions with Privacy Commissioners, or
similar bodies, to explore the availability of this information
to Community Service workers.
Enhancing communication RACP
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That the College … advocate increasing the level of
communication by:
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Facilitating effective communication channels between
health professionals, Community Services Departments and
other key people in the foster child's life e.g. schools, carers
and parents;
Establishing specific communication avenues such as
community based inter-agency forums for more complex
cases;
Listening and responding to foster children’s opinions and
ideas as to how their health needs may be best met; and,
Engaging birth parents in their child’s ongoing health
planning where possible.
The case for comprehensive mental
health assessment and intervention
(RANZCP)
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Every child entering OOHC has a multimodal mental
health assessment as part of the admissions to care
process
Children with potential psychopathology should have
a comprehensive mental health assessment within 30
days
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A profile based on a developmental framework of
psychopathology that identifies risk and protective factors
that contribute to resilience should be documented for each
child at this time
All children with intellectual disability entering OOHC
should have a comprehensive mental health
assessment routinely
The case for comprehensive mental
health assessment and intervention
(RANZCP)
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Treatment plans that organise and prioritise
interventions in the major areas of a child’s life
should be developed with emphasis on enhancing
strengths through therapy or activities that promote
the child’s development. These plans may include
medication to improve functioning and reduce
symptoms
Children in OOHC with MH problems should be given
special attention and priority access to MHS
A cost-effective process for assessing these children
that does not rely solely on specialist clinicians needs
to be developed
What should happen re health in KtS,
National and NSW OOHC standards?
Keep them Safe (2008-2009)
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Proposed principles (Wood)
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Children and young persons should be assisted to gain regular access to
education, health and other services to meet their changing needs and to
enable them to grow and develop
Restoration decisions should not take longer than six months, particularly
for younger children
Greater in-depth assessment of children and young persons coming into
care through more comprehensive assessment and interventions in the
crucial early stages of placements should be part of agency placement and
planning processes
Care arrangements for children and young persons should be based on their
assessed needs, and the assessed capacity of carers to meet these needs
There should be sufficient health and specialist services including dental,
psychological, counselling, speech therapy, mental health and drug and
alcohol services available to meet the needs of children and young persons
in OOHC
What should happen re health in KtS,
National and NSW OOHC standards?
Keep them Safe (2008-2009)
 Proposed principles (Wood)
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There should a system common to all agencies delivering
services to children and young persons in OOHC that collects
essential health information and monitors their health and
educational outcomes. This should include an accessible,
comprehensive medical record or a transferable record for
children and young persons in care
Interventions for high needs children and young persons in
OOHC should include strong case management, integrated
multi-agency work, and highly skilled staff and carers who
receive expert supervision, ongoing training and support
What should happen re health in KtS,
National and NSW OOHC standards?
Keep them Safe (2008-2009)
 Recommendations (Wood)
Recommendation 16.3
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Within 30 days of entering OOHC, all children and young persons
should receive a comprehensive multi-disciplinary health and
developmental assessment. For children under the age of five years
at the time of entering OOHC, that assessment should be repeated
at six monthly intervals. For older children and young persons,
assessments should be undertaken annually. A mechanism for
monitoring, evaluating and reviewing access and achievement of
outcomes should be developed by NSW Health and DoCS
Govt response: Supported. Role of GPs to be explored
Recommendation 16.4
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NSW Health should appoint an OOHC coordinator in each Area
Health Service and at The Children’s Hospital at Westmead.
Govt response: Supported.
What should happen re health in KtS,
National and NSW OOHC standards?
Keep them Safe (2008-2009)
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Recommendations (Wood)
Recommendation 16.6
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The NSW Government has a responsibility to ensure that all children and
young persons removed from their parents and placed in its care receive
adequate health treatment. Thus, there should be sufficient health services
including speech therapy, mental health and dental services available to
treat, as a matter of priority, children and young persons in OOHC
Govt response: Supported
Recommendation 16.7
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The introduction of centralised electronic health records should be a priority
for NSW Health. Given that this is likely to take some time, an interim
strategy should be developed to examine a comprehensive medical record
or a transferable record for children and young persons in OOHC, which
should be accessible to those who require it in order to promote or ensure
the safety, welfare and well-being of the child or young person.
Govt response: Supported. Interim - Blue book to have OOHC modules
What should happen re health in KtS,
National and NSW OOHC standards?
Keep them Safe (2008-2009)
 Recommendations (Wood)
Recommendation 16.11
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A common case management framework for children and young
people in OOHC across all OOHC providers, should be developed,
following a feasibility study on potential models including the
Looking After Children system
Govt response: Supported – CS will undertake a feasibility study
with a new model to be introduced in 3-5 years
Recommendation 16.13
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There should be sufficient numbers of care options for children and
young persons with challenging behaviours that include specialised
models of therapeutic foster care
Govt response: Supported – CS will develop new models of care
What should happen re health in KtS,
National and NSW OOHC standards?
Draft National OOHC standards (2010)
 Standard 4. A comprehensive health assessment is provided to
children and young people entering care, with ongoing medical
needs attended to in an appropriate and timely way, and
children and young people have their own written health record
which moves with them if they change placements.
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Standard 5. Children and young people entering into care
receive timely and appropriate therapeutic assessment and
support as needed.
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Standard 13. Each child and young person has a case plan
developed that details their health, education and other needs,
which is implemented and reviewed regularly, with the children
and young people supported to participate in both the
development and updating of their plan.
What should happen re health in KtS,
National and NSW OOHC standards?
NSW standards (2010)
3.
8.
9.
11.
14.
Children and young people’s wellbeing is actively safeguarded
Children and young people are cared for in placements which
meet their specific emotional, social and behavioural needs
Children and young people’s health and developmental needs
are addressed
Children and young people have initial assessments based on
their best interests and are placed according to their
identified needs and where relevant, the Aboriginal and
Torres Strait Islander Placement Principles
Children and young people have effective behaviour support
and management plans where necessary
What is happening now (NSW)
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20% of children entering care had a health
assessment in 60 days (NSW audit)
Fragmented information systems and poor
access to personal and family health
information (Wood)
No standard or consistent approach to the
collection of data for health screening and
assessment (Wood)
Activity in Other States
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Queensland – Child Health Passport to facilitate placement and
annual checks
Victoria – health plans under LAC reviewed every 6 months or
annually plus comprehensive intake assessment by GP,
paediatrician, mental health professional
WA - children and young persons in OOHC have health and
education assessments and plans covering physical, mental and
dental care. It is envisaged that the assessment model chosen
would review physical growth, progress towards developmental
milestones and psychological/emotional development.
SA - Health Standards for Children and Young People under the
Guardianship of the Minister. This involves an agreement
between the Department of Families and Communities and the
Department of Health that Health will provide a comprehensive
paediatric assessment upon entry into care
Does health assessment make
a difference to outcomes?
Outcome of SCH health assessments N=100
 75% received 4 or more recommendations
– Medical review 59%
– Dental review 52%
– Immunisation 44%
– Counselling/psychological service 42%
– Ear, nose and throat review 42%
 In 43 children’s cases, DOCS did not know if one or
more recommendations had been implemented
Health benefits - SCH
 Of the 363 recommendations where a recordable health benefit
was applicable, almost 50% were unknown by the caseworker.
Examples of health benefits
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Of 26 children referred by the clinic for further formal developmental
assessment, 12 were found to have significant delays, and relevant
educational interventions were in progress
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14 of the 24 children referred for speech assessment had so far been
screened, of whom nine were currently receiving speech therapy and
making significant language improvements.
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There were also examples of children who had undergone major
dental work and of children prescribed glasses.
Status of SCH recommendations
Reasons for Recommendations non-completion
Systems Issues
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Frequent change of carer
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High turnover of caseworker and delays in reassignment of a new caseworker
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Poor record keeping
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Lack of knowledge regarding service providers
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Reluctance to place children on waiting lists until the courts had finalised placement decisions
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Caseworkers themselves commented on their own lack of time and resources
– for accessing the recommended allied health services
– and for tracking the child’s ongoing progress through the health system
Lack of services
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Counselling
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Peer and carer support,
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Public dental services
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Long waiting lists for allied health services
– e.g occupational and speech therapy.
Conclusion from SCH study
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Benefits of health assessment uncertain
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Routine comprehensive health screens clearly improve detection of
previously unmet or unrecognised health issues
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Screening provides a baseline record of the child’s current health and
well-being.
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Reasonable to assume that the information and advice provided to
carers and caseworkers by the clinic was likely to improve a child’s
access to appropriate health services.
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Agencies should have systems to ensure better communication and
collaboration between the health and community services systems.
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Regular medical reviews while a child remains in care and improved
inter-agency liaison over
implementation of the child’s health plan
may improve health outcomes
for these children
Is health assessment of children entering
OOHC sufficient to improve outcomes?
Benefits of comprehensive
assessments
 Are there risks from not having a
comprehensive health/mental health
assessment?
“Children with hidden emotional distress are a
particular risk of not being referred or picked
up by services. They...have a relationship
style that tends to hide their needs from
view.”
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“Closed book children”
“Too good to be true”
(Schofield et al 2000; Crittenden 2009)
Benefits of comprehensive
assessments
“The prevalence, scale and complexity of mental health difficulties experienced by
these populations are so great, that delineation between primary and specialist
levels of care for these children is blurred.
They require universal, comprehensive clinical/psychosocial-developmental
assessments following entry into care or adoption. These assessments identify
risks and casework-related issues that may contribute to future mental health
difficulties, or detract from their development or well-being in other ways. This
applies as much to children who enter care with few mental health difficulties.
Universal, comprehensive assessment by specialist clinicians following entry into
care is thus preferable to mental health screening, because it is designed for
prevention of future difficulties as much as detection of present ones.
Furthermore, mental health screening alone does not identify critical influences on
children’s development that have a bearing on other psychosocial-developmental
outcomes (that could be remedied if detected early enough). Beyond initial
assessment, there remains a need for a primary care (i.e. population-wide)
approach to provision of specialist mental health services, equating to a
primary–specialist care nexus.”
( Tarren Sweeney, 2010)
What others have said…
– Children who have experienced long-term foster care do
not benefit from the receipt of outpatient mental health
services (Bellamy et al 2010)
– “there is little empirical basis for the notion that a higher
frequency of services necessarily translates into
improved outcome” (James et al 2004)
– “coordination of care studies suggest that increased use
of formal child mental health treatment does not
translate into fewer behavioural or emotional difficulties”
(Bickman et al 1995, 1997, 2000)
– Often improve without treatment anyway
Lambert et al 2004)
(Burns et al 2004;
Why?
 Untested treatments with questionable effectiveness
– Treatment programs based on dialectical-behaviour
therapy, cognitive-behavioural, cognitive-analytical
have yet to be evaluated on their specificity and
effectiveness (Chanen et al 2008 James et al 2008)
 Poor client engagement
 Lax intervention fidelity
Health assessments – Necessary but Insufficient
 Do health assessments need to occur earlier in a child’s child
protection trajectory?
– Children placed in care before the age of 7 months had fewer
attachment and behaviour problems than those placed later (TarrenSweeney 2008)
– Children placed late may find it difficult to form secure attachments
(Rushton et al 2003)
 Is it possible to identify children at risk of chronic maltreatment
so that they can be placed in care earlier?
– “The challenges are correctly identifying this group so that children
are not wrongly separated from their biological parents and
predicting which parents are capable of making substantial
improvement in their care-giving”
(RANZCP 2008)
Need for whole of government responses
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No single agency can meet the needs of children in OOHC
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Coordinated interagency commissioning, planning and service delivery
are required – requires committed management
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Agreed care pathways and protocols are needed
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Multimodal programs integrated with existing service systems that
address children’s safety and basic needs, quality of care, carers’ skills
and children’s emotional needs
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Training and consultative activities for front-line staff
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Specialised service within mainstream teams could help develop skills
and expertise eg Redbank House (Vostanis, 2010, Chambers et al
2010,Golding 2010)
Need for managers to be committed
“A commitment to making integrated services and teams
work requires a management structure that is
prepared to give time to team and service
development as well as ensuring that team members
are getting the job done. Time is needed for building a
team identity, shared vision and ethos and for
reflection and the building of relationships. It is easy to
give such tasks a lower priority in the face of high
need, but ultimately without this, misunderstanding,
and miscommunication will weaken service delivery.”
(Golding 2010)
What about the carers?
Improved support and training
for foster carers - RACP
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Ensuring the provision of therapeutic foster
placements by providing adequate support
and training for foster carers and
ensuring that foster placements are not
overcrowded or in other ways unable to
meet the needs of the child; and,
Developing optimal permanency planning
for children in alternative care.
What should happen re carer support in
KtS, National and NSW OOHC standards?
Keep them Safe (2008-9)
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Proposed principles (Wood)
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Interventions for high needs children and young persons in OOHC should
include strong case management, integrated multi-agency work, and highly
skilled staff and carers who receive expert supervision, ongoing training and
support
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Care arrangements for children and young persons should be based on their
assessed needs, and the assessed capacity of carers to meet these needs
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Carers should be provided with timely information about those in their care,
their needs, and the type of support they need to flourish in their care
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Foster, kinship and relative carers should be supported in caring for children
and young persons, including managing those with challenging behaviours, to
improve the stability of placements. This should include access to regular and
planned respite care, behavioural management support, and other evidence
based specialist services
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Interventions for high needs children and young persons in OOHC should
include strong case management, integrated multi-agency work, and highly
skilled staff and carers who receive expert supervision, ongoing training and
support
What should happen re carer support in
KtS, National and NSW OOHC standards?
Keep them Safe (2008-2009)
 Recommendations (Wood)
Recommendation 16.13
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There should be sufficient numbers of care options for children and
young persons with challenging behaviours that include specialised
models of therapeutic foster care
Govt response: Supported – CS will develop new models of care
What should happen re carer support in
KtS, National and NSW OOHC standards?
Draft National OOHC standards (2010)
 Standard 6. Children, young people and
carers are able to access objective advice, ask
for help, have their concerns listened to, and
have information and access to review
mechanisms
 Standard 12. Carers are assessed and receive
relevant ongoing training, development and
support.
What should happen re carer support in
KtS, National and NSW OOHC standards?
NSW standards (2010)
17. Appropriately skilled and experienced carers
and staff are selected through fair and
consistent processes
18. Carers and staff have appropriate training
for their role and are provided opportunities
for further professional development
19. Carers and staff have supervision and
support which is useful and timely to
facilitate better outcomes for children and
young people
Quality of first relationships
(Rees, 2010)
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Alternative parenting alone is an insufficient remedy
but is the principal tool of recovery
Recovery from inadequate early care involves carers
managing the consequences of ineffective early
regulation
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Ineffective parenting influences programming of stress
regulation systems probably influencing gene expression at
an epigenetic level with lifelong and potentially
intergenerational implications
A professional priority is to equip carers through
information, advice, support and adequate respite to
facilitate this
Recovery rarely follows an orderly sequence
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Easing forward rather than fixing
Recovery through therapeutic
relationships (Rees, 2010)
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“Supporting recovery from abuse and neglect is a
long-term multi-professional task, requiring a broad
perspective, initiative, pragmatism and attention to
detail. It involves bridging gaps between professional
groups, particularly between CAMHS and
paediatricians.”
Difficulties relating to abuse and neglect are
multifactorial in cause, manifestation, consequences
and management.
They are fundamentally problems of relationships;
recovery is essentially achieved through
relationships.”
Tasks to be achieved for
competent adulthood (Rees, 2010)
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Understanding of relationships
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Effective verbal and non-verbal communication
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Understanding of the value, safety, reliability and predictability of
relationships
Effective strategies for using relationships
Appropriate concepts of normal behaviour, roles and responsibilities
Intuitive attunement to others’ feelings; empathy
Understanding of pragmatics, nuance, words for feeling, facial
expression
Understanding of self
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Good self esteem; coherent life story; healthy identity
Awareness of personal strengths and limitations; valued roles and
responsibilities; ability to exercise choice
Safe personal boundaries
Tasks to be achieved for
competent adulthood (Rees, 2010)
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Understanding of the world
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Awareness of danger; ability to judge and manage risk
Education; practical independence skills
Parenting skills
Adaptability and resilience
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Safe coping and stress-regulation strategies
Tolerance of change; ability to relinquish control
Effective executive function: planning, concentration,
learning from experience
Ability to regulate emotion, anxiety, temper, mood
Ability to ‘reframe,’ accept and learn from difficult
experiences
Ability to use services effectively
Evidence-based interventions
for foster carers (Rees, 2010)
Attachment and biobehavioural catch-up (Dozier ’06)
 Targets infants and toddlers
 Intervention targets dysregulation by helping foster
carers create an environment that enhances
regulatory capabilities
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Caregivers learn to follow child’s lead
Caregivers appreciate value of touching, cuddling and
hugging their child
Caregivers create conditions that allow children to express,
learn to recognise and understand emotions
Children in intervention group had lower cortisols and
fewer behaviour problems
Evidence-based interventions
for foster carers (Rees, 2010)
Fisher’s Multidimensional Treatment Foster Care
for Preschoolers (Fisher ’05)
 Targets 3-5 year olds
 Emphasises importance of supporting caregivers to
respond consistently and contingently to positive and
negative behaviour
 By supporting foster-child carer relationship adverse
effects of early stress on HPA axis and related neural
systems will be reversed leading to improvements in
psychosocial functioning
 Children in intervention group had improvements in
attachment security and decreases in avoidant
attachment and fewer permanent placement failures
Evidence-based interventions
for foster carers (Vostanis, 2010)
Preventive Intervention for maltreated children in OOHC
(Zeanah et al, 2001)
Intensive attachment based programs for maltreated children
and carers that increased likelihood of adoption
Relational treatment for maltreated children and their
carers (Sprang, 2009)
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A relational program for maltreated children and their foster
carers that specifically targeted the regulation of the carers’
behaviour and affective attunement that resulted in positive
carer and child outcomes.
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Programs build on parent training – combine social learning and
attachment theory – enable carers to make links between
children’s experiences of trauma and their emotions and
behaviours
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Effective interventions have
lifelong benefits
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Child abuse and neglect is a public health issue with
lifelong consequences
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US Centers for Disease Control and Prevention, 2008
Statutory child protection services present a
compelling and underused approach for addressing
the immediate and long-term consequences of severe
stress in early childhood.
(Forensic) evaluations at the time of abuse need to
be augmented by comprehensive developmental (and
mental health) assessments and provision of
appropriate intervention by skilled professionals
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Shonkoff, Boyce & McEwen, 2009
Stress and epigenetics
What’s the difference?
Rat studies showing persistent effects
of early maternal behaviour
Summary
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(Michael Meaney 2010)
“The results of these (rat) studies suggest that the
behaviour of the mother toward her offspring can
program stable changes in gene expression that then
serve as the basis for individual differences in
behavioural and neuroendocrine responses to stress
in adulthood. The maternal effects on phenotype are
associated with sustained changes in the expression
of genes in brain regions that mediate responses to
stress and form the basis for stable individual
differences in stress reactivity…..
Summary
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“These findings provide a potential
mechanism for the influence of parental
care on vulnerability/resistance to
stress-induced illness over the lifespan.”
Summary
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“Variations in mother-infant interaction modify the
epigenetic marks on regions of DNA that affect the
regulation of the HPA response to stress. These
marks are stable, enduring well beyond the period of
maternal care, and thus provide a molecular basis for
a stable maternal effect on the phenotype of the
offspring.
Thus the behaviour of the mother directly alters
cellular signals that then actively sculpt the
epigenetic landscape of the offspring, influencing the
activity of specific regions of the genome (our genetic
code) and the phenotype of the offspring”
So what does this mean for
humans?
1.
2.
3.
We know that severe adversity in childhood is
linked to markedly increased responsiveness of the
HPA (hypothlamus-pituitary-adrenal) axis to stress,
depression and suicide attempts
We have begun to identify the factors that
contribute to differential vulnerability to adverse
experience – for example, variants in the gene
encoding serotonin reuptake transporter influence
the risk of depression in response to stress
Human parallels to the rat study….
Adverse experience produces
epigenetic modification of genes
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Nr3C1 gene expression in hippocampus and
total glucocorticoid expression was reduced in
suicide victims who had been abused as
children, but not in suicide victims who had
not been abused nor in those who had died
suddenly of causes other than suicide
Reduced glucocorticoid expression resulted in
higher cortisol levels, enhancing effects of
stress in adulthood and vulnerability to mood
disorders.