Common disorders, such as ADHD or conduct disorder, are being 'grossly under-identified' amongst adopted and fostered children, according to a new study by King's College London. Instead, clinicians are over-identifying more complex 'attachment disorders', and as a result children are missing out on appropriate treatments.
The findings are published today in the journal Child and Adolescent Mental Health.
Researchers reviewed 100 consecutive referrals from across the UK to the National Adoption and Fostering Service, a specialist service based at the South London and Maudsley NHS Foundation Trust (SLaM).They compared the referral letters with each child's clinical assessment within the service, and to the expected rate of mental health disorders from national data.
Best current estimates of the prevalence of mental health disorders for adopted or fostered children are based on the mental health of 'looked after children' (children in the care of the state)who have significantly higher rates of common disorders such as conduct problems, Attention Deficit Hyperactivity Disorder (ADHD), learning problems and neurodevelopmental disorders compared to children in birth families.
The researchers found that attachment disorders were over diagnosed among adopted and fostered children whereas common disorders, such as conduct problems, ADHD, anxiety or autism were under diagnosed.
Attachment problems were mentioned in 31% of the referrals. Upon clinical assessment, only one child was identified as having potential attachment symptoms but this was for a child in the 69% not initially identified with attachment problems.
Only 4% of referrals identified conduct disorder but rates of conduct disorder were approximately 10 times higher in the national data. In the clinical assessment, common disorders were diagnosed much more frequently than attachment disorders, with conduct disorders diagnosed 13 times more frequently than attachment disorders.
Attachment disorders occur when infants and young children have not had the opportunity to form attachments to their primary caregivers, usually because of grossly inadequate childcare, or extremely frequent changes in caregivers. Whilst disruptions to early caregiving are almost always present in adopted or looked after children,attachment disorders are relatively rare. Unlike more common mental health disorders, there are no evidence based treatments for attachment problems.
Dr Matt Woolgar, lead author of the paper from the National Academy of Parenting Research at King's College London's Institute of Psychiatry, and consultant clinical psychologist at the National Adoption and Fostering Service at SLaM, says: "There is real confusion around the term 'attachment disorder'. Clinicians appear to be using this diagnosis to try and capture the complex mental health problems that adopted or fostered children often have. It seems that clinicians may be making the diagnosis based more on the assumptions due to the child's history, rather than because of specific symptoms. In doing so, the danger is that they are blinded to some of the more straightforward diagnoses, like ADHD, or conduct disorders, for which there are good, evidence-based treatments. As a result, children are missing out on the treatments they need."
Woolgar, M. et al. "Attachment disorders versus more common problems in looked after and adopted children: comparing community and expert assessments." Child and Adolescent Mental Health. 2014. DOI: 10.1111/camh.12052.