Looked After Children And Mental and Behaviour Disorders

1. Looked After Children AndMental and Behaviour Disorders Often the most tricky cases we see My starting point—what is in the literature?

2. The mental health of young people looked after by localauthorities in England rates of disorders for children looked after by local authorities compared with those obtained from the 1999 ONS survey of the mental health of arepresentative sample of 10,500 children living in private households 5- to 10-year-olds Any childhood mental disorder: 42 % cf 8 %. Emotional disorders: 11 % cf 3 %. • Conduct disorders: 36 % cf 5 %. • Hyperkinetic disorders: 11 % cf 2 %. Meltzer 2002

3. The mental health of young people looked after by localauthorities in England 11-15 year olds Any childhood mental disorder: 49% cf 11 %. Emotional disorders: 12 % cf 6 %. • Conduct disorders: 40 % cf 6 %. • Hyperkinetic disorders: 7 % cf 1 %. • Meltzer 2002

4. The mental health of young people looked after by local authorities in England Meltzer 2002 Overall, nearly three quarters, 72 %, of the young people in residential care were clinically rated as having a mental disorder: 60 % conduct disorders, 18 % emotional disorders, 8 % hyperkinetic disorders, 13 %less common disorders. ASD 11% cf 2 % Factors increasing likelihood of disorder Male gender, older age ie 11-15, neurodevelopmental condition, ID in care giver multiple placements Ford BJP

5. The limitation of diagnostic systems in looked after children • The types of psychiatric diagnoses following abuse/neglect etc are not specific to the condition eg physical/sexual abuse • Many children have multiple symptoms, many are subthreshold for any one diagnosis • Most diagnoses are phenomenological not pathophysiological • But they structure thinking, should improve communication and may support evidence based treatments.

6. Psychiatric diagnoses in ‘Looked after CYP’ Causal relationships unclear Genetic predisposition/parental mental and neurodevelopmental disorders Environmental experience in and out-utero Care experiences Educational experiences and attainments

7. Situations of Severe deprivation Followed by adoption outcome

8. Romanian orphanage adoption study– psychopathological outcomes but not in all children • Disinhibited attachment disorder • Quasi-autism • Cognitive impairment • Overactivity/inattention Many children developed challenging behaviour in adolescence Conclusion that Q-A and DA were deprivation specific ? Predominantly neglect/limited or no attachment figure Sensitive period: early months but ‘down stream’ effects Physical and dev. measures at adoption did not predict outcome (exception-language development )

9. Other evidence for the impact of severe early deprivation on brain development? • Animal models suggest deprivation and emotional disruption causes structural brain changes involving learning, attention and memory through altering length and spine density in pre-frontal cortex and dopaminergic pathways

10. How does this help us with the clinical presentation of a complex behaviour problem with impaired social relatedness as a key feature Diagnostic question: Is this ASD or Attachment disorder or neither?

11. Potential diagnostic categories relevant to impaired ‘social relatedness’ • Intellectual disability • Speech/Communication/language disorder • DCD • Mood disorder • ASD • ADHD • Callous unemotional traits • Attachment disorder

12. ASD describes: Behavioural symptoms from early childhood of impairments in social interaction and social communication affecting reciprocal relationships combined with restricted repetitive interests and behaviours, often with sensory sensitivities and stereotyped mannerisms. The manifestations change over time and context and are often associated with other neurodevelopmental and mental/behaviour strengths and weaknesses and medical symptoms and conditions. Evidence of a neurobiological basis, heterogenous in manifestation and causation

13. The SCQ in an unselected (mainstream) population N=411 ASD cut-off >=15; autism cut-off >=22

15. Autism: a genetic disorderFamily studies High concordance in MZ twins Increased risk for sibs

16. Pairwise concordance for autism, social and cognitive disorder Bailey, Le Couteur, Rutter. 100 Cognitive only percentage Social only Social and cognitive 50 autism Cognitive only MZ DZ

17. Extended phenotype of subtle social deficits, language and circumscribed interests –four factors (Losh 2008). • a language factor (untactful, pragmatic language and speech impairment); • a rigidity factor (overly conscientious, rigid); • anxiety (anxious, hypersensitive); • sociability (aloof and friendships) 2 factors - social communication and rigidity • Literacy (Parr 2009)

18. ASD Total population Broader phenotype All ASDs Autism

19. Autism : a disorder of neuropsychological functions Multiple primary deficits or system lesion Bottom up (sensory processing) versus top down (expectant mentalising in joint attention) Theory of mind Lack of central coherence Emotional/social brain deficit Executive dysfunction

20. Autism : a neurobiological disorder Increased rates of epilepsy Increased head size ? from birth ?mainly white matter increased volume?myelin abnormality Most consistent finding is of abnormality in limbic/cerebellar circuits/Reduced Purkinje cells Pathway: purkinje---medial loci of amygdala---enterorhinal cortex Timing/regression critical?: period of dentritic growth, myelination and pruning

21. Wing subtypes • Aloof • Passive • Active but odd

22. Quasi-autism • 15% British adoptees showed persistent autistic symptoms BUT cf ASD is associated with • Smaller head size/early puberty • Disinhibited attachment behaviour • ‘improvement’ in autistic features • More flexibility in types of communication • More emotional difficulties and disruptive behaviour in adolescence

23. Callous unemotional interpersonal behaviours Impaired emotional responsiveness to the feelings of others and lack of concern for others distress. Often failure to show own emotions in most circumstances, lack of remorse, egocentricity, limited capacity for loving relationships. Can be manifest separately from antisocial behaviour Evident from mid childhood and persistent

24. Reactive attachment disorder DSM 4 Markedly disturbed and developmentally inappropriate social relatedness in most social contexts before the age of 5 years, persistent over time and not due to intellectual disability or ASD and presumed due to pathogenic care. (history of the latter is a requirement in DSM) Clinical subtypes of emotionally withdrawn/indiscriminantly social or both

25. Concepts of ‘attachment’ and ‘Attachment disorder’ • Based on concepts of secure/insecure/disorganised attachment in infancy • Is this categorisation predictive of outcome? • When is attachment the primary problem that impairs the child beyond interaction with the primary caregiver? • Some diagnosed with an ‘attachment disorder’ may have secure attachments and some have no attachment • Only a minority of abused ,neglected, institutionalized children develop an attachment disorder— • Is the word ‘attachment’ right when applied to attachment disorder since the definition describes ‘disturbed and developmentally inappropriate social relatedness’

26. What is required to develop ‘Social relatedness’? Innate biological components, individual capacity to respond to care giver input due to general cognitive ability or specific deficits eg theory of mind, emotional recognition and empathy, language skill. Development of an internal but dynamic model of social understanding and relationships through Gene-environment interaction NB parents may have mental health problems, LD; ASD etc What features of the environment are necessary? An attachment figure? Responsive socially empathic parenting? Is there a difference between ‘Positive harm’ versus ‘neglect’. and relationship to later social behaviour.

27. What is required to develop ‘Social relatedness’? • Could there be similar affected cognitive pathways with neurodevelopmental disorders and the effects of severe deorivation? • ?Critical period for development • First year: Effortful control, self regulation of attention & emotions, joint attention skills

28. Psychogenic theories of autism Kanner wrote that he noted ‘a geniune lack of maternal warmth’ Bettelheim: autism due to a lack of bonding with cold distant mothers. Lasting problems of ‘blame’ and ‘guilt’ in parents of children with autism : should they give vaccinations/other medical treatments etc

29. Features differentiating Reactive Attachment disorder from ASD History of pathological care-giving/social neglect etc Behaviours remit in an environment providing responsive care-giving Child has a normal capacity for social reciprocity Language may be delayed but lacks the qualitative abnormalities of ASD Not associated with persistent severe cognitive impairments Persistently restricted repetitive behaviours, interests and activities not present

30. Disinhibited attachment/social engagement v ASD History of pathological care-giving/social neglect/absence of care-giver attachment etc in DAD Diagnostic problems more likely to arise in the Active but Odd ASD Wing subtype. Indiscriminate social approaching friendly attention seeking behaviour. Poor peer social interaction Often other emotional/behavioural disturbance particularly hyperactivity Language may be delayed but lacks the qualitative abnormalities of ASD in DAD Persistently restricted repetitive behaviours, interests and activities not present in DAD

31. What assessments are helpful? • ‘Strange situation’ limited predictive value of ‘disorganised’ attachment in infancy. • Modified stranger/reunion procedure—is insecurity the right concept? • Attachment play based assessment and interview (an internalised model) • ADOS and ASD interview tools • Reactions to emotions/pictures of emotional situations/CU interviews/ratings • TOM tasks. NB no comparative studies

32. How does diagnosis affect management? Reactive attachment disorder assumes capacity and focuses on care-giver quality Disinhibited attachment disorder appears to be persistent. Co-existing conditions require specific treatment. Peer and other social relationships are specific needs. ASD has variable persistence and manifestation. Co-existing conditions require specific treatments. Peer and other social relationships are specific needs. CU behaviour may benefit from specific cognitive approaches ID—appropriate peer group Communication/language disorders—appropriate communication support and peer group Mood disorder including anxiety: range of evidence based treatments ADHD : relevant evidence based traetment

33. Final thoughts Pathogenic care (absence of a care-giver attachment figure) can cause a ‘reversible’ disinhibited attachment disorder Pathogenic care can cause a persistent deficit in social relatedness and quasi-autism not associated with ‘secure or not attachment’. What is the mechanism? How far can we generalise from the institutional studies to other ‘looked-after ‘children Mediators? What is the threshold for pathogenic care? Harm v neglect Is there a critical period? Pathophysiology? ? Shared with other disorders that cause impaired social relatedness which are not related to pathogenic care The diagnostic approach offers a framework for thinking about the whole family In ‘looked after’ children other diagnoses should be sought and treated