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Assessing the health and wellbeing needs of children entering out of home care – necessary and sufficient? Professor Graham Vimpani Clinical Chair, Kaleidoscope.

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Presentation on theme: "Assessing the health and wellbeing needs of children entering out of home care – necessary and sufficient? Professor Graham Vimpani Clinical Chair, Kaleidoscope."— Presentation transcript:

1 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

2 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?”

3 Overview The case for comprehensive health assessments on entering care 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 The role of epigenetics

4 Why children enter OOHC

5 What is the health status of children entering care? “The majority of children in care are in good physical health and display improvements in psychological functioning over time” (Osborn & Bromfield, AIFS 2007) Mental health problem 18%; disability 20%; intellectual disability 14% (Vic govt audit)

6 What is the health status of children entering care? South Australian study 61% (N=326 aged 6-17 yrs) in clinical range for behaviour problems (Sawyer et al, 2007) 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 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) “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) Language delays or disorder in 63% Oral health problems in 37%

7 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

8 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

9 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

10 Health Problems - 3  Infections - 14 –Respiratory – URTI, ear –Skin –impetigo, infected eczema, warts, fungal  Skin - 17 –Eczema –Scars –Nappy rash –Impetigo –?Psoriasis

11 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

12 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

13 The case for comprehensive assessments 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)

14 DoCS – Health MOU (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.

15 DoCS (NSW) procedures prior to Keep them Safe All children and young persons should undergo a health, developmental and mental health/behavioural assessment within 60 days of entering care. 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. 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 2. immunisation register check 3. physical examination that checks for growth delay (eg careful measure of weight, height and head circumference) and signs of malnutrition 4. screening for visual and hearing deficits 5. 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) 6. dental health screening

16 DoCS (NSW) procedures prior to Keep them Safe 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

17 RACP proposals Ensuring that physical, developmental and mental health assessments are performed on all children who enter out-of- home 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.

18 Components of comprehensive health care assessment (RACP) 1 General health assessment including 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

19 Components of comprehensive health care assessment (RACP) 2 Developmental assessment incorporating standardised screening tools 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

20 Components of comprehensive health care assessment (RACP) 3 Mental health screening using accessible and validated tools 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.

21 Development of an individualised health plan - RACP Based on results of comprehensive assessment and in conjunction with CPS:- 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.

22 Ensuring equitable health care - RACP Working with CPS, Education, Health to:- 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

23 Data collection - RACP 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:- 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-of- home care and aggregating this data to monitor and identify the effective interventions.

24 Improved access to health records of birth parents - RACP 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:- 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.

25 Enhancing communication - RACP That the College … advocate increasing the level of communication by: 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.

26 The case for comprehensive mental health assessment and intervention ( RANZCP) 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 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

27 The case for comprehensive mental health assessment and intervention ( RANZCP) 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

28 What should happen re health in KtS, National and NSW OOHC standards? Keep them Safe ( ) Proposed principles (Wood) 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

29 What should happen re health in KtS, National and NSW OOHC standards? Keep them Safe ( ) Proposed principles (Wood) 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

30 What should happen re health in KtS, National and NSW OOHC standards? Keep them Safe ( ) Recommendations (Wood) Recommendation 16.3 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 NSW Health should appoint an OOHC coordinator in each Area Health Service and at The Children’s Hospital at Westmead. Govt response: Supported.

31 What should happen re health in KtS, National and NSW OOHC standards? Keep them Safe ( ) Recommendations (Wood) Recommendation 16.6 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 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

32 What should happen re health in KtS, National and NSW OOHC standards? Keep them Safe ( ) Recommendations (Wood) Recommendation 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 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

33 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. Standard 5. Children and young people entering into care receive timely and appropriate therapeutic assessment and support as needed. 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.

34 What should happen re health in KtS, National and NSW OOHC standards? NSW standards (2010) 3. Children and young people’s wellbeing is actively safeguarded 8. Children and young people are cared for in placements which meet their specific emotional, social and behavioural needs 9. Children and young people’s health and developmental needs are addressed 11. 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 14. Children and young people have effective behaviour support and management plans where necessary

35 What is happening now (NSW) 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)

36 Activity in Other States 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

37 Principles for Implementation Recognise at different stages of development children and young people have different capacities and accordingly interactions with children and young people should be appropriate to these stages Align with current state and territory standards and provide for mutual recognition, wherever possible Align with other relevant standards in health, education and other community sector services, with consistent terminology and measurement (where possible) Focus on those children and young people with Children’s Court ordered care arrangements, particularly where the responsibility for the child/young person has been transferred to the Minister/Chief Executive Take into account differences in the duration of placements and when in the duration of a placement National Standards will apply

38 Principles for Implementation Take a phased approach to implementing National Standards with implementation commencing from 1 July 2011 Ensure the minimum data set is based on consistent and common information that reflects the current and future performance at state and territory, and national level Ensure the data collected is capable of supporting research and further interrogation Focus on continuous improvement, rather than meeting minimum requirements Minimise additional burden on service providers and the costs for governments and service providers relating to data collection, collation and reporting systems Recognise the importance of getting National Standards right and building in appropriate review and evaluation mechanisms.

39 Does health assessment make a difference to outcomes?

40 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

41 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  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  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.  There were also examples of children who had undergone major dental work and of children prescribed glasses.

42 Status of SCH recommendations

43 Reasons for Recommendations non-completion Systems Issues  Frequent change of carer  High turnover of caseworker and delays in reassignment of a new caseworker  Poor record keeping  Lack of knowledge regarding service providers  Reluctance to place children on waiting lists until the courts had finalised placement decisions  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  Counselling  Peer and carer support,  Public dental services  Long waiting lists for allied health services –e.g occupational and speech therapy.

44 Conclusion from SCH study  Benefits of health assessment uncertain  Routine comprehensive health screens clearly improve detection of previously unmet or unrecognised health issues  Screening provides a baseline record of the child’s current health and well-being.  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.  Agencies should have systems to ensure better communication and collaboration between the health and community services systems.  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

45 Is health assessment of children entering OOHC sufficient to improve outcomes?

46 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.” “Closed book children” “Too good to be true” (Schofield et al 2000; Crittenden 2009)

47 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)

48 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 (Burns et al 2004; Lambert et al 2004)

49 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

50 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 ( Tarren- Sweeney 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)

51 Need for whole of government responses  No single agency can meet the needs of children in OOHC  Coordinated interagency commissioning, planning and service delivery are required – requires committed management  Agreed care pathways and protocols are needed  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  Training and consultative activities for front-line staff  Specialised service within mainstream teams could help develop skills and expertise eg Redbank House (Vostanis, 2010, Chambers et al 2010,Golding 2010)

52 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)

53 What about the carers?

54 Improved support and training for foster carers - RACP 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.

55 What should happen re carer support in KtS, National and NSW OOHC standards? Keep them Safe (2008-9) Proposed principles (Wood) 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 Care arrangements for children and young persons should be based on their assessed needs, and the assessed capacity of carers to meet these needs 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 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 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

56 What should happen re carer support in KtS, National and NSW OOHC standards? Keep them Safe ( ) Recommendations (Wood) Recommendation 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

57 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.

58 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

59 Quality of first relationships (Rees, 2010 ) 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 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 Easing forward rather than fixing

60 Recovery through therapeutic relationships (Rees, 2010) “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.”

61 Tasks to be achieved for competent adulthood (Rees, 2010) Understanding of relationships Understanding of the value, safety, reliability and predictability of relationships Effective strategies for using relationships Appropriate concepts of normal behaviour, roles and responsibilities Effective verbal and non-verbal communication Intuitive attunement to others’ feelings; empathy Understanding of pragmatics, nuance, words for feeling, facial expression Understanding of self 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

62 Tasks to be achieved for competent adulthood (Rees, 2010) Understanding of the world Awareness of danger; ability to judge and manage risk Education; practical independence skills Parenting skills Adaptability and resilience 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

63 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 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

64 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

65 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) 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. 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

66 Effective interventions have lifelong benefits Child abuse and neglect is a public health issue with lifelong consequences 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 Shonkoff, Boyce & McEwen, 2009

67 Stress and epigenetics

68 What’s the difference?

69 Rat studies showing persistent effects of early maternal behaviour

70 Summary (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…..

71 Summary “These findings provide a potential mechanism for the influence of parental care on vulnerability/resistance to stress-induced illness over the lifespan.”

72 Summary “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”

73 So what does this mean for humans? 1. 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 2. 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 3. Human parallels to the rat study….

74 Adverse experience produces epigenetic modification of genes 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.


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