© 2007 The Royal College of Psychiatrists
Psychiatric disorder among British children looked after by local authorities: comparison with children living in private households
Institute of Psychiatry, King’s College London
Department of Health Sciences, Leicester University
Institute of Psychiatry, King’s College London, London, UK
Correspondence: Dr Tamsin Ford, Box 085, Department of Child and Adolescent Psychiatry, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK. Email: t.ford{at}iop.kcl.ac.uk
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Background Children looked after by local authorities are at higher risk of poor psychosocial outcomes than children living in private households, but nationally representative and random samples of the two groups of children have not previously been compared.
Aims To find explanations for the increased prevalence of psychiatric disorder in children looked after by local authorities.
Method We examined socio-demographic characteristics and psychopathology by type of placement among children looked after in Britain by local authorities (n=1453), and compared these children with deprived and non-deprived children living in private households (n=10 428).
Results Children looked after by local authorities had higher levels of psychopathology, educational difficulties and neurodevelopmental disorders, and ‘looked after’ status was independently associated with nearly all types of psychiatric disorder after adjusting for these educational and physical factors. The prevalence of psychiatric disorder was particularly high among those living in residential care and with many recent changes of placement.
Conclusions Our findings indicate a need for greater support of this vulnerable group of children.
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Children and young people who have been looked after by the local authority are at increased risk of poor outcome in terms of child and adult mental health, educational attainment, employment and criminality, yet studies from North America and Europe suggest that they often lack access to appropriate services (Rosenfeld et al, 1997; Geen et al, 2005; Viner & Taylor, 2005; Browne et al, 2006). Despite their high risk, children looked after by local authorities are often excluded from epidemiological studies owing to their high mobility and difficulties surrounding parental responsibility and informed consent (Rosenfeld et al, 1997). Understanding how the distribution of potential risk factors in children who are looked after compares with those in children living in private households may provide important clues about aetiology that can be used in targeting interventions (Jenkins, 2001). To our knowledge this is the largest epidemiological study of looked after children, and is unusual in using a random sample and including young people from the full range of placements. We examined the relationships of care-related variables and other correlates to psychiatric disorder and compared children looked after by UK local authorities with children living in private households to look for explanations for the increased prevalence of childhood psychiatric disorder.
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Samples
We combined data from three surveys of looked after British children and one survey of British children in private households; all these surveys were nationally representative and used the same instruments to assess psychopathology and some of its correlates (Meltzer et al, 2000, 2003, 2004a,b).
Children looked after by local authorities
Random samples of children (aged 5–17 years) looked after by local
authorities were selected from the relevant databases in England, Scotland and
Wales (Fig. 1). A contact
person in each administrative area was sent child summary forms for each child
selected from that area. After obtaining whatever consent the local authority
deemed necessary, the contact person was responsible for ensuring that the
child’s social worker completed the information on the child summary
forms and for returning the completed forms to the Office for National
Statistics.
 View larger version (41K): [in a new window] [as a PowerPoint slide] |
Fig. 1 Diagram illustrating the sample selection and response rate from the
surveys of children looked after by local authorities in England, Wales and
Scotland, listing the five main reasons for ineligibility in each country.
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Private household sample
The child benefit register was used as the sampling frame for England,
Wales and Scotland, and 14 250 children were sampled by postal sector.
Information was collected on 10 438 (83%) of the 12 529 eligible children,
aged 5–15 years 5.5% (790) were ineligible and 6.5% of families (931)
opted out (Meltzer et al,
2000).
Measures
We used the Development and Well-Being Assessment (DAWBA;
Goodman et al, 2000)
to assess psychiatric disorder in all four surveys. This structured interview
was administered by lay interviewers to the parents or carers of all children,
and also to the children themselves if they were at least 11 years old, and
the interviewers also recorded detailed verbatim descriptions of any problem
areas. An abbreviated version was sent to the child’s teacher. A small
team of experienced clinicians used the information provided by all the
informants, combining information as they would in the clinic, to make
diagnoses according to ICD–10 criteria
(World Health Organization,
1993). In the validation study, the DAWBA provided excellent
discrimination between community and clinical samples
(Goodman et al,
2000). Within the community sample, children with DAWBA diagnoses
differed markedly from those without such a diagnosis in external
characteristics and prognosis, whereas there were high levels of agreement
between the DAWBA and case notes among the clinical sample (Kendall’s
tau b=0.47–0.70).
Parents, teachers and children aged 11 years or over also completed the Strengths and Difficulties Questionnaire (SDQ; Goodman, 2001) a well-validated measure of common childhood psychopathology comprising the following scales: total difficulties, emotional symptoms, conduct problems, hyperactivity, peer problems, prosocial behaviour and impact. Parents or carers were asked whether their child suffered from a list of conditions, and the derived variable ‘neurodevelopmental disorder’ included children reported to have cerebral palsy, epilepsy, muscle disease or weakness, or coordination problems. Teachers provided data on attainment, an estimate of mental age and reported whether the child had a Statement of Special Educational Needs. Social workers and carers of the children looked after by local authorities provided data on the child’s care history.
Analysis
The analysis was conducted using Stata 8 and the Statistical Package for
the Social Sciences (SPSS) version 12.01 for Windows. We tested differences in
socio-demographic characteristics, diagnosis and placement history according
to type of placement using chi-squared tests for categorical variables and
one-way analysis of variance for continuous variables, in the whole population
of children looked after by local authorities (n=1543). We classified
children living in private households as disadvantaged if their parents had
either never worked or worked in unskilled occupations. We tested differences
between the three groups using logistic regression to adjust for age and
gender, because the children looked after by local authorities were
significantly older and more likely to be boys (see
Table 2) and the prevalence of
childhood psychiatric disorder varied by both these characteristics (Meltzer
et al, 2000,
2003). As psychological
adjustment is more than the presence or absence of a psychiatric disorder, we
used the bandings for the carer-completed SDQ to identify particularly
well-adjusted children on the basis of scores within the normal range for all
of the sub-scales. Finally, we explored the relationship between potential
correlates of psychiatric disorder among children looked after by local
authorities and the private household survey using logistic regression and
used general linear modelling to examine the fit of the data to multiplicative
and additive models.
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View this table: [in a new window] | Table 2 Comparison of children looked after by local authorities with children living in private households |
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Children looked after by local authorities
Children looked after by local authorities from different types of placement differed significantly in relation to socio-demographic characteristics (Table 1), with a higher proportion of boys in residential care, and of girls and children from Black and minority ethnic groups living independently. Black and minority ethnic children and children from England and Wales were the least likely to be living with their natural parents. Younger children tended to live with kinship carers (mean age 10.5 years 95% CI 9.9–11.0), foster carers (11.8 years, 95% CI 11.5–12.0) or their natural parents (11.2 years, 95% CI 10.7–11.7), whereas adolescents were more likely to be living in residential settings (13.6 years, 95% CI 13.3–13.9) or independently (16.6 years, 95% CI 16.4–16.8); F=55.4, P<0.001. Placement type also varied by care history, with children who entered the care system in adolescence and more recently most likely to be living in residential care or independently, in contrast to children who were taken into care at a very early age or had been in care for several years, who were more likely to be living in a family placement.
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View this table: [in a new window] | Table 1 Socio-demographic characteristics, care history and psychiatric disorder in British children (age 5–17 years) looked after by local authorities, according to type of placement |
There were also significant differences in the prevalence of psychiatric
disorder according to the type of placement, with high rates of emotional and
conduct disorder among children in residential placements or living
independently. Hyperkinetic disorder showed a similar trend and the failure to
detect a significant association may relate to lack of power and/or the older
age of children living in this setting, who would be less likely to have these
symptoms. Children with psychiatric disorder entered the care system later
(mean age 7.7 years, 95% CI 6.7–7.3, v. 7.0 years, 95% CI
7.3–8.0; F=8.6, P=0.003), reported more changes in
placement within the past 12 months (1.4 changes, 95% CI 1.3–1.5, in
those with a psychiatric disorder v. 1.0 changes, 95% CI
0.9–1.1, in those without, F=39.4, P<0.001), and
had lived for less time in their current placement (2.4 years, 95% CI
2.3–2.6 v. 3.0 years, 95% CI 2.8–3.1, F=30.4,
P<0.003). However, missing data about all three care-related
variables varied systematically with the type of placement, in that children
living with their natural parents or independently were particularly likely to
have missing data (age first looked after 
2=10.4, d.f.=4,
P=0.03; changes of placement within the past year
2=879, d.f.=4, P<0.001; duration of current
placement 2=27.0, d.f.=4, P<0.001). Children with
psychiatric disorder were also overrepresented among those with missing data
(2=8.9, d.f.=1, P=0.003).
Comparison of the two groups
Children looked after by local authorities had a higher prevalence of
educational and neurodevelopmental difficulties than the disadvantaged and
non-disadvantaged children living in private households
(Table 2). After adjusting for
age and gender, the prevalence of most psychiatric disorders was also
significantly higher, whether the comparison group was all children from
private households or just the most disadvantaged children from private
households. For most disorders, the highest prevalence was for the children
looked after by local authorities and the lowest prevalence was for the
non-disadvantaged children from the private households; disadvantaged children
from private households generally had intermediate rates.
The proportion of children without a psychiatric disorder who were
particularly well adjusted in terms of scoring in the normal range on all six
SDQ sub-scales was 9% (58 of 670) among the looked-after sample as opposed to
41% (265 of 649) among the disadvantaged children and 53% (4619 of 8733) among
the rest of the private household sample (2=506, d.f.=2,
P<0.001).
Complete data on correlates were available for multivariate analysis on 72%
of children, but children with a psychiatric disorder (2=14.6,
d.f.=1, P<0.001) and children who were looked after
(2=32.7, d.f.=1, P<0.001) were more likely to have
missing data on correlates. The odds ratios in
Table 2 indicate that looked
after status was an independent correlate of all the psychiatric disorders
that were more common in this group with the exception of autistic-spectrum
disorders and generalised anxiety disorder, even after adjusting for other
potential correlates. Looked after status had the strongest association with
disorders in which environmental factors are believed to have a leading role,
such as post-traumatic stress disorder and conduct disorder. Literacy and
numeracy problems were correlates of all disorders except depression among
children who were looked after, whereas global learning disability was related
only to pervasive developmental disorders and generalised anxiety disorder
(more details of this analysis are available from the authors). The
relationship of age and gender varied with the different types of psychiatric
disorder in the looked after children, as one would predict from
epidemiological findings in children living in private households. Thus, older
children were more likely to have generalised and other anxiety disorders,
post-traumatic stress disorder, depression and conduct disorder, whereas
younger children were more likely to have oppositional defiant disorder,
hyperkinetic disorder and separation anxiety disorder. Girls were more likely
to have post-traumatic stress disorder; boys were more likely to be diagnosed
with hyperkinetic disorder, and conduct or oppositional defiant disorder.
Table 3 shows how the influence of looked after status interacted with other correlates in relation to the presence of psychiatric disorder. Looked after status interacted with learning difficulties in an additive way, with learning difficulties resulting in a similar percentage increase in the prevalence of psychiatric disorder in children who were and were not looked after. In contrast, looked after status interacted with gender and age in a multiplicative way, with similar odds ratios in children who were and were not looked after. The findings for neurodevelopmental difficulties were intermediate, with an interaction that was more than additive but less than multiplicative.
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View this table: [in a new window] | Table 3. Comparison of the impact of four risk factors on rates of psychiatric disorder in children looked after by local authorities and children in private households. |
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Our study suggests that British children who are looked after by the local authority have a higher prevalence of both psychosocial adversity and psychiatric disorder than the most socio-economically disadvantaged children living in private households, and that care-related variables are strongly related to mental health. The prevalence estimates from the surveys that provided data for this paper ranged from 45% to 49%, falling in the middle of the range of previous estimates of 17% to 89% from other studies conducted in Britain, America and Canada (Wolkind & Rutter, 1973; Stein et al, 1994; McCann et al, 1996; Quinton et al, 1998; Dimigen et al, 1999; Leslie et al, 2000, 2005; dosReis et al, 2001; Farmer et al, 2001; Garland et al, 2001; Meltzer et al, 2003, 2004a,b; Blower et al, 2004; Mount et al, 2004; Rodrigues, 2004; Costello et al, 2005). Some of the variation among the prevalence rates for children looked after by local authorities can be attributed to differences in the date, duration and size of the studies; the measures of psychopathology used; and the age and placement of the children studied. Since psychological adjustment is more than the absence of a psychiatric disorder, it is important to note that even after excluding children with a psychiatric disorder, fewer than one in ten children looked after by local authorities demonstrated particularly good psychological adjustment, compared with around one in two children living in private households. Whether judged categorically or dimensionally, our study showed that children looked after by local authorities had significantly poorer mental health than the most disadvantaged children outside the care system.
Our study also replicates and extends the findings of three North American groups that have compared children in the public care system with disadvantaged children living in private households, all of which reported higher rates of psychopathology in the children looked after in public care (Stein et al, 1996; dosReis et al, 2001; Farmer et al, 2001). Stein et al (1996) compared children fostered by the Children’s Aid Society with a clinical and a general population sample in Canada. The same correlates (socio-economic deprivation, parental criminality and male gender) predicted psychopathology regardless of group membership. Both our findings and those of Stein et al suggest that by the time children are in the care system they have experienced high levels of psychosocial adversity, which provides an explanation for the raised prevalence of some psychiatric disorders. dos Reis et al (2001) reported higher rates of mental health service use among children on Medicaid because they were in foster care (62%), compared with groups receiving Medicaid because of physical or psychological disability (29%) or poverty (4%). Fostered children had higher rates of attention-deficit hyperactivity disorder (ADHD), depression and adjustment disorders compared with the other groups. Differences in the types of psychiatric disorders prevalent in different groups of children in that study and in our study provide potential clues about aetiology. Developmental difficulties such as autism and ADHD may be more prevalent among children looked after by local authorities owing to the failure of services to provide adequate support to families trying to cope with these very demanding children. The increment in psychosocial adversity may partially explain the parallel increment in the more environmentally mediated disorders (post-traumatic stress disorder, depression, anxiety and conduct disorder) among the disadvantaged and looked after groups compared with the more advantaged children living in private households. Our findings suggest that age, gender and learning disability act in a similar manner in both populations, with age and gender multiplying the prevalence and learning disability increasing it by a fixed proportion. If these patterns of interaction are replicated by further studies, they may offer clues to psychopathological mechanisms; for example, additive effects may reflect causal pathways in parallel, whereas multiplicative effects may reflect causal pathways in series.
Strengths and limitations
The strengths of this study include data drawn from large population-based
samples that used the same methodology and measures administered by the same
team of researchers to nationally representative groups of children who were
and were not looked after. The sample of children who were looked after
included children living in all kinds of placement types, rather than just
focusing on foster care, as found in other studies
(Stein et al, 1996;
Phillips, 1997;
Quinton et al, 1998;
Leslie et al, 2000;
Farmer et al, 2001),
and did not include children in contact with social services for other reasons
(Garland et al, 2001;
Burns et al,
2004).
Unfortunately there were few shared potential correlates between the children looked after by local authorities and those living with private households, limiting our comparison. Such lack of access to historical information is one of the common difficulties of working with and studying children looked after by local authorities, and also makes it difficult to draw conclusions about how far looked after status contributes directly to poor mental health. Children looked after by local authorities had higher levels of educational disadvantage than deprived children living in private households, so the relationship of looked after status to psychiatric disorder might be due to confounding by other aspects of social adversity that we were not able to control for. The fact that children living in residential care were more likely both to have a psychiatric disorder and to have had multiple placements within the past year indicates the problem of studying these factors in cross-sectional studies. Are children with psychiatric disorders more likely than other children to suffer multiple breakdowns in placement and end up in residential placements, or do multiple placements and/or communal living precipitate psychiatric disorder? Although psychological difficulties may be the result of placement instability, it is not unusual for children who are looked after to be referred to mental health services with an undetected psychiatric disorder (Rubin et al, 2004). We suspect that both processes are at work, but prospective longitudinal studies are needed to assess their individual impact. In addition, both the care-related variables and educational disadvantage may be markers of abuse, trauma or attachment difficulties that might explain both the increased prevalence of psychiatric disorder and the poor educational attainment and care history in these children.
Between a third and a half of the original random samples were deemed ineligible, meaning that despite a high response rate respondents might not be representative of children looked after by local authorities. Children undergoing adoption or returned to their parents might be expected to have a lower prevalence of psychiatric disorder, whereas local authority or carer refusal to grant access may be an indicator of poor mental health, making it difficult to estimate how our findings might be influenced by our difficulty in accessing the children looked after by local authorities. Missing data on care-related variables for the looked after children varied systematically by the type of placement, with more missing data on young people living independently or with their natural parents, making the results less reliable in these groups. The disproportionate loss of data on possible correlates among looked after children with psychiatric disorders reduced our power to detect positive associations, but we can be confident of the associations that we have detected. Despite these limitations, our study is one of the largest and most systematic studies of children looked after by local authorities carried out to date.
Clinical and policy implications
Concerns about the unmet needs and poor outcomes of children in the care
system in America led to the development of ‘treatment foster
care’ and the increased use of kinship care
(Rosenfeld et al,
1997; Chamberlain,
2003). Similar initiatives in Iceland, Norway, Slovenia and the UK
aim to minimise the number of children in institutional care, but alternatives
to institutional care are underutilised in much of the rest of Europe
(Browne et al, 2006).
In Britain, children looked after by local authorities are recognised by the
children’s National Service Framework
(Department of Health, 2004)
and Every Child Matters (Chief
Secretary to the Treasury, 2003) as a group who are particularly
vulnerable to psychological difficulties and are often denied access to
services, leading to the development of dedicated mental health teams.
Our findings underline the need for services to ensure that the emotional and behavioural difficulties of children looked after by local authorities are understood by professionals working with these children. In some cases, the diagnosis of a psychiatric disorder may provide access to evidence-based treatments and reduce the chance of a placement breaking down. In other cases it might be more appropriate to focus on changing the care or educational environment rather than labelling affected children as psychiatrically disordered. Specialist mental health services need to support other professionals working in this area to minimise the impact of being looked after and to allow a greater proportion of these children to fulfil their potential as adults. This study shows that residential social workers are dealing with many children with serious psychiatric disorders, and yet many have little training or support for the identification and management of these difficulties. Evaluations of treatment foster care suggest that foster carers and social workers could also benefit from this kind of input (Chamberlain, 2003). Given the high levels of educational disadvantage among children looked after by local authorities, and given that carer-reported learning difficulties were frequently an independent predictor of psychiatric disorder, professionals working with this population should try to ensure that these children are provided with suitable school placements and adequate additional support where necessary.
Future research
Our findings suggest that fewer than one in ten of the children looked
after by local authorities had positively good mental health and that their
substantially increased prevalence of psychiatric disorder was at least
partially explained because they had also experienced particularly high levels
of psychosocial and educational adversity. However, there was also a strong
association between psychiatric disorder and care-related variables.
Longitudinal studies of the mental health of children looked after by local
authorities are required to tease apart the causal relationship of
care-related variables, early physical and psychosocial adversity, and
constitutional factors in the child.
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  M. K. Sekar Psychiatric disorder and looked after status The British Journal of Psychiatry, October 1, 2007; 191(4): 360 - 360. [Full Text] [PDF]
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T. Ford, P. Vostanis, H. Meltzer, and R. Goodman Authors' reply The British Journal of Psychiatry, October 1, 2007; 191(4): 360 - 361. [Full Text] [PDF]
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- Re: Psychiatric disorder and looked after status
- Murali K Sekar
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