Social Care Professionals

 Working in social care can be both rewarding and challenging, with huge pressure being placed on key decision-makers on occasions and very little time to gather information and make decisions.

Whilst ADHD in the general population has a prevalence of between 3% and 7%, this rises considerably in population groups affected by homelessness, substance use, family conflict, offending, and learning disability. In other words, the very people with whom social care professionals are likely to engage.

Looked after children and young people have a very high ‘risk’ of having an underlying psychiatric or psychological disorder, with almost 50% being identified as such in a recent UK study.

Given that the majority of young people and adults with ADHD in the United Kingdom have not been diagnosed, it can often be difficult to determine the degree to which the immediate problems that are presenting themselves are the result of family context or an underlying disorder (or a combination of both). Furthermore, with heritability rates of around 0.75, it is likely that multiple generations in the same household can be affected by any neurodevelopmental disorder, including ADHD.

Teasing apart the causal strands that explain why individuals or families are struggling is particularly problematic, especially when rapid decisions have to be made to reduce risk.

Unfortunately, clinical services for the assessment of children and young people are generally underfunded and difficult to access, particularly when the need is acute.

To support social care professionals in assessing the complex factors that are contributing to the difficulties that young people are facing, the British Association of Social Workers recently recommended the following:

• Use of the Strengths and Difficulties Questionnaire (SDQ) with
  looked after children has been shown to provide a good estimate
  of the prevalence of mental health conditions, allowing the
  identification of children with psychiatric diagnoses based on the
  Development and Well-Being Assessment (DAWBA).
  • Caregivers’ and teachers’ responses on the SDQ have proven to be
  more useful than self-reports and its use as a screening tool during
  routine health assessments for looked after children has been shown
  to increase the detection rate of socio-emotional difficulties.
  • The SDQ, Child Behaviour Checklist (CBCL), Children’s Global
  Assessment Scale (CGAS) and DAWBA can be scored and assessed
  to determine children’s clinical needs. The SDQ, CBCL and
  CGAS may be more useful as broad measures of well-being than
  for assessing specific conditions.
  • The DAWBA’s use of different types of questions and added focus
  on patterns, duration and impact of symptoms may explain why it
  is most effectively used by clinicians, especially with complex cases
  where clinical judgements are needed.
  • The reliability of assessments depends on who is completing
  the instrument; in what context; and the skills of the person
  interpreting them.

ADHD is of course, only one of a number of disorders that may be having impact on the development of any young person, but given the very high prevalence, particularly in population groups that are likely to be receiving support from social services, a good understanding of the nature of the condition and possible interventions could enhance the impact of any involvement on the family, and reduce long-term resource implications if appropriate measures put in place in the short.

Where there is an existing diagnosis, care should be taken to accept this is only one, but very significant part of, a young person’s profile, and that ADHD may have a pervasive influence on the development of an individual but may express itself in a wide range of different ways dependent upon environmental factors. I.e., we must be careful not to typecast or stereotype because of a diagnostic label.

It is not for any social care professional to dispute a clinically-derived diagnosis but rather to use this for guidance when translating what may be regarded as a “medical condition” into a social care setting.

The following may be helpful as a guide:

“Looked-after children are amongst the most vulnerable group in our society in terms of their risk of a range or poor outcomes, including mental health, educational attainment and social wellbeing (Metzer, Gatward, Corbin, Goodwin, & Ford, 2003).  Over the last decade, it has become increasingly clear that LAC have a higher prevalence of mental health problems than the general population, including children living with their families in ‘high-risk’ populations.  These children present with high rates of both emotional and behavioural problems, and also neurodevelopmental problems.

The importance of using existing diagnoses with LAC is highlighted in several articles [in the accompanying research journal[1]].  Professionals can often fail to consider common childhood mental health problems (including neurodevelopmental ones) because the experiences of parental unavailability, neglect, abuse and loss have been so striking, that problems get formulated generically as ‘emotional’ or as the child having ‘attachment difficulties’.  We remind professionals of the importance of bearing in mind the excellent epidemiological data with this group, which highlights how frequent mental health problems (including post-traumatic stress disorder, depressive episode, ADHD, conduct disorder etc.) are for LAC…

Some of the most successful interventions with LAC are also presented, with the caveat that given the potential complexity of the problems faced by these children, treatments should be underpinned by thorough assessment and diagnosis, and be based on the latest research.

….LAC benefit from mental health services that have been adapted specifically for them, and that take into account their views.  There is extensive evidence that many LAC suffer from diagnosable psychiatric disorders due to an array of predisposing factors, some but not all, related to the reasons for them being taken into care and that these can become chronic if they are not treated, or if treated with the wrong intervention.  A ‘one-size-fits-all- treatment plan based just on their experience of being looked-after is unlikely to help them.  As with children living with their birth families, LAC and young people require a thorough assessment that takes into account their complexities, and this should be undertaken in partnership with both the children and their carers using a bio-psycho-social approach.”

Editorial: Looked-after children – a perspective into a more resilient future[2]

Carmen Pinto and Matt Woolgar

National Adoption and Fostering Service

The Michael Rutter Centre

Maudsley Hospital London 

[1] The Virtual Issue (Looked-after children, October 2015; http://onlinelibrary.wiley.com/journal/10.1111/(ISSN) 1475-3588/homepage/LAC.htm

[2] Child and Adolescent Mental Health 20, No. 4, 2015, pp. 181