It is now well established that early childhood adverse experiences are strongly associated with risk of developing problems in later life [1]: in terms of later health [2], social development [3], mental health and wellbeing [4], and educational attainment [5].
Children entering foster care are at high risk of having experienced considerable early adversity and demonstrate high levels of psychopathology, educational difficulties, and neurodevelopmental disorders compared to peers reared at home [5–7]. Children in foster care may also have a higher prevalence of attachment disturbances; Smyke et al. [8] found higher rates of Reactive Attachment Disorder (RAD) in institutionalised children compared with those who had never been institutionalised. RAD is a severe disorder of social functioning thought to be caused by early maltreatment. It is persistent [9] and is associated with significant psychiatric morbidity [10, 11], suggesting increased vulnerability of these children, in both early childhood and the future.
Because of the clearly increased risk of children in foster care developing later problems, it is crucial that these children’s needs are assessed accurately and as early as possible, for example, to ensure that interventions can be implemented quickly. Clinicians are often required to make assessments of children when they first enter care, and the child’s apparent profile of needs may have an effect on where they are placed and the support they receive. Several studies have assessed children when they first come into foster care [6, 12]; however, the authors of these studies also acknowledge the difficulties in assessing this young and vulnerable group at such a turbulent time.
Historically, foster parents’ perceptions of difficulties were seen as a cornerstone of assessing the child’s needs: “it is the foster parents’ perceptions of the seriousness of the problem that are all important” [13]. More recent experts in the field have taken a different stance, suggesting that the foster carer report alone is not sufficient. Carter et al. [14] identified a number of challenges related to assessing infants in care. These include contextual influences, child behaviour, overlap between problems, problems finding reliable informants, and the difficulty of symptoms being indicative of more than one domain; for example, a child may score lacking self-control, but this could in fact be a reflection of global developmental delay. As there is still a reluctance to identify mental health problems in very young children, caregivers are sometimes unable to distinguish between normative behaviours and clinically concerning behaviours. This makes it difficult when trying to detect problems early. A child’s birth parent may be able to provide information about the child’s former or usual presentation, but in the legally and emotionally fraught period following the child’s accommodation, they may not be reliable informants. Also, there are often multiple challenges in their own lives that may impact the ability to provide an objective, valid assessment. It is crucial, therefore, to use multiple approaches and informants [14].
Minnis [15] recently described a new concept: Maltreatment-Associated Psychiatric Problems (MAPP), a syndrome of overlapping complex neurodevelopmental problems in children who have experienced abuse or neglect in early life. Minnis argues that the early life events these children face place them at an increased risk of developing problems and that when problems do arise in the context of maltreatment, they are likely to be complex and overlapping.
While it seems important to interpret social and emotional problems in line with what is known about the child’s cognitive development, it should be noted that cognitive ability may not be a stable measure in these children. O’Connor et al. [16, 17] demonstrated “developmental catch-up” following adoption of Romanian orphans placed into UK homes, in which young children placed in the UK significantly increased their cognitive scores when they were followed up at the age of 6 years.
When assessing the mental health of a young child who has been accommodated recently, assessments may reflect an especially transitory picture, due to active processes of change and the recent trauma that the child may have experienced in the move from their birth parents. Furthermore, when relying on caregivers who have not known the child long to provide information, it may not be possible to gain a full perspective on the child’s state over the period specified by assessment measures, or of how current behaviour compares with his/her usual functioning.
A recently accommodated child has just been through a major life event (loss of primary caregivers) and is subject to processes of adjustment, with associated emotional and behavioural sequelae, such as despair, crying, and aggression [18]. Best practice guidelines for Posttraumatic Stress Disorder [19] note that particularly traumatic events are those likely to cause “pervasive distress in almost anyone” and recommend watchful waiting in situations where symptoms are mild and have been present for less than four weeks following a traumatic event. However, a good understanding of the child’s current difficulties may allow appropriate supports to be put in place, for example, to prevent foster placement disruption.
Accommodated children also endure attachment disruption [20]; Bowlby described children move from protesting the separation from primary caregivers to despairing and losing hope of reunion, and finally reattaching to an available alternative caregiver. A variety of factors can impact the speed and quality of this process, such as the child’s age, previous experiences, and resiliencies, as well as the quality of alternative caregiving and any ongoing contact with original caregivers [21].
This article was interested in describing the results of the assessments conducted with children entering foster care as well as some data which aims to disentangle some of the issues which need to be considered when assessing children when they enter foster care.