Professionals working in the field of adoption and fostering have long been aware that outcomes for children in care and adopted children are affected by multifactorial issues. In recent decades, there has perhaps been a perception that poorer outcome has been most strongly associated with adverse life experience leading to compromised attachment and mental health problems. However, it is increasingly clear that genetic and neurobiological factors are involved in human adaptation. The focus of the most recent CoramBAAF Health Group conference was on redressing the balance in our current understanding of the complexities involved in emotional development and outcome and to consider an appropriate response in service provision.
The conference was well attended by around 125 delegates, most of them healthcare professionals. The speakers included a mixture of research and clinical professionals with a poster presentation available at break times. The sessions were chaired by Lynn Snow, Designated Doctor for Looked After Children, Leicester.
In the opening presentation Jonathan Green, Professor of Child and Adolescent Psychiatry, University of Manchester, set out the challenges associated with the development of appropriate provision for adopted children who present some of the most complex mental health needs in our community. He acknowledged the woeful gap in the provision of mental health and development experts to meet the needs of these children and adolescents. Instead, a parallel ecosystem has developed outside of mainstream health care that focuses on attachment but does not consider the multi-layered consequences of genetic, biological, neurodevelopmental and psychological development within these individuals. Professor Green’s research has suggested that high numbers of adopted children have Autism Spectrum Disorder (ASD) or broad ASD (Disinhibited Social Engagement Disorder, quasi ASD). In his study of 60 children, 30% were found to have disorders in these categories – an extraordinary statistic.
Professor Green outlined his research project, a six-year follow-up of parent-mediated pre-school intervention (Pre-school Autism Communication Therapy) which has demonstrated beyond doubt that autistic children can effect dramatic improvement in communication during intervention, but which is also sustained over follow-up. There are clear implications for services to consider developing interventions for neurologically vulnerable children, with an enrichment of early social experience in interaction producing long-term symptom reduction in ASD-type behaviour.
Helen Baldwin, Research Fellow in the Department of Social Policy and Social Work, University of York, outlined her research illustrating the multifactorial nature of outcomes for children in care. Her study compared the mental health of children looked after due to abuse and neglect with children who have not been looked after but have experienced similar adversity resulting in them becoming subject to child protection plans. Previous studies, while consistently finding high rates of emotional and behavioural difficulties among looked after children, have been unable to disentangle the effects of being in care from the adversity experienced previously. The prevalence rates for emotional and behavioural problems were found to be high in each group compared to the general population, but highest in the looked after group. This suggests that both groups have emotional difficulties as a consequence of adversity but there may be an additional element of negative impact relating to subsequent care, or possibly a greater risk associated with more types of abuse and neglect.
John Simmonds, OBE, Director of Policy, Research and Development at CoramBAAF, considered the part that resilience plays in human adaptation and emotional development. He opened by drawing on Helen’s important point that the interpretation of data has always been difficult and assumptions cannot be made based on simplistic analysis. Dr Simmonds continued with a thoughtful presentation considering the peculiar ability of human beings to trust, learn and adapt within protective, relational worlds. Like other species, we are programmed to survive but it seems that key elements in our individual capacity for resilience have become embedded in our genes. He presented the findings of a number of studies looking at the impact of trauma and bereavement, noting that high levels of resilience exist in people who have suffered major adversity.
Human beings survive and adapt in the context of their experience, which includes compromise in the anticipation and control of threat. New opportunities to reformulate survival strategies may be experienced as ongoing threat by individuals who have already adapted to trauma. This is the dilemma for looked after and adopted children who may be less able to embrace possibilities for connection, participation and achievement. Dr Simmonds concluded with his passionate belief in the advantages of transformative family experience in bringing about improved outcomes relating to personal, social, cultural and economic capital.
Jana Kreppner, Associate Professor in Developmental Psychopathology, University of Southampton, presented an update regarding key findings from the young adult follow-up of the English and Romanian Adoption Study Team. This extraordinary work continues to yield important information, now encompassing the effect of the critical period of emergence into adulthood where the adoptees are subject to less structure and additional risk, as well as opportunities for personal development. Child to adult trajectories of deprivation-specific neurodevelopmental problems (Disinhibited Social Engagement, quasi-autism and ADHD) and emotional and conduct problems reveal persistence of symptomology. There is even an increase in risk of attention disorder in teenage years and young adulthood. There appears to be little doubt that the persistence of attention disorder is compromising outcome in terms of social dysfunction and unemployment. Heterogeneity in outcome is increasing our understanding and leading to the development of further research into the social and biological moderators and mediators of the persisting effects of deprivation.
Eamon McCrory, Professor of Developmental Neuroscience and Psychopathology, University College, London, introduced the delegates to fascinating research that encompasses the concept of latent vulnerability caused by early adversity, leading to mental health problems in adulthood which are less likely to respond to traditional treatments. He noted the high threshold for access to treatment in our healthcare systems and proposed some ways in which understanding the pathogenesis of intractable mental health issues caused by adversity might lead to more targeted, preventive psychiatric intervention at an earlier stage in vulnerable individuals. Professor McCrory presented the theory for epigenetics whereby environmental factors lead to DNA methylation which represses gene activity. Rat studies have shown that different patterns of maternal care lead to methylation or demethylation of the gene responsible for certain behaviour. Thus, individuals subject to different life experiences could express the same genes differently. Such epigenetic modification may result in adaptive behaviour that best optimises function but may embed latent vulnerability to future stressors.
Professor McCrory went on to explain how functional brain imaging demonstrates observable neurocognitive changes in maltreated individuals. Studies have shown that reactivity of the amygdala is calibrated in response to environmental adversity. It seems that prior reactivity to threat acts as a vulnerability factor, possibly reducing cognitive capacity and likelihood of interpersonal conflict with peers. He offered a tantalising glimpse of new ongoing research into the concept of autobiographical memory and its links with amygdala reactivity. It appears that different memory styles involved in response to life experience with over-general, avoidant styles leading to poorer social problem-solving. This wide-ranging presentation made the case for the development of screening tools to identify children most at risk of future disorder, together with preventive interventions involving recalibration of neurocognitive systems.
Matt Woolgar, Consultant Clinical Psychologist at SLAM NHS Trust, considered the range of problems presented by looked after children and whether they are properly identified in clinical practice. His talk encompassed the range of ‘mind-blowing’ complexities ‘like a bowl of spaghetti’ in terms of the effects of foetal toxins, maltreatment and neglect on interrelated biopsychosocial levels. A number of case presentations gave a helpful clinical focus and reminded delegates to keep an open mind and be aware of changing development over time.
Yuning Zhang, PhD candidate at the London-based Institute of Psychiatry, presented her research on the characterisation of shared versus unique effects of abuse and neglect on behaviour, cognition and epigenetic function. She discussed the qualitative and quantitative effects of different types of childhood adversity on outcome. Shared effects included psychological and behavioural symptoms while parental neglect appears to be more uniquely associated with hyperactivity and inattention. She presented the Emotion Recognition Task as a useful tool for evaluating individuals’ ability to understand ambiguous and clear facial expressions, and demonstrated the differences in results for groups exposed to different types of adversity. Dr Zhang also referred to the growing understanding of the role of epigenetic processes leading to calibrated response to adversity and evidence of shared and unique epigenetic signatures for different types of adversity. Like Professor McCrory, she feels that while the previous history of adversity cannot be changed, our understanding of the nature of shared and unique effects and latent vulnerability offers opportunities to design more precise and effective treatment plans.
Lorna Fulton, Foetal Alcohol Spectrum Disorders (FASD) Clinical Co-ordinator in NHS Ayrshire and Arran, presented her pilot FASD diagnostic project. Her dedicated Foetal Alcohol Assessment and Support Team aims to provide a diagnostic service with post-diagnostic services offered alongside training and preventive measures.
The final talk of the day was by Helen Palmer, a retired community paediatrician and adoptive parent of a child with FASD. This powerful presentation included the key challenges for professionals involved in the care of adolescents with FASD. The poster presentation by Eleanor Dawson, ST8 Community Paediatrics, Northern Deanery, demonstrated the characteristics of the FASD population in Gateshead and linked well with the contributions from Lorna Fulton and Helen Palmer.
All of the presentations throughout the day provoked enormous interest. Necessarily strict chairing left little opportunity for discussion but it was very clear that there is much more to understand about the impact of trauma on emotional development and ways of improving outcomes for the most vulnerable children in our society. This was an exceptionally thought-provoking conference.
