Looked after and adopted children: applying the latest science to complex biopsychosocial formulations

Reasons for referral

Lucas ¹ was a 15-year-old boy referred to the National Adoption and Fostering Clinic by his post-adoption social worker, using the Adoption Support Fund, ‘for a comprehensive assessment to further understand his cognitive and emotional development, so that specialist support could be gained’. He had had longstanding difficulties at home and school with challenging behaviour, maintaining focus, behavioural outbursts and lying to avoid responsibility. His parents were also concerned about his lack of empathy and poor emotional literacy.

Birth family history

Lucas’s birth parents had problematic backgrounds and both had confirmed behavioural problems as children themselves. His birth mother was reported to be verbally and physically aggressive and his birth father was referred to child and adolescent mental health services (CAMHS) and reviewed by psychiatry for his aggression when aged eight. Due to the severity of these problems, he was accommodated in care at the age of 12 and progressed with the years into severe offending behaviour, including burglary and firearm possession.

There was evidence of both parents’ limited attainment at school, with reports of the mother’s reading and spelling difficulties and the father’s low average intellect. There was limited information on a history of mental health problems: the birth mother had anorexia but there was no confirmed mental health diagnosis for the father. Information about the parents’ smoking or alcohol intake was not known. However, both had longstanding problems with substance misuse and were addicted to heroin.

Pregnancy/neonatal history

Lucas’s mother kept on taking heroin during pregnancy and did not attend any of the antenatal appointments. When he was born, she was 17. It was a preterm pregnancy at 34 weeks (frequently associated with heroin use; Ornoy, et al., 2001) and was by normal vaginal delivery. Lucas was withdrawing from heroin and showed some of the features of infants prenatally exposed to opiates; for example, he was a small baby (2.6 kg, 2nd‒9th centile) and had a small head circumference (34 cm, in the 10‒25th centile) (Preece and Riley, 2011).

As he was born withdrawing from heroin (shown by high irritability, high pitched crying, sleep problems and poor feeding) (Bandstra, et al., 2010), Lucas was in the special care baby unit (SCBU) for his first 23 days of life. Unknowingly to staff, his birth mother used to breastfeed him while she continued to misuse heroin. During this time in the SCBU, there was also an episode in which the baby was abducted by his birth parents for 36 hours. All of the above, together with his mother's inability to engage in a methadone rehab programme, led to Lucas being accommodated by social services in foster care directly from hospital at the age of 23 days.

Early months in foster care

Lucas was placed with a very experienced foster carer from the time he was three weeks old to 10 months old. He was described as ‘a restless baby’ and had several fits during the first three months in care. His adoptive parents remained in contact with the foster carer once Lucas came to live with them, so that this important figure was not lost from his life.

During this period, there were sessions of supervised contact with the birth parents who were inconsistent, not attending regularly; if they did, their care was described as inadequate and dangerous, e.g. they would fall asleep and on one occasion dropped him, although this resulted in no head or other injury.

Adoptive family

At 10 months, Lucas was adopted. His adoptive father had been married previously and had two adult daughters. His adoptive mother had had relationships but never married. The father ran his own business and she worked as a teaching assistant supporting primary school children with complex needs. The couple were unable to conceive and after 10 cycles of IVF decided to adopt and finally they were matched to Lucas. Both adoptive parents were very committed to the boy and had many different strategies for managing his behaviour. They had attended parenting courses and seemed to have a good understanding of social learning theory parenting techniques.

Medical history

Lucas had several medical problems: he had chronic diarrhoea and projectile vomiting till he was two-and-a-half years, due to a dairy intolerance which was not diagnosed until later. He had mild asthma and used an inhaler. At five, he was diagnosed with a childhood disease of the hip that caused him to use a wheelchair for five years. This had a major psychological impact on him as he had been a very active child and keen on sports. Interestingly, although the aetiology for this disease is still unknown, it is thought that individuals affected by it are hyperactive (Perry, et al., 2013) and some studies state that they have a higher risk of Attention Deficit Hyperactivity Disorder (ADHD); it is also thought that the associated hyperactivity could drive some of the physical damage that occurs in this disease. In addition to this, Hailer and Nilsson (2014) identified higher risk for depression and suicide in later life.

History of presenting problems/concerns at early years

From the beginning, Lucas’s adoptive parents noticed that several of the concerning behaviours described by the foster carer were still present, e.g. he was restless, he would not want physical contact and would scream non-stop. His adopters described how he had always struggled to sleep, starting as an infant. Aged two-and-a-half, Lucas’s behaviour was already extremely challenging, so much so that the strain it placed on his parents led them to separate for three months. He resisted affection, showed a limited attention span and difficulties in regulating his volume and emotions. He was further described to be rough with animals and show no empathy towards people.

Education

In nursery, staff struggled with Lucas’s behaviour as he was hurting children on a daily basis and hiding under the table and not coming out. In primary school, they had trouble managing him from the beginning, with particular problems of aggression towards other children. He started secondary education in his local mainstream school where, despite not having had a formal diagnosis, they promised support as they had a specialist Autism Spectrum Disorder (ASD) unit, but eventually he was unable to attend this due to his extreme behavioural problems. While there, Lucas had treatment from the early intervention team for anxiety, social skills and anger management. Although these three problem areas are common in social communication disorders, ASD was not seen as the explanation for them; instead ‘attachment problems’ were highlighted (see ‘Previous formulations and interventions’ below) on account of his adoption. Lucas left this school due to being bullied and was faced with the threat of permanent exclusion.

At 13 and up to the point of the assessment, Lucas attended an Academy. He continued to display challenging behaviour, avoiding writing tasks and being ‘the class clown’. As a result, he ended up being educated in ‘seclusion’, which meant a whole day on his own with a teacher in a room, not seeing his peers even for lunch or breaks. School staff had different views on his presentation: the school’s special needs co-ordinator acknowledged that Lucas presented with some elements of ASD, but that the problem was that ‘his parents did not manage him properly’. However, his class teacher, who had known Lucas for four years, reported that he had ‘definite traits of ASD’ and that she had been treating him as if he was on the spectrum all these years.

Previous formulations and interventions

At five years, Lucas was referred to CAMHS following the diagnosis of the above-mentioned physical illness affecting his hip, as his need to use a wheelchair was thought to be contributing to his emotional and behavioural difficulties. Following this assessment, he was referred for ‘attachment work’, but the only rationale articulated in the report was that he was adopted. As a result, he received intensive psychodynamic psychotherapy for five years: three times a week for the first two, two days a week for a year and once a week for the last six months. In the psychotherapy closing report, Lucas’s sleep problems, soiling, smearing faeces, making compulsive strange and animal-like noises and crawling around in imitation of animals were understood in terms of his ‘early history prior to adoption, which may well have impacted severely on his emotional and cognitive development in ways that had been difficult to assess’. In the psychotherapy assessment sessions, it was reported that he was ‘enthralled’ while playing with toy figures that engaged in ‘mutually destructive and repetitious battles’ and that he ‘often would deny any responsibility without any obvious sense of guilt or regret’. During the latest assessment, Lucas reported that he ‘didn’t like the therapist much as he was “annoying” and went on a bit too much’, adding that he would ‘rather have a spider crawl on my arm than go through this experience again’.

Aged 10, his psychotherapy ended and this coincided with an assessment and diagnosis of ADHD. His medication was monitored by a specialist nurse practitioner at his local CAMHS. His regime had been increasing over the years, so that at the point of referral to our clinic he was on a very high amount of medication: Elvanse (Lisdexamfetamine) 70 mg once daily, Equasym (Methylphenidate) XL 20 mg once daily, Equasym (Methylphenidate) XL 50 mg at 13:00, Risperidone 0.5 mg once daily and Melatonin 8 mg at night.

Also at the age of 10, Lucas had an initial ASD assessment using gold-standard measures: the Autism Diagnostic Interview – Revised (ADI-R) (Rutter, Le Couteur and Lord, 2003; 2008), a semi-structured interview with the parents and the Autism Diagnostic Observation Schedule (ADOS) (Lord, et al., 1999) and observational measure of autism with the child. It was concluded that Lucas did not meet the criteria for autism, but did show a ‘lack of insight and expressive language deficits’.

At 15 years old, Lucas had a second ASD assessment using the 3Di (Skuse, et al., 2004), a structured parental interview on autism symptoms given to his parents and a new ADOS. He met criteria in the 3Di but, as for the previous time, he did not reach threshold in the repeated observational ADOS assessment.

Assessment by the National Adoption and Fostering Clinic

Three months after the last ASD assessment, when Lucas was still 15, he was referred to the National Adoption and Fostering Clinic which specialises in adopted and fostered children’s mental health. The multidisciplinary team undertook an in-depth assessment that included a thorough revision of past records and reports, and clinical interviews with parents (that also included past history), teachers and Lucas himself.

Parents’ views on current/past problems

Behavioural problems and prosocial emotions. Parents told of daily temper tantrums comprising shouting, verbal abuse, throwing things and damaging property. Lucas was reported to change ‘from calm to rage in a second’, more often with his adoptive mother. He was described as ‘touchy’ and very easily irritated/annoyed by others, an angry and resentful boy from early childhood. He always refused adults’ requests, argued with them and defied rules.

Lucas would blatantly lie and would never admit to having done so. However, he did not engage in physical violence, his aggression being entirely verbal. He had ‘a thing with knives, like a fascination’, although he had never used them to threaten or hurt anyone. He had exhibited physical cruelty to animals when he was younger, such as bending the dog’s leg and harming the pet rabbit, so animals avoided him. He stole money from his parents regularly, sometimes minor sums to buy sweets for his friends but also higher amounts, as when he took money from his parents’ online account to pay for games he was ‘obsessed with’. Over the three months it took for this to be discovered, Lucas had spent more than £300 per month.

Lucas was described as ‘very inappropriate’ with his adoptive mother, always touching her breasts from as young as three. At that age, he would also want to see other children’s bottoms. As a teenager, he started sexting and some of the things he wrote were extreme and probably inspired by pornography. However, there had been no behaviour to suggest he was likely to carry out such actions as he was afraid of relationships.

The main area of concern for his parents was his apparent lack of prosocial emotions: Lucas did not seem to feel remorse or guilt if he hurt someone. He would not take responsibility for his actions: ‘even if you caught him red-handed, he would deny it’. He showed little empathy; he did not seem to care about other people’s feelings, other than as an instrumental ‘façade’ in front of friends in a bid to be accepted and popular. He did not care who got hurt or humiliated in the process. He had the ability to make people laugh, but usually at the expense of others, not understanding or caring if the joke was inappropriate. Both parents described him as cold and his mother reported that he could be intentionally cruel. Lucas would not do nice things for other people when there was nothing for him. He cared about how well he did at football, at which he was quite gifted, and would have liked to get good grades but would not make the effort. He blamed others if he did not do well in something rather than take responsibility for his poor performance. He did not show his feelings and emotions openly to others, ‘only his anger’ and other negative emotions. When he showed feelings, they did not seem real, sincere or genuine: ‘if he shows love, there is a reason behind it, he wants something’. His parents said they did not get any emotion from him but he would now say ‘I love you’ in what felt ‘a learned way’. When something bad happened to someone else, he did not seem genuinely upset. For instance, his parents said that ‘at his grandfather's funeral, he had his earphones on and did not get why people were crying. He was annoyed his dinner was not ready when we arrived back home.’

Social communication. Lucas’s parents were asked about his behaviour, both when he was four to five years old and currently, and about its impact on his and the family’s personal functioning. In terms of social communication and social interaction, his parents reported deficits in social-emotional reciprocity: he could only have a normal back-and-forth conversation if it was about football and he had never spontaneously opened up conversations with his parents nor shared his interests or emotions. He would not initiate or respond to social interactions, unless it was football-related or with his friends to be popular. His language was described as one-sided, used to request rather than comment.

Lucas’s parents also reported some deficits in non-verbal communicative behaviours: ‘When he was small there was no eye contact; now it is better but he has to be reminded.’ The use of body language or gestures was limited but he had a variety of facial expressions.

There were major deficits in developing, maintaining and understanding relationships and although Lucas was very interested in peers, he was not popular or liked. This was already the case in primary school: despite throwing a big birthday party every year, he did not get invited back and this was still the situation now. As a child, he used to have an imaginary friend for whom his parents had to set the table. Lucas could not understand the subtleties of friendships and ‘in his mind he has loads of friends, but they are all on a short-term basis’. He had one friend from primary school with whom he played football and idealised him, not realising that this boy ‘just tolerates him, he will never phone’. Lucas was described as ‘socially naïve’ because the other children would wind him up, so he engaged in arguments with teachers for their entertainment.

His parents described several restricted and repetitive patterns of behaviour. Although there had never been motor stereotypies (e.g. hand flapping), there had been repetitive use of objects (when younger he would line up toys and now still does it with monopoly cards) and definite repetitive speech (he would use the same phrase over and over again for many days, asking the same question, speaking in accents ‘till he drives us insane. He cannot stop it till he has it perfect’) and idiosyncratic phrases. This type of repetitive behaviour lasted for a certain period of time before he would move to something else, such as a game or obsessively learning to whistle, trying it at inappropriate times like during meals.

Lucas’s adoptive parents reported that he was very insistent on playing by very fixed rules that only he could determine, different from convention. In any situation he needed to know what and when things would happen. From an early age he had no imagination at all; he hated role-play or dressing up. He had difficulties with major transitions, e.g. at school from one teacher to the other or if they took a different route. He insisted on wearing the same restricted set of clothes –approximately 10% of his wardrobe – and would not eat certain foods. Change was a problem even in football and he had to dress in a ritualised pattern (e.g. he had a fixed routine about which gloves go with each game). He had fixated interests that were abnormal in intensity even for a teenager; for example, he obsessively followed two YouTube bloggers.

Lucas had a very high pain threshold and never cried in pain. He was very sensitive to texture: he did not like bits in yoghurt or casseroles where foods are mixed together: ‘He likes to see separately what he is eating, so no soups as he does not know what is there.’ He was sensitive to noise, despite being very loud himself. He liked to feel things and often sniffed his fingers and the washing powder or conditioner on his clothes.

Lucas never had any motor deficits ‒ he had always been athletic and never clumsy ‒ but suffered from severe language impairment and was very slow to talk. He used to self-injure, banging his head on the floor, but this stopped after the toddler years. He still hit himself really hard with both arms if he got agitated, saying ‘It’s as if my head is going to explode. Why is my brain like this?’

Attachment. The assessment of attachment was undertaken by clinical interview with the parents, asking them to focus their responses on Lucas’s behaviours before the age of five, which is the time when attachment should be assessed. Before this age he would always come for comfort when upset or hurt or ill and had a preferential attachment figure in his mother. However, she felt that she could never effectively comfort him: ‘I could never make things better for him; whatever I did, it would not be enough.’ When he first joined his adoptive parents, he would cry constantly, he would scream and climb out of his cot and was very difficult to settle. He would seek comfort when hurt, upset or frightened by screaming, but not raise his arms to be picked up. He responded to cuddles by being stiff and tense. His parents reported that although it was less obvious now, he was still uncomfortable being cuddled. His mother always had to lie with him, sometimes for hours, before he fell asleep but could not touch him.

Lucas was never wary of strangers and could be overfriendly with unknown adults. He would not check back on his parents in unfamiliar settings, but was unlikely to go off with a relative stranger.

Systematic enquiry. Other aspects that were highlighted in the assessment were obsessive-compulsive symptoms (that can be frequently seen in ASDs) and some residual social anxiety. Sleep was a longstanding problem that is often seen in children with neuro-developmental difficulties. At the time of the assessment, he was not soiling any more but still did not properly wipe himself or flush the toilet.

There were no concerns around substance misuse, psychotic illness, mood disorders, PTSD or tic disorder.

Lucas’s views and clinic observations

Behaviour and prosocial emotions. In our assessment, Lucas remained pleasant and co-operative throughout the sessions and did not present with any oppositional, aggressive or anti-social behaviour towards either of the assessors. He mentioned that while he normally felt ‘just annoyed’ at school, he was always ‘plain angry’ at home and shouted more there. He reported that he would sometimes punch or kick a wall and if he hurt other people, he would not feel guilty as they probably deserved it. In general, he provided vague responses to questions relating to emotions or empathy and also appeared to find it difficult to give specific examples that related to his past emotional experiences.

Social communication. Lucas’s eye contact was somewhat limited. He generally looked down while completing each psychometric task and indicated verbally that he had completed an item, often without looking up at the assessor. He showed little variation in his facial expressions but was noted to look, smile or laugh briefly when recalling a funny incident or when the assessors smiled at him. He did not display facial expressions, such as worry or anger, at any point, despite reporting on difficult issues or when requested to show them. Lucas spoke clearly, at an appropriate pace but in a mostly flat tone. He talked about his friendships in a very different way from his parents and teachers. He said he was popular and had friends home every weekend. He admitted that he was sometimes confused about how others were feeling.

Diagnosis and differential diagnosis

The assessment confirmed the ADHD diagnosis that had been identified six years after first presentation but acknowledged that this was not the only neuro-developmental problem that was present: the complexity of his presentation was not explained merely by impulsivity, hyperactivity and problems with concentration.

Part of Lucas’s presentation could be described by a new diagnosis of conduct disorder, unsocialised (F91.1) as he came across with high levels of irritability, oppositionality and defiance, together with more serious symptoms including lying, hitting and stealing. ADHD is highly comorbid with behavioural disorders. The conduct problems were further elaborated by being described as (a) ‘unsocialised’ because he was not popular with his peer group and (b) characterised by limited prosocial emotions, given his lack of guilt or remorse, poor empathy and displaying shallow emotions.

Despite his parents’ extensive descriptions in different interviews, clinical observations and teachers’ reports, the social communication presentation of Lucas’s behaviours were never formulated as part of the ASD but as ‘attachment problems’. In the current assessment, taking into account that his care history was not disruptive or marked by multiple separations or gross neglect, and that extensive information was available on his developmental history and clinical details from multiple informants, observations in clinic and clinical interview, it was established that Lucas met the criteria for ASD.

In our differential diagnosis, we ruled out that he had an attachment disorder. He did not meet the criteria for a Reactive Attachment Disorder (RAD) as he always used to come for comfort to a preferential figure (his mother) when upset or hurt or ill. He did not accept comfort in a conventional manner, but this was attributable to sensory issues (part of his ASD); he did not like to be touched, whether or not his attachment system was activated. Lucas was never wary of strangers and could be over-friendly; he would not check back on his parents in an unfamiliar setting. Although these are potentially strong indicators of a disinhibited attachment presentation like Disinhibited Attachment Disorder (F94.2) [ICD-10] and Disinhibited Social Engagement Disorder (313.89) [DSM-5], Lucas did not experience significant neglect early on – indeed he was looked after by an ‘excellent’ foster carer from three weeks after leaving hospital until his adoption at 10 months. Furthermore, he has very severe ADHD and thus his disinhibition extends to all situations (in Disinhibited Attachment Disorder/Disinhibited Social Engagement Disorder, the disinhibition is specifically social). Given the context of his pre-existing neurodevelopmental problems and the absence of either pervasive neglect or frequent changes in caregivers, an attachment explanation was discounted.

Diagnosis and differential diagnosis

The failure to identify biological factors is clearly evident in Lucas’s case. It took many years until the first neurodevelopmental problem (ADHD) was recognised and many more till the second (ASD), which had been discounted twice, was finally identified. Important aspects of his behavioural disorder, especially that he lacked prosocial emotions, were also missed. Not establishing these three core diagnoses meant that for a long time there was no intervention for ADHD, which can be easily treatable and radically alter a child’s experience at school and with peers, leading to academic achievement, more friends and better self-esteem (NICE, 2018). Missing the ASD diagnosis also had serious clinical implications as it meant that Lucas and his family did not receive all the psycho-education and services around social communication available, educational planning and specific interventions (Green, et al., 2016). Likewise, while behavioural problems were prominent, his deficits with prosocial emotions were not identified, which would have helped with tailoring the parenting advice more effectively. Having said this, the parents were never offered a parenting intervention, the evidence-based therapy for behavioural disorders (NICE and SCIE, 2013), one of the best researched interventions in mental health. So all these years, Lucas’s adoptive mother and father felt blamed for being unable to offer good enough parenting for him to develop an attachment with them and Lucas was treated individually with psychodynamic psychotherapy, with no impact on his functioning.

Professionals might have suspected that attachment issues could not be the only explanation for this child’s severe problems had they considered that attachment theory is clear about the capacity for recovery in children who have been neglected: he was taken directly from hospital into the home of a good foster carer at three weeks and adopted at 10 months. The attachment system starts in earnest around six to nine months (Zeanah, et al., 2011), so Lucas was adopted around the time when children start to be aware of their main, discriminated attachment figure. In principle, a child without other psychopathology is likely to develop an attachment to his or her adopters spontaneously (Smyke, et al., 2010); the fact that this child started presenting with such severe problems from a very early age should have alerted professionals to consider other eminently biological aspects related to his birth family, such as genetic risks and in-utero events discussed below.

Genetics

We all run genetic risks and it is well known that mental illness runs in families. But genes also interact with the environment and sometimes good parenting can help diminish the risk of an individual who carries high genetic risk from presenting with an illness (Uher, 2010). If we classify mental illness and disorders in two broad groups (‘any mental illness’ and ‘severe mental illness’), we see that the likelihood of the offspring developing an illness varies according to its severity and if one or both parents suffered from it. Very often in adopted children we do not have these data or it is incorrect: sometimes a diagnosis is mentioned as a suggestion in a report and then, in subsequent ones, is recorded as a formal diagnosis, the wrong information becoming perpetuated. (For instance, a possible mention of bipolar affective disorder in somebody with emotional dysregulation turns into the final diagnosis in reports related to the children. This is important as the genetic risk for the child will be very different.)

In Lucas’s case, we have a confirmed diagnosis of anorexia in his birth mother and very clear early-onset severe behavioural disorders in both birth mother and father (who progressed into forensic history, hinting to even more severity and persistence). Two different types of conduct disorder can be distinguished: the childhood onset and the adolescent onset types (Caspi and Moffitt, 1995). Each one is thought to have different aetiology and although the genetics are still in the process of being understood, those with childhood onset tend to have lower IQ, more attentional and impulsivity problems, poorer scores on neuro-psychological tests and greater peer difficulties (Moffitt, et al., 2001). In addition, they tend to have poorer outcomes later in life in the domains of violence, mental health, substance misuse, work and family life (Moffitt, et al, 2001). Lucas’s birth parents appear to have presented with this more severe childhood onset type of conduct disorder and, indeed, their son presented with early onset severe Oppositional Defiant Disorder (ODD). Temperamental factors should have been considered in this case as they can contribute to the development of ODD in toddlers, and the comorbidity between ODD and ADHD is predicted by temperamental over-activity (Stringaris, et al., 2010).

Lucas showed impairment in his prosocial emotions, characterised by having rather blunted emotional reactivity to the distress of others, little concern for their disapproval and more interest in asserting control and gaining advantage over others than in companionship. Limited prosocial emotions seem to be highly heritable (Viding, et al., 2005) and characterised by poor recognition of emotion (particularly fear) in facial expression (Blair, Leibenluft and Pine, 2014; Dadds, et al., 2006). It is likely that Lucas’s birth father had some of these traits as well, taking into account his history of involvement with the criminal justice system.

Lucas’s birth parents also had problems with substance misuse. Research in the last four decades has provided evidence of the importance of genetic influences in alcohol misuse which indicates that 40% to 60% of the phenotypic variance in alcoholism can be attributed to genetic factors (Dick and Foroud, 2003). Twin studies have found that genetic factors also play a significant role in the transitions from drug initiation to dependence, and many studies have found that personality variables, such as sensation-seeking, play an important role in the prediction of substance misuse (Kosten, et al., 1994). This could point to the fact that some of the personality traits observed in Lucas (impulsivity, sensation-seeking, risk-taking) might be partly inherited. In addition, it is important to bear in mind as he grows into adulthood, that he carries a higher risk to develop a substance misuse disorder.

As seen above, the behavioural history of Lucas’s birth parents, together with their substance misuse, point towards highly impulsive traits in both of them. Lack of organisation, problem with completing tasks and difficulties with attention can be problematic when raising a child. Luckily, Lucas was not exposed to his birth parents’ parenting as he was removed from their care on leaving the hospital, but one could hypothesise that they had traits or even frank ADHD (undiagnosed). Neurodevelopmental disorders are common in the general population and, as the above-mentioned epidemiological studies show, even more frequent among looked after/adopted children and young people (Ford, et al., 2007).

We gave Lucas a diagnosis of ASD, despite his having been assessed for this twice before. The role of genetic mechanisms in autistic disorder is suggested by the fact that siblings are at a 22-fold or greater risk of autism than the general population and studies of monozygotic (identical) and dizygotic (fraternal) twins have shown an increased concordance for autism in monozygotic twin pairs. Several chromosomes are currently being studied and multiple genes are likely implicated (Rutter, 2005). Again, we do not have history of Lucas’s birth parents in this respect, but we believe that the diagnosis was delayed because of his adopted status. Instead, attachment problems were suggested when it is known that children on the autism spectrum are capable of forming selective, secure attachments (Teague, et al., 2017).

Intra-uterine environment

Another important aspect for the formulation that could give support to Lucas’s neuro-developmental problems was his birth mother’s heroin intake during pregnancy and breastfeeding: we know infants prenatally exposed to opiates are at an increased risk for neuro-developmental impairment. There are very few long-term outcome studies of the developmental effects of heroin due to methodological limitations in study design (including small sample sizes, poorly defined comparison groups and difficulty controlling for important environmental variables), making available results difficult to interpret. However, detrimental foetal effects of heroin exposure in terms of prematurity and intra-uterine growth restriction have long been recognised: babies exposed to heroin have decreased birth weight, length and head circumference compared to non-exposed infants. In addition, evidence from relatively small neonatal studies of prenatally heroin-exposed samples has indicated decreased cognitive performance in younger children and increased rates of behavioural problems in eight to 17-year-olds. Prenatal opiate exposure is also associated with ADHD and disruptive behaviours at age 10 (Ornoy, et al., 2001).

Implication for services

Multidisciplinary assessments by specialist teams who are familiar with the latest research and experienced in evidenced formulation and interventions are needed for the most complex of adopted and looked after children. One can hypothesise that these teams are not widespread because they are expensive, but the long-term cost for families and society of not giving them the appropriate interventions at the right time is much greater.

In terms of what can be done to disseminate the well-established knowledge that has been discussed, the main answer is professional development in the staff working with this highly complex group. It seems that a ‘one size fits all’ approach is used in many cases, explaining all of these children’s problems solely in terms of attachment, trauma and loss. Generic services ought to receive training in a scientific approach to attachment theory. Likewise, private providers helping adoptive families need to be trained in the importance of a bio-psychosocial approach with these children in particular, especially regarding neuro-developmental problems.

Prognosis

The discussion in this article focuses on a single case study; this is because the assessing team was a national service giving recommendations to be applied locally. Nevertheless, all of the recommendations made could be accessible in generic CAMHS, apart from more specialist updated life-story work that could be led by the post-adoption social worker. One of the features of specialist teams is that they can often open doors to local services that otherwise would not accept a case as it does not reach threshold on paper. This was not so with Lucas who had been under services for years. The prognosis for this particular case is difficult to establish as his conduct problems featured with marked limited prosocial emotions (callous unemotional traits) and this is associated with worse outcomes. It may be that the combination of a school that understands social communication problems and Lucas’s parents’ unconditional love can be a protective factor for what could otherwise be a problematic future.