Adoption & Fostering

In the process of creating a care plan or finding a placement for children, assessment of their health and developmental needs will be undertaken. This can involve the interpretation of complex family history information and may also include undertaking and interpreting the results of genetic testing, when within professional guidelines. This study explores opinions, knowledge about and experiences of adoption professionals in relation to genetic information and testing in Wales. Semi-structured qualitative interviews were conducted with six social workers and seven medical advisers. The data were transcribed and thematically analysed. Themes included the challenges to collation of family history, how the willingness of professionals to undertake genetic testing in children awaiting adoption was altered by the availability (and non-availability) of family history information, and the uncertainty that genetic information can generate for professionals and prospective parents. Uncertainty for both professional groups emerged from apparent inconsistency in current practice and from concern over their own lack of genetic knowledge. As new genetic technologies increase the scope of uncertainty, there is a need for social workers and medical practitioners working in adoption to have a greater understanding of genetics alongside opportunities to discuss cases in a multidisciplinary setting when appropriate.

From its origins, human attachment has always been viewed as a primary, biologically-based phenomenon with strong evolutionary roots. The last few decades have seen a large increase in research studies from developmental science and neighbouring disciplines that attest the role of biology in attachment processes. This review aims to provide a concise and up-to-date summary of research on the biological bases of attachment throughout the lifespan. We review the role of genetics, physiology ‒ focusing on oxytocin and cortisol ‒ and brain mechanisms that underlie attachment behaviour and its consequences. Findings are complex in that they often do not apply equally to all patterns of attachment, to all ages, or all temperament styles, among other factors. In addition, some important evidence is indirect, coming from studies that investigate the impact of variations in caregiving quality, such as differences in maltreatment and separation from caregiving figures, and on biology, and vice versa, rather than looking at differences in attachment per se, which complicates their interpretation. Implications for practice are raised throughout.

Looked after and adopted children are among the most vulnerable in our society and it is well established that they present with a higher prevalence of mental health problems than children who live with their birth family. In their histories, they frequently have birth parents who have lived chaotic lives, some with mental health problems and substance misuse, and have experienced disruptions of care as well as exposure to neglect and/or abuse. However, often when they try to access mental health services, all their problems are formulated as ‘trauma and attachment issues’ with lack of data to support these. This article presents a case study of a 15-year-old boy whose severe difficulties were understood and formulated in terms of ‘attachment problems’ for many years. Neuro-developmental issues, unrelated to his being removed from his birth parents and adopted, had not been considered as the biological factors of the formulation (e.g. genetics and intra-uterus events) were ignored. Because there are no evidence-based interventions for a vaguely defined presentation such as ‘attachment problems’, he was given non-evidenced therapies for years and the parents felt blamed. Understandably, there was then little progress with his difficulties and this in turn had a very detrimental impact on his family, academic and social life. It is recommended that looked after and adopted children have their presentations formulated using a biopsychosocial model that takes into account their complexities to personalise future interventions, just like children who live with their birth parents. It is imperative they stop receiving mental health services where ‘one size fits all’ and that the training of staff working with this group ensures that children’s whole life experiences are understood.

There is a well-established association between childhood maltreatment and later poor mental health and increasing recognition that we need to find ways to support children following such experiences to improve long-term outcomes. We suggest that the rationale for such a preventive approach is directly informed by the emerging findings from the field of functional neuroimaging. Here, we review the evidence from four neurocognitive systems: threat processing, reward processing, emotion regulation and executive control. We briefly summarise what is known about each system, review the evidence that altered functioning is implicated in common mental health problems and describe how the functioning of each system is altered following maltreatment. Across domains, these neurocognitive alterations following child maltreatment are in line with those seen in adults presenting with mental health problems yet most maltreated children studied do not have a presenting ‘disorder’. This suggests that these neurocognitive alterations may potentiate the risk of future psychopathology. We discuss this possibility in the context of the theory of latent vulnerability (McCrory and Viding, 2015). According to this model, children may respond to early adverse environments in ways that are potentially adaptive in the short term but which create vulnerability to future mental health problems in the long term. We also consider the clinical implications of the neuroimaging evidence ‒ in particular, the growing need for a more preventive clinical approach.

Childhood maltreatment is a risk factor for poor physical health outcomes in later life, such as cardiovascular disease and type 2 diabetes. In order to target preventive interventions to reduce this risk, it is important to understand the biological mechanisms linking childhood maltreatment to cardiometabolic disorders. Research reviewed here suggests that maltreated children show alterations in biological systems relating to metabolism and the immune system which could, in turn, increase the risk of long-term cardiometabolic disease risk. Specifically, maltreated children show an elevated risk of obesity in adulthood and greater inflammation levels in adolescence and adulthood. These findings from observational studies of humans are consistent with evidence from experimental animal models showing the causal effects of early life stress on obesity and immune function. To help prevent maltreated children from developing cardiometabolic disease later in life, clinical assessment and treatment should focus on physical as well as mental health.

Research findings from diverse studies converge in suggesting that the experience of early severe and protracted stress is associated with a wide range of behavioural and physical health problems. The public health and clinical implications of these findings are substantial, but their successful applications to improve child health have been limited. What is clear is that this successful application depends, at least in part, on a clear understanding of the mechanisms involved. The current review considers the likely role of stress physiology and the Hypothalamic-Pituitary-Adrenal (HPA) axis, one dominant model for explaining how early stress exposures may have lasting effects on mental and physical health. In addition to highlighting illustrative findings, we consider the practical barriers and challenges for increasing the presence of biological markers in clinical research.

Understanding the interplay between genetic factors and family environmental processes (e.g. interparental relationship quality, positive vs negative parenting practices) and children’s mental health (e.g. anxiety, depression, conduct problems, ADHD) in the contexts of adoption and foster care research and practice is critical for effective prevention and intervention programme development. While evidence highlights the importance of family relationship processes (e.g. interparental relationship quality, parent‒child relationship quality) for the mental health and well-being of children in adoption and foster care, there is relatively limited evidence of effective interventions specifically for these families. Additionally, family-based interventions not specific to the context of adoption and foster care typically show small to medium effects, and even where interventions are efficacious, not all children benefit. One explanation for why interventions may not work well for some is that responses to an intervention may be influenced by an individual’s genetic make-up. Alternatively, the targets of family relationship level interventions (e.g. parenting processes) may not always affect the specific environment ‘trigger’ deemed salient to specific child/adolescent outcomes. This article summarises how genetically informed research designs can help disentangle genetic from environmental processes underlying psychopathology outcomes for children, and how this evidence can provide improved insights into the development of more effective preventive intervention targets for adoptive and foster families. We discuss current difficulties in translating behavioural genetics research to prevention science and provide recommendations to bridge the gap between behavioural genetics research and prevention science, with lessons for adoption and foster care research and practice.