Alignment of Borderline Personality Disorder and Complex Post-traumatic Stress Disorder With Complex Developmental Symptomatology.

Cluster analysis of maltreatment-related mental health symptoms manifested by adolescents in foster care suggest the absence of an underlying taxonomic structure. To test this further, we investigated alignment between mental health symptom profiles derived through cluster analysis and nominal diagnosis of Borderline Personality Disorder (BPD) and Complex Post-traumatic Stress Disorder (C-PTSD), among a sample of 230 adolescents in long-term foster care. Nominal DSM-V BPD and ICD-11 C-PTSD caseness was estimated from Child Behaviour Checklist and Assessment Checklist for Adolescents score algorithms, and alignment of case assignment with previously-derived symptom profiles was examined. Nineteen BPD and three C-PTSD nominal cases were identified. Low C-PTSD prevalence reflected low concordance between PTSD and 'disturbances in self organization' (DSO) case assignment. The BPD and C-PTSD cases were aligned to more complex and severe symptom profiles. While the complex and severe presentations identified in the present study included core symptoms and clinical signs of BPD, they were also characterised by clinical-level inattention/over-activity and conduct problems. The present findings provide some support for the validity of the BPD construct for describing complex and severe psychopathology manifested by adolescents in foster care, and no support for the C-PTSD construct. However, the symptom profiles point to high variability in combinations of multiple symptom types that does not conform to traditional definitions of a 'diagnosable' mental disorder. Further research is needed to determine if complex post-maltreatment symptomatology can be validly conceptualised as one or more complex disorders.

Mental Health Symptom Profiles of Adolescents in Foster Care.

The article describes an investigation of the nature, patterns and complexity of carer-reported mental health symptoms for a population sample (N = 230) of adolescents (age 12-17) placed in long-term foster and kinship care following chronic and severe maltreatment. Two cluster analyses of Child Behaviour Checklist DSM-oriented (CBCL-DSM) and Assessment Checklist for Adolescents sub-scale scores of clinical cases were performed. The first yielded 8 profiles of attachment- and trauma-related symptoms as measured across eight ACA scales (N = 113 cases). The second yielded 11 profiles of a broader range of symptoms, as measured across five CBCL-DSM and five ACA sub-scales (N = 141 cases). The symptom profiles derived from both cluster analyses are differentiated more by symptom severity and complexity, than by symptom specificity - suggesting that trauma- and attachment-related symptomatology does not conform to a taxonomy of discrete disorders. Five of the 11 CBCL-DSM/ACA profiles describe severe and complex symptomatology that does not correspond to discrete DSM-5 or ICD-11 diagnoses. Accurate measurement and formulation of clinical phenomena is an essential component of evidence-based psychological and psychiatric practice. Clinicians who carry out mental health assessments of children and adolescents in care should be aware of the limits of the diagnostic classification systems for formulating complex attachment- and trauma-related symptomatology.

Helping Young People in Out-of-Home Care: Basic Elements.

Children and adolescents (young people) who experience maltreatment early in life and are subsequently placed in out-of-home care (OOHC) are specifically at risk for poor mental health outcomes.1 Although rates vary by survey and location, up to half of these young people have clinical-level mental health difficulties, and another 20% to 25% have difficulties approaching clinical significance.2 These difficulties are characterized by high symptom complexity and severity, and include maltreatment-related mental health symptoms.2 Many young people in OOHC are difficult to engage with and retain in treatment, compounded by a lack of specialized mental health services3 and a history of problematic social interactions with supports.4 They are often reluctant to seek help because of stigmatization and confidentiality concerns, limited opportunities for decision making, service inaccessibility, distrust of mental health services, and their perception that professionals do not understand their circumstances.5 We propose 6 clinical practice modifications for mental health services working with young people in OOHC to enhance therapeutic engagement and to maximize their therapeutic outcomes.

Psychosocial screening and monitoring for children in foster care: Psychometric properties of the Brief Assessment Checklist in a Dutch population study.

Children in foster care experience higher levels and rates of psychosocial difficulties than children from the general population. Governments and child welfare services have a responsibility to identify those children in care who have need for therapeutic services. This can be achieved through systematic screening and monitoring of psychosocial difficulties among all children in foster care. However, general screening and assessment measures such as the Strengths and Difficulties Questionnaire (SDQ) and Child Behavior Checklist (CBCL) might not adequately screen for the range of difficulties experienced by foster children. The Brief Assessment Checklists for Children (BAC-C) and Brief Assessment Checklists for Adolescents (BAC-A) are measures designed to screen for and monitor attachment- and trauma-related difficulties among child welfare populations. This article reports psychometric properties of the BAC-C and BAC-A, estimated in a population study of 219 Dutch foster children. The results suggest the BAC-C and BAC-A perform both screening and monitoring functions well. Their screening accuracy, internal reliability and concurrent validity are comparable to those estimated for the SDQ within the same child and adolescent sample. Future research is needed to assess the value of the Brief Assessment Checklists (BAC) compared to other measures and to validate cut-points for the BAC. This study further establishes the BAC-A and BAC-C as valid and useful mental health screening and monitoring measures for use with children and adolescents in foster care.

The Mental Health of Adolescents Residing in Court-Ordered Foster Care: Findings from a Population Survey.

The mental health of a representative sample of 230 adolescents residing in foster care in New South Wales, Australia, was estimated in a state-wide epidemiological survey from carer-report responses on the Child Behavior Checklist (CBCL) and the Assessment Checklist for Adolescents (ACA). Rates of CBCL total problems, externalizing and internalizing scores above the borderline range cut-points were 49, 44 and 29% respectively, representing a relative risk of 3.8, 3.7 and 2.7 respectively in comparison to Australian children at large. These rates are 10-14% lower than that previously estimated for pre-adolescent Australian children in foster care. Whereas older age is associated with poorer mental health among pre-adolescent children in foster care, the present study findings suggest that this effect does not extend into adolescence. Around half of adolescents residing in foster care have mental health difficulties requiring referral to treatment services, including attachment- and trauma-related difficulties that are uncommon among clinic-referred children at large.

Rates of meaningful change in the mental health of children in long-term out-of-home care: A seven- to nine-year prospective study.

Children residing in long-term out-of-home care have high rates of clinical-level mental health difficulties. However, the stability of these children's difficulties throughout their time in care is uncertain. This paper reports estimates of the seven- to nine-year stability of carer-reported scores on the Child Behavior Checklist (CBCL) and Assessment Checklists for Children (ACC) and Adolescents (ACA) for 85 children in long-term foster or kinship care. Prospective score changes on the CBCL total problems and ACC-ACA shared-item scales were assigned to one of four change groups: 'sustained mental health'; 'meaningful improvement'; 'no meaningful change'; and 'meaningful deterioration'. On each of the two measures, more than 60% of children manifested either sustained mental health or meaningful improvement in their mental health, while less than a quarter showed meaningful deterioration. Mean mental health scores for the aggregate sample did not change over the 7-9year period. Findings discount the presence of a uniform, population-wide effect-suggesting instead, that children's mental health follows several distinct trajectories. Rather than asking whether long-term care is generally therapeutic or harmful for the development of previously maltreated children, future investigations should focus on the questions "…what are the systemic and interpersonal characteristics of care that promote and sustain children's psychological development throughout childhood, and what characteristics are developmentally harmful?" and "…for which children is care therapeutic, and for which children is it not?"

Behavior Problems and Post-traumatic Stress Symptoms in Children Beginning School: A Comparison of Pre- and Post-Earthquake Groups.

INTRODUCTION: Literature reviews caution that estimating the effects of disasters on the behavior of children following a disaster is difficult without baseline information and few studies report the effects of earthquakes on young children. In addition the relationship between age at the time of disaster and consequential behavior problems have not been reported for young children who experience disaster-related stress during a developmentally sensitive period. METHODS: Behavior problems and symptoms of post-traumatic stress (PTS) were reported for two groups of children from nearby neighborhoods during their first term at school, using the Behavior Problem Index by teacher report, following approved informed consent procedures. Data on one group, "Pre-EQ" (N=297), was collected four years before the beginning of the earthquakes on children born 2001-2002. Data on the second group, "Post-EQ" (N=212), was collected approximately three to four years after the beginning of the earthquakes on children born 2007-2009 and living in heavily damaged neighborhoods. The Post-EQ group had significantly more children from high socioeconomic neighborhoods but no other significant differences on main demographic characteristics. RESULTS: The mean behavior problem score was significantly higher in the Post-EQ group (Mean =6.11) as compared to the Pre-EQ group (Mean = 3.78). PTS symptoms were also significantly higher in the Post-EQ group (Mean =2.91) as compared to the Pre-EQ group (Mean=1.98) and more children had high PTS scores (20.9% v. 8.8%, OR= 2.73, 95%CI =1.57, 4.76). Model testing identified that a younger age at the time of exposure was the only significant predictor of high numbers of PTS symptoms in the Post-EQ group. Discussion: Rates of teacher-reported behavior problems in young children more than doubled following the Christchurch earthquakes. Younger children may be more vulnerable to the effects of earthquakes that occur during a developmentally sensitive period. Additional research is needed to consider the effects of age and duration of disaster effects to better understand the effects of disasters on children, their families and communities.

An investigation of complex attachment- and trauma-related symptomatology among children in foster and kinship care.

The paper reports an investigation into the nature, patterns and complexity of mental health symptomatology reported for a large (N = 347) population sample of children in foster and kinship care. Cluster analyses were performed on caregiver-reported Child Behavior Checklist (CBCL) and Assessment Checklist for Children (ACC) scores. The derived profile types are characterized more by symptom complexity than specificity, and are delineated more by elevation than shape. The analyses indicate that social and interpersonal relationship difficulties are hallmark features of clinical presentations of children in care; that anxiety is more often observed as a component of felt insecurity than as generalized or trauma-specific anxiety; and that attention-deficit hyperactivity is rarely manifested in isolation from other difficulties. Whereas 35 % of children had clinical difficulties that could plausibly be construed as discrete mental disorders or comorbidity, another 20 % displayed complex attachment- and trauma-related symptomatology that is not adequately conceptualized within DSM or ICD classifications.

Concordance of mental health impairment and service utilization among children in care.

This paper describes caregiver-reported patterns of mental health service use for 347 pre-adolescent children in foster and kinship care in New South Wales (NSW), Australia. Children's mean time in care and mean time with their present caregivers were 4.3 and 3.3 years respectively. Forty-four percent of children received individual therapy or counselling, 45% received interventions in the form of clinical guidance for their caregivers, and 31% received both forms of service. Among children scoring in the clinical range on any CBCL sub-scale (N = 191), equivalent rates of mental health service use were 60%, 55% and 41% respectively. Although not directly comparable, these findings describe a higher rate of service use than that reported for children in care elsewhere. While children with more complex and severe difficulties had higher rates of service use, there was no evidence of variable access for treatment of different types of disorder. Predictors of service use are reported and contrasted with previous findings. The paper considers several features of the NSW child welfare, health and education systems that may account for the relatively high rate of service use.

It's time to re-think mental health services for children in care, and those adopted from care.

Much of what is written in this special issue points to the need for a clinical workforce that has much greater knowledge and skills for working with children with a history of alternate care, including those who are subsequently adopted. Standard child clinical conceptualization, assessment methods, and formulations miss the mark for these vulnerable populations in a number of critical ways. The present paper proposes 10 principles to guide the design of mental health services for children in care, and those adopted from care. Effective specialization in child welfare work by clinical child psychologists, psychotherapists and psychiatrists, requires: (i) specialized knowledge and skills; (ii) a shift from traditional clinical practice to a clinical psychosocial-developmental scope of practice; and (iii) a strong advocacy role. To support such specialized practice, service design should be guided by: (iv) a primary-specialist care nexus, that includes universal, comprehensive assessments; (v) a shift from acute care to preventative, long-term engagement and monitoring; (vi) integration within the social care milieu; (vii) a shift from exclusion to active ownership of these client groups; (viii) normalization strategies; and (ix) alignment of services for these client groups. Finally, it is argued that mental health service provision for these children is strengthened by policy that promotes (x) "whole of government" accountability for their mental health needs.

Beginning school with asthma independently predicts low achievement in a prospective cohort of children.

BACKGROUND: Concerns about the achievement of children with asthma and respiratory conditions are especially important in New Zealand, which has one of the world's highest rates of childhood asthma. The present study evaluated whether entering school with asthma was associated with low achievement after the first year. METHODS: A child cohort was recruited to a prospective study at time of first enrollment into randomly selected schools in Christchurch. Parent interviews covered demographics and respiratory status. Physician reports were sought for children with asthma, and all respiratory information was clinically reviewed. The children's achievement in reading and math was individually assessed at school entry and reassessed after 12 months. Schools reported absences. Intelligence subtests were administered. RESULTS: Two hundred ninety-eight children were recruited, including 55 (18.5%) with current asthma. At 1-year follow-up, retention was 93.7%. Children who entered school with asthma were more likely to be ≥ 6 months behind other participants in reading words (P = .023) and books (P = .026), but not in math (P = .167) at the end of the first year of school. Achievement was not related to asthma severity. Entering school with asthma reliably predicted low reading achievement independent of other known covariates of low achievement (high absenteeism, minority status, male gender, single-parent family, poor academic skills at school entry, and low socioeconomic status). CONCLUSIONS: Entering school with asthma was a significant predictor of low achievement in reading at 12-month follow-up, independent of asthma severity, high absenteeism, or other covariates of low achievement.

An exploratory investigation of abnormal pain response among preadolescent children in foster care.

The present article describes a pattern of abnormal responses to pain (APR) among children in care, suggestive of pain insensitivity or failure to communicate felt pain. Exploratory analyses of caregiver-reported APR were conducted within a larger epidemiological study of 347 preadolescent children in foster and kinship care. APR items were generated from clinical assessment reports and a clinician survey, during development of a psychiatric rating scale for children in care. An APR construct was identified in factor analysis. Nine per cent of the sample had scores suggesting clinically meaningful APR, with a high level of corresponding psychological disturbance. Various analyses suggest the phenomenon may be a discrete, but integral component of complex, multifaceted psychopathology. Concurrent and retrospective measures of a large number of potential risk variables did not discriminate between APR scores and other estimates of psychopathology. However, moderate correlations between APR and ad hoc measures of impulsivity, dissociative behaviours, and inhibited-avoidant attachment difficulties suggest a number of hypothesized developmental mechanisms that might be explored in further studies.

The mental health of children in out-of-home care.

PURPOSE OF REVIEW: To review the scale, symptomatology and determinants of mental health problems of children in alternate care, and to consider the need for specialized knowledge and clinical competence for assessment and treatment of these problems. RECENT FINDINGS: The scale of mental health problems among children in care is exceptional for a nonclinical population, approaching that of clinic-referred children. Children in residential care have more mental health problems than those in family-type foster care, while those in kinship care have fewer problems. Children manifest complex psychopathology, characterized by attachment difficulties, relationship insecurity, sexual behaviour, trauma-related anxiety, conduct problems, defiance, inattention/hyperactivity, and less common problems such as self-injury and food maintenance behaviours. SUMMARY: Children in care have complex symptomatology that is not well represented in present classification systems. There is a need for research into the characteristics and meaning of these complex presentations, and some re-appraisal of present taxonomies. Clinicians should consider these difficulties in their entirety, rather than as discrete disorders. It is recommended that assessment and intervention are provided by clinical teams that have specialist knowledge of children in care, and that use an ecological approach to assessment.

Predictors of problematic sexual behavior among children with complex maltreatment histories.

Exploratory analyses of sexual behavior problems (SBP) were conducted within a larger epidemiological study of 347 preadolescent children in foster and kinship care. SBP was estimated from carergiver-reported scores on the Assessment Checklist for Children. The study simultaneously examined a large number of discrete and cumulative influences on the development of children at high risk for SBP. Most children with SBP had corresponding psychopathology, most notably conduct problems, inattention, and interpersonal behavior problems suggestive of attachment disturbances. Several correlates identified in previous studies were not associated with SBP. High concordance of SBP was found among 52 sibling dyads. Independent predictors of SBP were older age at entry into care, female gender, placement instability, and contact sexual abuse. The findings emphasize the significance of cumulative risk among children exposed to multiple adversities. The findings generated several hypothesized mechanisms involving attachment disturbances.