The Mental Health of Children in Out-of-Home Care

Michael Tarren-Sweeney


Curr Opin Psychiatry. 2008;21(4):345-349. 

In This Article


Given their exceptional vulnerability, it is argued that children in care require preemptive, population-based assessment of their mental health at the time of entry into care.[38] This is supported by a number of professional bodies.[39,40] There is variability, however, in the extent to which statutory guardians recognize a duty of care to initiate such screening. Furthermore, in some locations, barriers to mental healthcare exist for children whose problems are identified in statutory assessments.[41] Beyond this, there are questions regarding the scope of mental-health assessments, and who is best placed to conduct them. A large proportion of children in care present with complex developmental impairments across multiple domains. This can lead to over-assessment, compartmentalization of problems, conflicting formulations, and lack of coordinated intervention. Caseworkers and foster parents also look to clinicians for guidance on such matters as preferred placements, restoration to parents, family contact, and decisions about permanency. Ideally, mental-health assessments should be performed by individuals or teams with reference to the child's total ecology, and with an eye to their functioning in the home, school and community.[42] This model sees mental health considered within comprehensive assessments of children's development, social relationships and wellbeing. Clinicians working within alternate care agencies, or in specialist alternate care clinics, are well placed to carry out comprehensive, ecological assessments of children in care, while those working in schools or traditional CAMHS services can be precluded from doing so.[42]

Another important consideration is clinical competence. Specialized knowledge and skills are required to competently assess this population. For example, children in care are often misdiagnosed with disorders on the autistic spectrum, because clinicians fail to identify co-occurring language delay and attachment disorder following deprivation in infancy. Similarly, treatment for these children requires specialist clinical knowledge and either novel or modified treatment protocols. Such knowledge is not readily acquired in graduate clinical training, or from experience gained in generic clinical services. Working with children in care also requires some understanding of ethical issues relating to provision of consent, and advocating for children's best interests.[43]

These considerations suggest that assessment and treatment of children in care are best served by specialist out-of-home care clinical services, either ‘in-house’ (i.e. within care agencies) or in the public health or education sectors. More broadly, there is a need to build professional frameworks for clinical specialization in child welfare and alternate care.


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