Why is assessment important?
Our multidisciplinary assessment provides a comprehensive formulation of the child’s strengths, difficulties, needs and protective factors – across the whole range of mental health disorders. We consider information from different sources and the child's presentation in different settings, such as home, at school, and in our clinic. We use the formulation to develop our care plan, which may address a range of problems e.g. mental health, educational engagement, and home needs. As part of the assessment, we may complete:
›› Individual assessment of attachments and identity
›› Individual psychometric assessment of abilities and emotional profile
›› Specialist neuropsychological and social communication assessment
›› Family environment review through interviews with caregivers and relevant professional networks
›› Educational attainment assessment and current school functioning by talking to teachers
What is involved?
Before our assessment, we will ask the parents/carers, the teachers and the child if old enough to fill in an online standardised screening questionnaire. This gives us very good preliminary information before the assessment because it highlights possible areas of concern from different points of view, so we can offer you a more focused and personalised assessment on the day. In addition, before your assessment, we will have reviewed all the relevant background information that we have access to (e.g., adoption records, health reports, previous CAMHS involvement, etc).
In our assessment, which is usually a morning session, our multidisciplinary team will see all the parents and the child, and maybe some professionals who wish to attend, together and separately. In the parent interview, our assessor will focus the assessment around the information we have already received and also widen the enquiry to see if there are any further issues that you want to raise on the day. We call these the 'Presenting Issues', and it is your chance to tell us your concerns in your own words. Meanwhile, the child will have a clinical interview and psychometric testing with one of our clinical psychologists. The child's session is adapted to best suit the child's age, developmental stage, and individual needs ( for example, sessions with younger children are generally more play-based, while a session with a teenager may be structured in a similar way to an interview with an adult).
What happens next?
After the assessment, we produce a draft report with the information we gathered in the assessment morning, combined with the information we received before the assessment and further information we may seek after it, for example from school, based on what we have learned on the day of the assessment. As part of our commitment to involve parents and carers in the process, we send an initial draft report back to you, to make sure we understood everything right and that the parents view is reflected.
The final report will include the revised parents/carers views, the child interview, psychometrics, interview with school, school observation (if needed), summary of previous records, results of the standardised questionnaires all the parties have completed, and any further psychological testing we have carried out. At the heart of the report is the biopsychosocial formulation, which provides an account of what the issues are, where they may have come from (what specific aspects in this child’s pre and postnatal life may have influenced their development); what made these issues become a problems in this child’s life, or what made them worse (what triggered the onset or worsening of the problem); what things are likely to make any issues continue or get worse (what factors could stop thing improving on their own); and, importantly what strengths the child or family has, or what could help the family make things better (what the resilience factors are what could be done to maximise well-being). The Formulation also discusses any mental health diagnoses we have identified as well as ruling some out. Sometimes ruling out what is not a mental health issue can be as important for a child and their family, as identifying something new.
Finally, this report will include recommendations for mental health, well-being, placement and education, as appropriate, some of which we might carry out, and some that may be better delivered by other services/agencies.
Lucas is a 15 year old boy who was referred to the National Adoption and Fostering Clinic for a comprehensive assessment: he had longstanding difficulties with behavioural outbursts, lying to avoid responsibility, lack of empathy and poor emotional literacy. Lucas had also a long history of services involvement.
Lucas was born addicted to heroin (which his birth mother took during pregnancy) and stayed in the special care baby unit for 23 days. Both birth parents had, apart from substance misuse problems, learning difficulties, forensic history and significant mental health problems.
Straight from hospital, Lucas was taken into a very experienced foster family, who took care of him for 10 months. They already noticed he was a restless baby and that his temperament was irritable (prone to crying and difficult to soothe). At that point, Lucas was adopted and from day one, his adoptive parents noticed the same issues - that he would “scream not stop” and refuse physical contact. As he was growing, behavioural problems emerged: Lucas would hit other children, and was cruel to animals. His social development was always unusual: he did not greet, had poor imagination, repetitive play, and rigid with routines. His speech was very delayed: aged 5-7, only his parents could understand him and he had speech and language therapy from an early age until teenage years.
Lucas was referred to CAMHS at 5, and started “attachment work”- we could find no rationale for this other than he was adopted and no treatment aims. A therapist provided intensive psychotherapy for 5 years: 3 times a week for the first 2 years, 2 days a week for a year and once a week for the last 6 months. In the final therapy report, Lucas’ sleep problems, soling, smearing faeces, and making compulsive, strange and animal-like noises were noted but it was felt that his “early history prior to adoption may well have impacted severely on his emotional and cognitive development in ways that had been difficult to assess”. Aged 10, when his psychotherapy ended, he was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and was transferred to CAMHS clinics for medication monitoring. At this time, he had his first Autism Spectrum Disorder (ASD) assessment, in which a diagnosis was ruled out, despite plenty of evidence, because he was adopted.
On our assessment, Lucas told us “that he would rather have a spider crawl on his arm than go through the experience of therapy again”. His behavioural problems were as prominent as ever, being frequently excluded from school, but the parents had never received any evidence-based intervention to manage his extreme challenging behaviours. We found out that Lucas had very limited prosocial emotions: he did not experience guilt and remorse after he had hurt somebody, he could not feel empathy, he did not care about his performance and his affect was shallow and superficial. This was important to help us formulate what maintained his problems, and inform the recommendations for the parents’ work. In addition, a clear neurodevelopmental picture emerged: apart from ADHD, Lucas was diagnosed with ASD [both issues that were likely to have been present in his birth parents]. This helped the parents understand some of his obsessions and rigidity, lack of reciprocity and non-verbal communication, as well as his fixations, which were beyond what a normal adolescent would present with. More importantly, it relieved the blame they had felt all these years when services and school had understood all the problems as part of “their attachment problems”. The family knew that attachment system gets activated at around 9 months, so they agonised with the question: “if he was in a good foster placement and he came to us at 10 months, what does it say about us if we could not develop an attachment?” But the answer was that most of his problems were set in motion before birth [e.g., very likely exposure to substance misuse and birth parental genetics].
Psychoeducation around ASD and the particular presentation of children with Limited Prosocial Emotions, all embedded in the formulation that took into account both genetics and the impact of opiates in the developing brain in helping the family move away from blaming themselves and helping their child. Likewise, school and other agencies could put in place measures to support Lucas develop his potential.