“How would you feel if you adopted a baby, and when he starts misbehaving everybody tells you it is your fault?”

This is how Lucas’ parents felt, when everybody around them said his behaviour was due to an attachment disorder: they had been unable to get him to attach to them!

I met Lucas when he was 15 and his adoptive parents were at the end of their tether. Lucas shouted and then damaged property, he threw things on a daily basis. He was easily irritated by anything, would lie, was cruel to animals and fascinated with knives. He stole money from his parents, and showed no remorse. He soiled himself, and did not care if he smelled. At school, he had similar problems.

In our assessment, we found a couple that had tried their best, and who were puzzled at what had gone wrong. They seemed to be using the standard parenting techniques one would expect to work with most children, and gave him a lot of love and affection. So, what went wrong and when?

We started by trying to understand what had happened in Lucas’ life, even before he was born. We learnt that his birth parents had mental health problems, and were aggressive-his father had even been in prison. Both of them took drugs, and birth mother took heroin during pregnancy. When Lucas was born, he was withdrawing from this drug and had to be taken into the incubator for a month. After that, he was discharged into foster care, where he spent the first ten months of his life, until he was adopted. This description gave us hints about what could have happened in Lucas’ neurodevelopment and what heritable risks he carried.

The months he spent in foster care, Lucas was very restless and irritable, and very hard to take care of. When he arrived to his adoptive parents, they noticed the same behaviours, and as he was growing up, he would be hurting children in nursery, soiling and smearing his poo, making mum sing the same song fifty times every night, and not liking to be touched.

His parents took him to CAMHS and he was diagnosed with "attachment disorder" because he was adopted. At 5 he was given intensive individual psychotherapy for five years, playing with a therapist while his parents just waited outside. Nothing changed at home, and his parents kept on blaming themselves.

Because Lucas was adopted, nobody had considered neurodevelopmental conditions, as some professionals still believe that all the problems in adopted and fostered children are related to the fact that they are adopted or fostered. They are not considered individuals, with multiple biological strengths and vulnerabilities, with positive and negative social experiences that make them stronger or weaker, different resiliencies and psychological processes that protect them or make them more vulnerable to different experiences that happen to them-and all of us- in life. It is a “one size fits all”.

Adopted and fostered children are individuals, and are not all "traumatised" children with "attachment problems", and you can read the whole story here.

Virtual Reality (VR) as therapy

I was fortunate to be part of Cornerstone's Virtual Reality panel discussion* last week (http://www.thecornerstonepartnership.com/using-virtual-reality-good/ ). A coming together of people from film, software, hardware, local authorities, cafcass, 3rd sector and myself as a therapist in adoption and fostering.

Virtual Reality  is an emerging technology. I spoke to people who had been involved from the early days around 2013. That's so new. As a technology, it's hardly more than a toddler. But if it took 20+ years to get from brick-like mobile phones to the latest iPhone, the progress for VR will be so much quicker, they predict. VR is not just here to stay, it will be transforming so much of what we do in so many ways. We need to take control of this possibility. And that means thinking about how we can use it creatively and effectively in therapy for looked after and adopted children.

I confess I only used VR for the first time 2 months ago, at the VR lab at IOPPN @ KCL ( https://www.kcl.ac.uk/ioppn/depts/psychology/research/ResearchGroupings/VRRG/Virtual-Reality-Research-Group.aspx) using both cheap goggles and the amazing Oculus Rift. I was blown away by what it can do. But turning that wow factor into something safe and powerful for helping children and young people live happier lives is more of a challenge. Luckily there is already research out there to help us understand how to do this. How to augment what we know works to make it better, quicker, more powerful, and to reach out and engage more children & young people.

I've also spoken to therapists who worry about 'the risks' of VR, but I've yet to hear a clear account of what the risks might be specific to VR. There is always going to be the possibility of some risks emerging if you are, for example, helping children and young people to work through traumatic events, but these should already be assessed and managed clinically. So depending on the nature of the work, risks that arise need to be managed by the clinician whether using VR or not.

Overall, I can imagine different ways of utilising VR and immersive technologies with different intensities and different levels of therapist involvement to suit different children. But these approaches will still be based on what we know, alongside existing therapeutic approaches. At least at first... so I'm really pleased for the opportunity to be working alongside the dynamic team at Cornerstone, and their other stakeholders to try to make this a possibility for Looked After and Adopted children now.

*You can see photos of the event here

Pre-Adoption Assessments

The "It’s All About Me" [IAAM] social impact bond is a good example of helping prospective adoptive parents to understand a child’ needs before adoption – to prepare them for the kind of child they may be welcoming into their home and to think about the kind of supports that might be needed.

Our team contributed to this process by providing a comprehensive mental health assessment to identify the child’s needs, and also, frequently, to address some of the issues that had been raised in expert opinion in Care proceedings – these reports, used to free children for adoption are frequently of little help or relevance to the process of matching a child to appropriate carers; and in any case, they can be of highly “variable” quality. After our assessment, prospective adopters could then make informed choices about the children they were considering, some of whom may have had concerns about high levels of need. In addition, focused support from our recommendations could be offered to them from Voluntary Adoption Agencies, to help make the placement viable over the next 10 years.

For example, we saw several children with global delay [including autism, fetal alcohol, etc] and having a report which described the child as they really are [in detail rather than as a top down label], enabled families to think more openly and creatively about their ability to look after a child with complex needs – thus promoting adoption. In fact we saw three 2 year olds in a row who all had a diagnosis of fetal alcohol disorder, who exemplified this:  all three were quite different individuals, with quite different needs and personalities,  different levels of developmental delay – and so probably different milestones and attainments. One was ont he autism spectrum disorder, the other two did not. All three were very different two year olds, and were probably better matches for different kinds of family.

The IAAM model is no longer in operation, but we do still occasionally offer this pre-adoption service for Local Authorities who want a fresh look at children who are hard to place for adoption.  Knowing as much as possible about children who are ready to be adopted empowers families to make informed decisions and helps to take some of the risk out of what can be a leap of faith.

Adoption is many things: Introduction to our blog

Our service is about designing treatments around individual children and their families. There is no one disorder or condition or problem that all adopted or fostered children have. Our motto is “adoption is not an illness – it is an opportunity” if supported and nurtured effectively as and when needed [more on that in other blogs…]

We think that a lot of the time when parents and carers and schools and services get stuck it is because organisations forget that these children and young people are individuals, with different and diverse needs. Losing sight of the individuality increases the chance that any help offered fails to unleash the therapeutic potential of a stable and sensitively attuned family life.

As an example, the list of conditions we have assessed over the last year or so in our clinic reads like a shopping list of problems and includes [but is not restricted to]:

Foetal Alcohol Disorders; Autism Spectrum Disorders; Epilepsy; ADHD; Sensory Integration Issues [which may or may not be part of a broader autism phenotype]; Neuropsychological Problems; Tic Disorders; Chromosomal Abnormalities, Genetic Problems and Behavioural Phenotypes;

Behavioural Problems and Conduct Disorders; Parenting Assessments; Attachment: Disorders, Problems & Issues in their wide diversity of understanding; Forensic Issues and Risks; Sexual Abuse and inappropriate behaviour; Child Sexual Exploitation and Risk of Sexual Harm to others

Trauma of both simple and complex aetiology [origins] with varied presentations and comorbidities [i.e., other co-occurring and complicating disorders]. 

Depression (i.e., Mood Disorder), with or without Self-Harm and Suicidal Ideation, alongside the active management of risk including in-patient admission to, and discharge from, specialist services; emerging Personality Disorders

Anxiety disorders including Separation Anxiety Disorder, as well as generalised anxiety [worry], social phobia (shyness) and ‘simple’ phobias.

Educational attainment issues including Specific Learning Disabilities such as Dyslexia; Global Learning Disability in its own right; problems with language development and understanding.

And crucially, a whole host of other non-psychiatric problems such as peer relations; social skills; emotional understanding; toileting [soiling and wetting]; hygiene; eating, feeding and hording/gorging; sleep…which can often be more important to children and their families than traditional, formal mental health diagnoses – but which may not get easily identified or treated in some non-specialist adoption & fostering services.

We can assess all these different issues under one roof in our clinic, but not in a one-size-fits-all way, squeezing all children into the same box. For example, in one month we assessed three toddlers in a row, each with fetal alcohol disorders. But they were so different from each other and needed quite different family contexts - all three were assessed by us pre-adoption to help with family finding, so that prospective adopters could know as much as possible about the children they were going to welcome into their homes and what sort of support they might need before they adopted them. Children are individuals– even ones who have the same disorders, “same” experiences, come from the same families, same headline issues…[more on this in later blogs].

Adopted and fostered children and young people are different from each other. They need personalised services and not one-size-fits-all approaches. They may also need different things, at different times, at different intensities and different urgencies, and quite possibly from different services, as part of their journey into and out of the care system. This need to keep an open mind, to keep thinking about difference, individuals, and developmental changes can make accessing the right services at the right time difficult for children, young people and their families.

This blog will discuss some issues we have come across relevant for thinking about the care of adopted and looked after children, young people and their families - and most of all thinking about how to keep their individuality at the heart of the picture; and how the evidence can help us do that.

Welcome to the National Adoption and Fostering Clinic

The National Adoption and Fostering Clinic is an NHS service for adoptive and foster families. We are situated in London but work with families both nationally and internationally. We are part of the South London & Maudsley NHS Foundation Trust.