Screening for Mental Health Difficulties in Looked After Children referred to a Specialist CAMHS Team using the Strengths and Difficulties Questionnaire: a Mixed Methods Study

Abstract

Looked after children (LAC) are at high risk of developing mental health difficulties. In England, 45 percent meet the criteria for psychiatric diagnosis (Ford, Vostanis, Meltzer & Goodman, 2007), while levels of emotional and behavioural difficulties may be significantly higher (Sempik, Ward, & Darker, 2008). The UK Government requires local authorities in England to use the Strengths & Difficulties Questionnaire (SDQ) to assess and monitor looked after children’s (LAC) mental health and emotional wellbeing. However, there is growing concern that this measure alone is not sufficient (Social Care Institute of Excellence, 2017).

This mixed-methods study aimed to assess the extent to which the single-informant SDQ accurately identified mental health difficulties in looked after children referred to a specialist CAMHS team. A further aim was to explore clinicians’ understanding of the reasons why some looked after children’s mental health difficulties are not identified by the SDQ. SDQ total difficulties scores for 144 children referred to a specialist LAC CAMHS team were compared to referral outcomes. Using a Total Difficulties Score of 17 (Youden’s Index), parent-report SDQs (n=97) predicted CAMHS treatment recommendations with a sensitivity of .67 and a specificity of .57. For teachers (n=41), a score of 17 yielded a sensitivity of .79 and specificity of .71. For self-reports, a lower Total Difficulties Score of 13 (Youden’s Index) achieved a sensitivity of .79 and specificity of .42. Overall, the number of children whose mental health difficulties were not identified was unacceptably high.

Interviews with clinicians working in the LAC CAMHS team (n=9) were analysed using Thematic Analysis. Four themes were identified: ‘Developmental trauma & attachment’, ‘A different kind of patient?’, ‘Seeing the “bad” but neglecting the sad’, and ‘The importance of clinical judgement’. Overall, the results support SCIE recommendations that the SDQ alone does not provide a sufficiently robust assessment of looked after children’s mental health. Low SDQ score should not prevent access to LAC CAMHS services.