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Prevalence of psychiatric disorders in young people in the care system

^a Highfield Family and Adolescent Unit, Warneford Hospital, Oxford OX3 7JX, ^b Department of Biostatistics and Computing, Institute of Psychiatry, London SE5 8AF

Correspondence to: Dr J B McCann, Leigh House Hospital, Chandler's Ford, Eastleigh, Hants SO53 1JY.

Recently, professional and political concern has grown about the severity and types of problems experienced by young people in the care system, this group being one of the most vulnerable in terms of psychological disturbance. Their risk of psychiatric ill health is higher than that of any other easily identified group in our society,¹ and studies have consistently identified a high incidence of behavioural problems.² No study has systematically examined the psychiatric disorders of adolescents being looked after by local authorities, so we aimed to assess the prevalence and types of psychiatric disorder among adolescents in the care system and compare them with those of a comparison group of adolescents.

Subjects, methods, and results

All adolescents aged 13 to 17 years looked after by the Oxfordshire local authority--that is, living in residential units and foster care--were included in this study. The comparison group consisted of adolescents with no previous or current contact with any local authority, matched for age and sex, and randomly selected from the same school or, when the adolescent was not attending school, from the same general practice. The study used a two phase, multimethod design. The first phase involved screening the adolescents using the Achenbach child behavioural checklist and the youth self report questionnaires.³ Adolescents who were identified as high scorers as defined by Achenbach were approached to enter the second phase of the study, when they were interviewed using the Kiddie schedule for affective disorders and schizophrenia.⁴ The main statistical analyses were carried out using SUDAAN version 6.34, using weighting methods for two phase sampling designs and allowing for non-responders as described by Pickles et al.⁵

Altogether 134 adolescents (69 boys and 65 girls) were being looked after by Oxfordshire local authority on a given date, 38 in residential units and 96 living with foster carers. Their mean age was 14.8 years (SD 2.5); the mean age at reception into care was 9.2 years (SD 5.3). The number of placements ranged from 1 to 24, with a median of 2; the cumulative time in care ranged from two months to 16 years, with a median of 2 years and 10 months.

The total response rate from the adolescents in the care system was 66% (88). Forty seven (53%) of the 88 responders were identified as high scorers. In the comparison group the response rate was 75% (100), with 12% identified as high scorers. The total weighted prevalence rate of psychiatric disorder in adolescents in the Oxfordshire care system was 67% compared with 15% in the comparison group, with 96% of adolescents in residential units and 57% in foster care having psychiatric disorders. The commonest diagnosis among adolescents in care was conduct disorder (22, 28%), followed by overanxious disorder (20, 26%). Worryingly, 23% (18) suffered from major depressive disorder, compared with 4% of controls. Eight per cent were diagnosed as having unspecified functional psychosis, with adolescents experiencing auditory hallucinations (table 1).

Table 1--Prevalence (%) of psychiatric disorders among
adolescents in the care system
------------------------------------------------------------------------
                                   In care        Controls
Diagnoses (DSM IIIR)              (n = 78*)      (n = 97+)
------------------------------------------------------------------------
Conduct disorder                     28              0
Overanxious disorder                 26              3
Major depressive disorder            23              3
Attention deficit disorder           14              2
Other depressive disorders           12              3
Avoidant disorder                     8              1
Unspecified functional psychosis      8              0
Oppositional disorder                 7              3
Panic disorder                        4              0
Bipolar depressive disorder           4              0
Substance abuse                       3              0
Bulimia nervosa                       1              0
Anorexia nervosa                      1              0
Obsessive-compulsive disorder         1              0
Phobic state                          1              1
Separation anxiety disorder           0              1
------------------------------------------------------------------------
*Among the 88 responders only 37 of the 47 high scorers were finally
interviewed as 10 refused or were missing.
+Among the 100 responders 3 of the high scorers refused to be
interviewed.

Comment

Adolescents in the care system showed particularly high levels of psychiatric disorder compared with adolescents living within their own families. Not only did they suffer from serious psychiatric disorders--notably, major depressive disorder; they also showed high levels of comorbidity, reflecting the complexity of these adolescents' difficulties. One of the most worrying findings was that a significant number of adolescents were suffering from severe, potentially treatable psychiatric disorders which had gone undetected. Local and health authorities need to direct their attention and ultimately resources to the types and complexities of psychiatric disturbances that are present in adolescents in the care system, as this disadvantaged group does not necessarily attract strong political advocates.

We thank the adolescents and their carers, along with Oxfordshire Social Services for their kind cooperation and participation in this study and Dr Stephen Wolkind for his encouragement and guidance.

Funding: Oxfordshire Regional Health Authority research scheme.

Conflict of interest: None.

1. Bamford F, Wolkind SN. The physical and mental health of children in care: research needs. London: Economic and Research Council, 1988.
2. Wolkind S, Rushton A. Residential and foster family care. In: Rutter M, Taylor E, Hersov L, eds. Child and adolescent psychiatry. Oxford: Blackwell Scientific Publications, 1994:252-66.
3. Achenbach TM, Edelbrock CS. Manual for the child behaviour checklist. Burlington, Vermont: University Associates in Psychiatry, 1983.
4. Chambers W, Puig-Antich J, Hirsch M, Paez P, Ambrosini PJ, Tabrizi MA. The assessment of affective disorders in children and adolescents by semi-structured interview: test-retest reliability of the K-SADS-P. Arch Gen Psychiatry 1985;42:606-702.
5. Pickles A, Dunn G, Vazquez-Barquero JL. Screening for stratification in two-phase ("two-stage") epidemiological surveys. Statistical Methods in Medical Research 1995;4:75-91.

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