Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697635197649.pdf (Australia)
Child: care, health and development Original Article doi:10.1111/j.1365-2214.2009.00978.x Non-infant adoption from care: lessons for safeguarding children C. A. Rees* and J. Selwyn† *Tyndalls Park Children’s Centre, and †School for Policy Studies, University of Bristol, Bristol, UKcch_978 561..567 Accepted for publication 29 March 2009 Abstract Aim To explore use of adoption in remedying abuse and neglect, to inform child protection practice and to identify professional responsibilities to adoptive families.
Method A cohort of 130 children was identiﬁed for whom adoption was recommended in 1991–1996 at a mean age of 5.7 years (range 3–11).

All were in local authority care for child protection reasons.

Background information was gathered from social work records.

The children were traced between 6 and 11 years later and their adopters interviewed.

The Strengths and Difﬁculties Questionnaire and the Parent–Child Communication Scale were completed.
Results All but three birth parents had traumatic childhoods involving abuse, neglect and/or time in care.

Eighty-six per cent had violent adult relationships.

Mental illness, learning difﬁculties and substance abuse were prominent.

Sixty-seven per cent of families were known to social services when children were born, but 98% experienced abuse or neglect.

Most adopters found the ﬁrst year challenging, though rewarding.

Depression, anxiety and marital problems were common.
Children’s learning difﬁculties, conduct problems, emotional ‘phoniness’ and rejection affected closeness.

At follow-up 28% described rewarding, happy placements, and 62% described continuing difﬁculties tempered by rewards.

However, 10% reported no rewards.

Hyperactivity and inattention frequently persisted despite stable adoption and were associated with conduct and attachment difﬁculties.

Use of professional services was substantial.


Thirty-eight per cent of children failed to achieve stable adoption.

Later entry to care correlated with poorer outcome.

Conclusions implications of parental childhood experiences, and indicates the risk of delay.

The high prevalence of domestic violence in birth families indicates the need for better resources for managing emotional dysregulation.
Adoption is a valuable therapeutic tool, but professional responsibilities in supporting it need to be acknowledged and adequately resourced.

Dysfunctional hypothalamus-pituitary-adrenal axis programming may contribute to persisting difﬁculties.

Supporting substitute care should be considered integral to safeguarding children.

This study highlights the importance in safeguarding children of considering the the viability of substitute care and of the professional resources needed to sustain it.
Keywords abuse, adoption, behaviour, deprivation, foster care, parenting Correspondence: Corinne A. Rees, Tyndalls Park Children’s Centre, 31 Tyndalls Park Road, Bristol BS8 1PH, UK E-mail: drcarees@doctors.org.uk Introduction Removing children from their parents’ care for their protection presupposes that the alternative will be better.
Safe decision making therefore requires understanding of the risks of delay, of The Adverse Child Experiences Studies demonstrate the high and long-term cost for physical and emotional health of early childhood deprivation (Felitti 2002).

Dysfunctional setting of © 2009 The Authors Journal compilation © 2009 Blackwell Publishing Ltd 561 562 C.A.

Rees and J. Selwyn hypothalamus-pituitary-adrenal (HPA) axis function appears to contribute to this (Heim et al.

1997; King et al.

1998; Shoal et al.


2003; van Bokhoven et al.

2005; Schore 2005).

Poor outcomes of foster care suggest, at best, qualiﬁed thera- peutic efﬁcacy.

For example, care leavers are substantially over- represented among both victims and perpetrators of crime.

A third experience homelessness.

Over 35% of girls become preg- nant while in care or within 2 years of leaving (Barn et al.

2005).
2005).

As infant adoption has declined, adoption has increasingly come to be used as a tool for counteracting neglect and abuse, 71% of children now being placed from local authority care (Department for Education and Skills 2003).

However, little is known either of its efﬁcacy or of its acceptability to adoptive parents.

This paper provides a proﬁle of the task of adopting older children.

The data form part of a larger study (Selwyn et al.
2006a) funded by the Department of Health to study costs and outcomes of adoption of older children from the care system.

Method A complete sample of 130 children originating from 90 fami- lies was studied.

Adoption was recommended when they were aged between 3 and 11 years (mean 5.7 years), during 1991– 1996.

All were assessed by a specialized adoption medical service.

The children were traced between 6 and 11 years after the recommendation and 80% of adoptive parents were interviewed.
Two researchers collected information on pre-coded sched- ules from social work ﬁles about parental risk factors (particu- larly childhood neglect), children’s home circumstances (e.g.

parental drug misuse, mental illness, domestic violence, neglect and abuse), experiences in care, contact with their birth family and use of professional services (inter-rater reliability was 0.97).

At follow-up, children’s adoptive or foster parents were inter- viewed.
An ‘investigator-based’ approach was used (Brown 1983; Quinton & Rutter 1988).

This allows ‘qualitative’ ques- tioning but ‘quantitative’ treatment of data.

It provides system- atic and detailed coverage of topics and numerically analysable data while providing extensive case material.

The interviewers met regularly to compare codings and interviews were tran- scribed.
Parents completed two standardized measures – the Strengths and Difﬁculties Questionnaire (SDQ; Goodman 1997, 1999) measuring emotional and behavioural adjustment, and the Parent–Child Communication Scale (Skinner et al.

1983) assessing the quality of communication and emotional exchange.

Children’s teachers also completed the SDQ.


Ethical approval was obtained from the Department of Health, the Association of Directors of Social Services and the School for Policy Studies (University of Bristol) ethics committee.

Results Sixty-three per cent of birth mothers and 57% of the 60 iden- tiﬁed birth fathers had been in care themselves.

Seventy-ﬁve per cent of mothers and 48% of fathers reported abuse.

Only three parents, who experienced later life-changing tragedy, reported secure childhoods.
Eighty-six per cent had violent adult rela- tionships.

Learning difﬁculties, mental health problems, sub- stance abuse and criminality were prominent.

Sixty-seven per cent of families were already known to social services when the child was born and 32% had had a previous child removed.

Despite the children’s ages when adoption was recommended, 79% had been referred to social services before their ﬁrst birth- day and 63% antenatally.
Multi-agency support often appeared to have been poorly targeted and evaluated, 68% remaining at home for 1–8 years in worsening or unchanging circumstances before removal to care.

Factors identiﬁed in retrospect as contributing to delay included limited analysis of available information, requests by courts for additional expert opinion and birth families’ moves around the country.

Action to remove children often started when neglect and abuse became more visible when they started nursery.
Although adoption was recommended for all 130 children, only 96 joined an adoptive family.

Eighty were legally adopted and with their adopters at follow-up.

The reasons why some were not adopted are complex and are reported elsewhere (Selwyn et al.

2006b).

Twenty-six per cent remained in long- term foster care or other permanent placements, while 12% achieved no stable home.

Some had had ﬁve or more placement breakdowns.

Most of these children were in specialist residential care at follow-up.
The 80 adopted children were placed into 66 families: 58 (73%) were adopted by ‘strangers’, 17 (21%) by their foster carers and ﬁve (6%) by relatives.

Twenty-eight per cent of ‘stranger adopters’ already had children.

Slightly older children with more complex histories and more special needs were gen- erally placed singly into these families.

Childless stranger adopt- ers tended to be younger and to adopt sibling groups of younger children with fewer special needs.
Sixty-seven per cent adopted because of infertility, while others did so for altruistic or reli- gious reasons.

Ninety-eight per cent (127) of the children had experienced abuse and neglect.
Of the 20 children who had been abandoned © 2009 The Authors Journal compilation © 2009 Blackwell Publishing Ltd, Child: care, health and development, 35, 4, 561–567 100 80 60 40 20 0 15 6 51 45 34 % of children Non-infant adoption from care 563 Physical disability 75 82 Physical health conditions Sex ualized behav iour Dev elopmental delay Poor concentration Attachment problems Emotional and behav ioural difficulties Figure 1.
Percentage of children with special needs at the time of the adoption best interest decision.

or rejected, 15 were boys.

When adoption was recommended, almost all had identiﬁed difﬁculties, predominantly with emo- tional, behavioural and developmental issues (Fig.

1).

However, only 7% had received psychological intervention, often because of difﬁculty in obtaining services before stable placements were achieved.

Few had received help with speech and language difﬁculties.
Matching of children with adopters, introductions and place- ment brought complex issues.

Desperation to parent reduced objectivity about possible difﬁculties and inﬂated conﬁdence in resolving them.

Most adopters had attended training courses, but some had thought that potential difﬁculties were being exaggerated.

Perceived competition for children led to fear that turning down the child offered could result in a long wait for another opportunity.
Difﬁculty in assimilating information and understanding its implications was compounded by the short period of introduc- tions.

This was experienced by adopters as a busy and stressful time bringing mixed and often confusing emotions of joy and apprehension.

Some admitted that excitement blinkered them to possible difﬁculties, a sense of reality gradually emerging.

Over half of the hitherto childless couples progressed, typically over about 8 weeks, to parenting more than one child.
Advice given to adoptive mothers to stop or reduce work added to the magnitude of their lifestyle change.

Most stopped almost all personal leisure activities.

Most adopters anticipated immediately loving the child, but the reality was more complex.

They described distress, anger and disappointment when feelings were not as anticipated.

Most described a short ‘honeymoon period’ before challenging behaviour emerged – some describing major difﬁculties.
Many worried about the implications of discussing concerns with the children’s social worker.

Adoptive placement affected all relationships.

A quarter of hitherto childless adopters felt that their marital relationship was strengthened.

However, more than half described difﬁcul- ties, particularly when children related selectively to one parent.

The reaction of children already in the household was critical to integration of a new child.
Almost a ﬁfth were delighted with their new sibling while a similar number disliked them or felt pushed out.

The remainder had mixed or neutral feelings.

They found it particularly difﬁcult if the child had learning difﬁcul- ties, principally because they felt that this adversely affected their friendships and school life.

Extended family and friends often provided essential support, although some grandparents were less supportive than had been anticipated.
Many adopters described anxiety and depression, 20% receiving medication.

Eighty-eight per cent of ‘stranger’ adopters found the ﬁrst year of adoptive placement very challenging and sought help, as did 61% of foster carer adopters although the child had already been living with them, sometimes because children’s realization that they would not return home led to deterioration in their behaviour.

Contact arrangements added to the complexity of the task.
Thirty-one per cent of children had plans for annual or bian- nual face-to-face contact with birth parents, 90% with siblings placed elsewhere and 34% with grandparents or other relatives.

Others exchanged letters.

Despite the difﬁculties, 74% of adopters said that they felt close to their children after a year, 45% describing the relation- ship as ‘as close as it could possibly be’.
Those who did not feel close particularly cited learning difﬁculties, conduct problems, emotional ‘phoniness’ and rejecting behaviour as affecting their feelings.

At follow-up, the children were aged between 8 and 19 years – many therefore being in adolescence.

Twenty-eight per cent of © 2009 The Authors Journal compilation © 2009 Blackwell Publishing Ltd, Child: care, health and development, 35, 4, 561–567 564 C.A.
Rees and J. Selwyn adopters reported a happy and rewarding experience with few problems, while 62% described sometimes considerable difﬁ- culties, tempered however by the rewards of progress.

However, 10% struggled to identify any rewards at all.

Seventy-three per cent of children were described as close to their adoptive parents.

A further 11% conﬁded feelings despite limited per- ceived closeness.
The strongest predictors of continuing difﬁculties were conduct problems and over-activity, identiﬁed by the medical adviser during pre-adoption assessment.

Particularly notewor- thy at follow-up was the high prevalence, despite a secure home, of hyperactivity, restlessness and inattention (deter- mined by adopters’ and teachers’ SDQ scores and researchers’ ratings of interview content), correlating with conduct disor- der (P < 0.000).

This in turn correlated with attachment dif- ﬁculty (P < 0.0002).
Adopters reporting extreme difﬁculty described never having got anything back.

However, their commitment gave the children a stable home and continuity of family relationships.

At follow-up, 67% of the adopted children had received extra educational support and 30% speech therapy.

Fifty-ﬁve per cent had been referred to child and adolescent mental health services (CAMHS) and 59% to other health professionals.

Half had a deﬁned physical health condition (e.g.

asthma), 11% a physical disability (e.g.


cerebral palsy) and 65% developmental delay.

Fourteen per cent had three or more diagnostic labels, many of which had emerged following placement.

Uncertain prognosis contributed to families’ stress.

Most service use related to emotional and behavioural prob- lems, including attachment difﬁculties, sexualized behaviour, enuresis and encopresis.

However, adopters expressed mixed views of the usefulness of interventions.
Only 31% of those referred received more than an initial assessment.

Some adopt- ers rejected the service offered as they felt blamed for difﬁcul- ties.

Some felt that professionals did not understand the complexities of adoption.

Thresholds for service provision sometimes seemed too high.

Difﬁculties in accessing services were compounded by uncertainty about who was responsible for co-ordinating care following moves.
Some complained that services were only available at crisis point and that too little was delivered too late.

Discussion Balancing risks and beneﬁts in safeguarding children requires awareness of the limitations of substitute care.

Removal of chil- dren from their parental homes for their protection presup- poses that the alternative will be better.

Poor outcomes for children in care challenge this assumption as far as foster care is concerned.
This study provides a proﬁle of the task of adopting children beyond infancy from local authority care.

In doing so, it contributes to understanding of the viability and efﬁcacy of adoption as a therapeutic option for traumatized children, and of its implications for adoptive families.

It is particularly infor- mative as it follows a complete cohort of children assessed by a local authority adoption service, all of whom were assessed by a specialized adoption medical service.
Identiﬁcation of the chil- dren at the point of recommending adoption, rather than at placement or legal adoption, enables limitations of this route to be demonstrated.

As adoption was recommended for these children, measures to reduce delay have led to a fall in the mean age of adoption from care to 4.5 years.

Children placed when younger may have experienced less adversity.

These ﬁndings may therefore represent the more challenging end of the current adoption spectrum.
The study design means that at follow-up some children had not reached adolescence.

This is frequently a particularly difﬁ- cult time for adopted young people.

Past neglect and abuse contribute to the complexities of establishing identity, while attachment difﬁculty paradoxically affects the course and times- cale of developing independence.

Some adoptees separate from their families in adolescence, returning in early adult life.
Follow-up only until adolescence may therefore give an unduly pessimistic view of long-term outcomes, counterbalanced by the fact that some were still pre-pubertal.

Follow-up into adult- hood would give a more complete picture.

The study draws attention to the need for professional skills in deﬁning inadequate emotional care to match those in deﬁn- ing physical and sexual abuse.
Achieving this requires intensi- ﬁcation of efforts to bridge the professional divide between paediatric and CAMHS practice, and recognition of the risks to children of this divide, particularly if services are under- resourced.

The current public and professional spotlight on the evidence base for physical and sexual abuse needs to be broadened to encompass family relationships with equal stringency.
Waiting for ‘evidence’ of inadequate parenting appears to have cost many of these children the opportunity of a long-term stable home.

It is of particular concern that almost two-thirds of families were already known to social services antenatally, yet the children went on to be abused and neglected, and, following removal, many never found a permanent home.

The cost to wider society, as well as to the individuals themselves, is likely to be high.
This highlights the risks of delay, and indicates the shortcomings of current prediction and assessment of parent- © 2009 The Authors Journal compilation © 2009 Blackwell Publishing Ltd, Child: care, health and development, 35, 4, 561–567 ing capacity.

While British childcare practice is underpinned by the assumption that children should where possible remain with their birth families, this is safe only if assessment of parent- ing is effective.
The study suggests that the importance of parental child- hood trauma in predicting parenting difﬁculty is currently underestimated.

Paramouncy of children’s needs means that a shift of emphasis is needed from demonstrating inadequate parenting to identifying the resilience which may allow adequate parenting despite risk factors.

Because of the risks of delay, the probability, not the possibility of achieving adequate parenting should determine practice.
The high proportion of parents who were themselves in care indicates the shortcom- ings of corporate parenting.

It suggests that health promotion priorities for young people in care should encompass parent- ing as well as its prevention.

Breaking intergenerational cycles of poor attachment requires education about parent–child relationships, starting long before the immediate need arises.
The high prevalence of domestic violence in the children’s birth families indicates the need to improve services for antici- pating and managing temper difﬁculties, and the public health importance of doing so.

Even stable adoption allows considerable residual scars.

Adverse early attachment is likely to underpin many of the difﬁculties described (Rees 2005).
However, assessment of this crucial area is limited by a lack of standardized assessment tools, and of consensus regarding deﬁnitions and terminology (Hughes 2003).

Early attachment experience has been shown to affect regulation of involuntary stress responses through HPA axis programming (Schore 2005).

This has lifelong implications for emotional and behavioural regulation and mental health (Heim et al.

1997).
1997).

Several studies show the relationship of sali- vary cortisol (reﬂecting HPA function) to behavioural difﬁcul- ties attention deﬁcit hyperactivity disorder, aggression and conduct disorder (King et al.

1998; Shoal et al.

2003; van Bokhoven et al.

2005).

The nature of difﬁculties per- sisting despite otherwise successful adoption suggests the rel- evance of dysfunctional HPA axis setting.
This indicates that safeguarding attachment should be a key consideration in child protection decisions and highlights the need for research in this area.

including The Adverse Child Experiences Studies demonstrate that adult emotional and physical ill-health, including major causes of mortality, relate strongly to childhood abuse and neglect (Felitti 2002).
This study demonstrates professional responsi- bilities to those for whom adoption offers the opportunity of recovery, and highlights the importance of timely, well- informed, well-co-ordinated support.

Simply providing chil- Non-infant adoption from care 565 dren with new parents does not remedy past deprivation.

It is an active and long-term task requiring a high level of professional commitment.
Decisions to remove children from their family homes for their protection should be seen as the start of a major professional task and resourced accordingly.

Particular vulner- ability during adolescence indicates the need for effective tran- sitional care.

While the needs of children requiring adoption have changed radically in recent years, those of adopters have not.

The major- ity still elect to adopt in response to fertility problems.
The transition from the hope for a normal healthy infant to taking on the legacy of abuse is considerable.

While most adopters in this study found the experience rewarding and became close to their child, it is of concern that for a substantial minority this was not so.

This highlights the importance of learning from follow-up, and of investing in development and evaluation of therapeutic services to counteract the legacy of abuse.

Adoption is a choice which profoundly affects the whole family.
Parents’ need for full information requires paediatricians to predict to an otherwise unfamiliar extent.

While the priority of adoption practice is identiﬁcation of parents for children, not the converse, adopters need guidance in making informed deci- sions.

The study describes parents’ difﬁculties in achieving objectivity.

The study gives insight into the complex effects of chil- dren’s learning difﬁculties for adoptive families.

High intelli- gence conveys resilience (Fonagy et al.

1994).
1994).

The identiﬁed effect of learning difﬁculties on parental attachment and sibling acceptance suggests that the protective effect of intelli- gence is not simply related to children’s ability to understand their circumstances, and indicates areas where support may be helpful.

for implications The study has service structure and funding.

Families have a right to assessment of need for post- adoption support (Department of Health 2003).
However, therapeutic services to meet identiﬁed needs are still develop- ing, and expectations may be unmet.

While adoptive families have access to mainstream services, they also have more spe- ciﬁc needs.

Service development must be supported by research.

For example, although attachment difﬁculties are common, interventions remain largely unevaluated.

The fun- damental importance of attachment needs to be reﬂected in clinical research.
Work in safeguarding children needs to be informed by awareness of the viability and implications of alternative care, and tempered by recognition of the professional responsibilities which follow from decisions to remove children from their family homes (Rees 2006).

The extent of the continuing legacy © 2009 The Authors Journal compilation © 2009 Blackwell Publishing Ltd, Child: care, health and development, 35, 4, 561–567 566 C.A.
Rees and J. Selwyn of neglect and abuse, even when adoption offers stability, dem- onstrates the importance of focusing clinical and research atten- tion on this area.

However, service development and research face challenges in being at the interface of very different profes- sional practices and beliefs.

A climate of ﬁnancial constraint and evidence-based practice leave services vulnerable when key out- comes are a generation or more away, not readily quantiﬁed, and yet to be evaluated.
Independent funding of agencies con- tributes to vulnerability when anticipated outcomes may fall within another budget.

However, the cost of failure to achieve adequate childhood attachment, the essential task of child pro- tection work and substitute care makes this an issue of major public health importance.

Key messages The efﬁcacy of alternative parenting in facilitating recov- ery from neglect and abuse should be a key consideration in child protection decisions.
The risk to long-term achievement of a stable adoptive home of late removal from neglectful care should inﬂu- ence child protection practice.

 Parental childhood deprivation, identiﬁable antenatally, frequently underlies unresolved parenting problems sufﬁ- cient to lead to adoption.

 Adoption can give abused children the stability necessary to recover, and is experienced as rewarding, although chal- lenging, by most adopters.
Paediatricians have long-term responsibilities in support- ing adoptive families, and in co-ordinating services to address the complex legacy of deprivation and abuse.

 Adoption may not correct problems associated with dysfunctional setting of hypothalamus-pituitary-adrenal function in relation to disturbed early attachment.

Funding: The Department of Health.

Competing interests: None.


Acknowledgements W. Sturgess contributed to data collection and analysis, D. Quinton contributed to data analysis and C. Baxter contributed to economic analysis.

References Barn, R., Andrew, L. & Mantovani, N. (2005) Life after Care: A Study of the Experiences of Young People from Different Ethnic Groups.

Joseph Rowntree Foundation, York, UK.


van Bokhoven, I., Van Goozen, S. H., van Engeland, H., Schaal, B., Arseneault, L., Seguin, J. R., Nagin, D. S., Vitaro, F. & Tremblay, R. E. (2005) Salivary cortisol and aggression in a population-based longitudinal study of adolescent males.

Journal of Neural Transmission, 112, 1083–1096.

Brown, G. (1983) Accounts, meaning and causality.

In: Accounts and Action (ed.

G. Gilbert & P. Abell), pp.

35–68.

Gower, Aldershot, UK.


Department for Education and Skills (2003) Children Adopted from Care in England 2002–2003.

Department for Education and Skills, London, UK.

Department of Health (2003) Adoption Support Agency Regulations.

HMSO, London, UK.

Felitti, V. J.

(2002) The relation between adverse childhood experiences and adult health: turning gold into lead.

Zeitschrift für Psychosomatische Medizin und Psychotherapie 48, 359–369.

Fonagy, P., Steele, M., Steele, H., Higgitt, A.


& Target, M. (1994) The Emanuel Miller Memorial Lecture 1992.

The theory and practice of resilience.

Journal of Child Psychology and Psychiatry, 35, 231–257.

Goodman, R. (1997) The Strengths and Difﬁculties Questionnaire: a research note.

Journal of Child Psychology and Psychiatry, 38, 581–586.

Goodman, R. (1999) The extended version of the Strengths and Difﬁculties Questionnaire as a guide to child psychiatric caseness and consequent burden.
Journal of Child Psychology and Psychiatry, 40, 791–801.

Heim, C., Owens, M. J., Plotsky, P. M. & Nemeroff, C. B.

(1997) Persistent changes in corticotropin-releasing factor systems due to early life stress: relationship to the pathophysiology of major depression and post-traumatic stress disorder.

Psychopharmacoloy Bulletin, 33, 185–192.

Hughes, D. A.

(2003) Psychological interventions for the spectrum of attachment disorders and intrafamilial trauma.

Attachment and Human Development, 5, 271–277.


King, J.

A., Barkley, R. A.

& Barrett, S. (1998) Attention-deﬁcit hyperactivity disorder and the stress response.

Biological Psychiatry, 44, 72–74.

Quinton, D. & Rutter, M. (1988) Parenting Breakdown: The Making and Breaking of Intergenerational Links.

Avebury Press, Aldershot, UK.

Rees, C. A.

(2005) Thinking about children’s attachments.

Archives of Disease in Childhood, 90, 1058–1065.

Rees, C. A.

(2006) The care of looked-after children.


Current Paediatrics, 16, 83–90.

Schore, A. N. (2005) Back to basics.

Attachment, affect regulation, and the developing right brain.

Linking developmental © 2009 The Authors Journal compilation © 2009 Blackwell Publishing Ltd, Child: care, health and development, 35, 4, 561–567 Non-infant adoption from care 567 neuroscience to paediatrics.

Paediatrics in Review, 26, 204–217.


Selwyn, J., Sturgess, W., Quinton, D. & Baxter, C. (2006a) Costs and Outcomes of Non-Infant Adoptions.

BAAF, London, UK.

Selwyn, J., Frazer, L. & Quinton, D. (2006b) Paved with good intentions: the pathway to adoption and the costs of delay.

British Journal of Social Work, 36, 561–576.

Shoal, G. D., Giancola, P. R. & Kirillova, G. P. (2003) Salivary cortisol, personality, and aggressive behavior in adolescent boys: a 5-year longitudinal study.
Journal of the American Academy of Child and Adolescent Psychiatry, 42, 1101–1107.

Skinner, H., Steinhauser, D. & Santa-Barbara, J.

(1983) The family assessment measure.

Canadian Journal of Community Mental Health, 2, 91–105.

© 2009 The Authors Journal compilation © 2009 Blackwell Publishing Ltd, Child: care, health and development, 35, 4, 561–567