Children living in care are more likely to experience mental health difficulties than children with no experience of care. Early intervention is important to ensure children living in care get access to the best evidence-based mental health treatment before reaching crisis point. This blog shares new findings that suggest current UK practice may not be sufficient for identifying children in care struggling with their mental health – and we suggest what might help improve things.
Background
More than 100,000 children live under local authority care in the UK (Department for Education, 2024a, 2024b; Senedd Research, Welsh Government, 2024; Northern Ireland Executive, 2025; Scottish Government, 2025). Children in care may live with foster carers, in residential children’s homes or other settings when it is decided they can no longer live safely with their birth family. Most children come to live in care after experiencing abuse or neglect, but many have also had other difficult experiences, such as witnessing domestic violence, parental substance addiction or parental mental illness (Department for Education, 2024a; Hiller et al., 2021).
We know that children living in care are more likely to experience mental health difficulties – both for common problems like anxiety or depression and for trauma-related mental health difficulties like post-traumatic stress disorder (PTSD) (Ford et al., 2007). Poor mental health outcomes are not inevitable for children living in care. Early identification of mental health difficulties is important to ensure children living in care get the right support.
In England, the government requires local authorities to collect a caregiver-completed questionnaire on the mental health of children they care for once each year (Department for Education, 2024b). This questionnaire, called the Strengths and Difficulties Questionnaire (SDQ), is widely used with children across the world (not just children living in care) to identify common mental health difficulties relating to emotions, peer relationships, behaviour and hyperactivity. A carer’s score on the SDQ is used to make decisions about the mental health support children living in care receive. However, there are questions about whether this caregiver-completed questionnaire is really enough to identify children who may be struggling with their mental health. Other nations in the UK do not have any statutory guidance about collecting mental health information about children living in care.
Early identification of mental health difficulties is important to ensure children living in care get the right support
Our study
In the Child Trauma and Recovery Group at University College London (UCL), we have worked with hundreds of children and young people living in care. Many of these young people have experienced struggles with their mental health, and these haven’t always been picked up early enough, too often leading young people to reach crisis point.
In this study, we wanted to understand whether the current government policy in England of using the carer-completed SDQ is enough to spot common and trauma-related mental health symptoms in children in care. We collected questionnaires from 342 children and their carers living across England and Wales in 13 different local authority areas. We collected carer-completed SDQs as well as child-completed disorder-specific questionnaires (called the RCADS-25 and the CRIES-8) to pick up symptoms of anxiety, depression and PTSD. Using this data, we aimed to identify how many children who reported clinically concerning symptoms of anxiety, depression or PTSD were missed by the carer-completed SDQ.
This study aimed to identify how many children who reported clinically concerning symptoms of anxiety, depression or PTSD were missed by the carer-completed SDQ
Findings
We found very high rates of mental health difficulties amongst the children in care who took part in this research. More than 6 out of 10 children scored above clinical cut-offs for at least one questionnaire they completed about anxiety, depression or PTSD symptoms.
The most important thing we learnt was that lots of children who self-report as having high levels of anxiety, depression or PTSD symptoms are not picked up on SDQs completed by their carers. In our study, 261 children scored above clinical cut-offs for PTSD, but only about half of these children scored above cut-offs on the carer-completed SDQ. For anxiety and depression, about a quarter of children with high levels of symptoms were missed by the carer-completed SDQ.
Going forward
These findings are worrying as the carer-completed SDQ is an important way for local authorities to identify which children under their care are struggling with their mental health, and to decide who to refer for further support. This fits with other research which has raised questions about whether the SDQ misses certain mental health profiles for children living in care (Frogley et al., 2019; Tarren-Sweeney et al., 2019; Wright et al., 2019).
This does not mean that local authorities should stop using the SDQ, as it can be a great tool for picking up common mental health problems in children, but it might not be enough by itself. Indeed, the SDQ is not designed as a one-stop shop for assessing all mental health difficulties and the tool developers always recommend collecting SDQs from multiple people (e.g., carer, child and teacher) (Goodman, 1997; Goodman et al., 2004).
Our findings suggest that we should give children in care a voice in sharing their mental health symptoms, and we should also consider using questionnaires designed to pick up specific difficulties more common among children in care (e.g., PTSD).
Our findings suggest that we should give children in care a voice in sharing their experiences of mental health symptoms
Conclusions
To summarise, current statutory practice in England is likely missing many children living in care who are experiencing high levels of anxiety, depression, or PTSD symptoms. The reliance only on the carer-completed SDQ, without including disorder-specific tools or child-completed questionnaires, limits the number of children struggling with their mental health who are identified and thus given access to the support they need. While there are pockets of good practice across the UK in identifying children in care who need mental health support early, these findings suggest a need for wider policy change.
Many children reporting concerning levels of anxiety, depression or PTSD symptoms were not picked up by current screening
Conflicts of interest. The authors of the blog and the original paper have no conflicts of interest to declare.
Links
Original article: Sprecher, E. A., Shelton, K., Holmes, L., Carter, B., Robinson, C., Javed, M., … & Hiller, R. M. (2025). Sufficiency of current practice: How well does the Strengths and Difficulties Questionnaire detect clinically elevated posttraumatic stress, anxiety, and depression symptoms in children in care? JCPP Advances, e70058. https://doi.org/10.1002/jcv2.70058
Department for Education. (2024a). Children looked after in England including adoptions 2023 to 2024.
Department for Education. (2024b). Children looked-after by local authorities in England: Guide to the SSDA903 collection 1 April 2024 to 31 March 2024 – Version 1.3.
Ford, T., Vostanis, P., Meltzer, H., & Goodman, R. (2007). Psychiatric disorder among British children looked after by local authorities: Comparison with children living in private households. British Journal of Psychiatry, 190(4), 319–325. https://doi.org/10.1192/bjp.bp.106.025023
Frogley, C., John, M., Denton, R., & Querstret, D. (2019). ‘They don’t meet the stereotypes in the boxes…’: Foster carers’ and clinicians’ views on the utility of psychometric tools in the mental health assessment of looked after children. Adoption and Fostering, 43(2), 119–136. https://doi.org/10.1177/0308575919841752
Goodman, R. (1997). The Strengths and Difficulties Questionnaire: A research note. Journal of Child Psychology and Psychiatry, 38(5), 581–586. https://doi.org/10.1111/j.1469-7610.1997.tb01545.x
Hiller, R. M., Meiser-Stedman, R., Elliott, E., Banting, R., & Halligan, S. L. (2021). A longitudinal study of cognitive predictors of (complex) post-traumatic stress in young people in out-of-home care. Journal of Child Psychology and Psychiatry, 62(1), 48–57. https://doi.org/10.1111/jcpp.13232
Goodman, R., Ford, T., Corbin, T., & Meltzer, H. (2004). Using the Strengths and Difficulties Questionnaire (SDQ) multi-informant algorithm to screen looked-after children for psychiatric disorders. European Child & Adolescent Psychiatry, 13(S2), II25–II31. https://doi.org/10.1007/s00787-004-2005-3
Tarren-Sweeney, M., Goemans, A., Hahne, A. S., & Gieve, M. (2019). Mental health screening for children in care using the Strengths and Difficulties Questionnaire and the Brief Assessment Checklists: Guidance from three national studies. Developmental Child Welfare, 1(2), 177–196. https://doi.org/10.1177/2516103219829756
Northern Ireland Executive. (2025). Children’s Social Care Statistics for Northern Ireland 2024/25. Northern Ireland Executive.
Scottish Government. (2025). Children’s Social Work Statistics 2023-24 Looked After Children. Scottish Government.
Senedd Research, Welsh Parliament. (2024). Care experienced children: Statistical briefing 2024. Senedd Research, Welsh Parliament.
Wright, H., Wellsted, D., Gratton, J., Besser, S. J., & Midgley, N. (2019). Use of the Strengths and Difficulties Questionnaire to identify treatment needs in looked-after children referred to CAMHS. Developmental Child Welfare, 1(2), 159–176. https://doi.org/10.1177/2516103218817555
About the author
Dr Eva A Sprecher is a Research Fellow at the Child Trauma and Recovery Group (led by Professor Rachel Hiller) at UCL and Anna Freud. Her research focuses on understanding how we can better support the mental health of young people living in care. She has worked on several large research studies working to improve evidence-based mental health support for young people living in care including the ReThink Programme (MRC UKRI-funded), MyVoice (NIHR-funded) and Reflective Fostering (NIHR-funded). She is a qualified secondary school teacher and trustee of Lighthouse Pedagogy Trust, an innovator in the children’s residential care sector.
