We totally agree with Dr Sekar's point that biological factors make an important aetiological contribution to the development of psychiatric disorder in children. We certainly did not intend to suggest that biological factors are any less important than psychological or social factors. Many childhood disorders are known to have a high level of heritability (Reference Rutter, Moffitt and CaspiRutter et al, 2006). However, we should not forget that both our and previous studies suggest that similar risk factors operate in looked after children as in children living in private households, but that looked after children tend to have been exposed to more of them, sometimes at greater intensity (Reference Stein, Evans and MazumberStein et al, 1996; Reference Ford, Vastanis and MeltzerFord et al, 2007). In our opinion, this includes biological as well as psychological and social factors.
Many studies have shown that parental psychiatric disorder is correlated with childhood psychiatric disorder (Reference RutterRutter, 2002). Although parental psychiatric disorder might increase the chance that children become looked after, this is not inevitable and there are many other reasons why children may enter the care system. In fact, only 6% of the children participating in the survey on which our analysis was based were accommodated primarily as a result of any type of parental illness.
As the survey involved no contact with the biological parents of participants and historical information about children who are looked after is notoriously scarce, we had no way of accurately assessing the mental health of the biological parents. Our paper refers to our frustration at the extremely limited amount of information available to the survey and in clinical practice, and we explicitly state that our analysis cannot be seen as covering all potential risk and resilience factors.
Even if we had access to data on the mental health of the biological parents, an excess of children with psychiatric disorder among parents with psychiatric disorder would not necessarily indicate a biological or genetic basis for this finding. The mean age that children participating in this survey entered the care system was between 7 and 8 years, and we know that mental illness can have an impact on parenting practices. Do the children of parents with mental illness have raised rates of psychiatric difficulties as a result of genetic vulnerability and/or exposure to maladaptive parenting, or perhaps both processes occur at the same time and/or moderate each other? The literature suggests that parenting is an important mediating variable, although other genetic and environmental factors also play a part in the familial aggregation of psychopathology (Reference Ramachandani and SteinRamachandani & Stein, 2003). Cross-sectional surveys are not able to disentangle such complex questions, as data about exposures and outcomes are gathered at the same time. Longitudinal designs would be needed to explore Dr Sekar's theory.
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