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To review the scale, symptomatology and determinants of mental health problems of children in alternate care, and to consider the need for specialized knowledge and clinical competence for assessment and treatment of these problems.The scale of mental health problems among children in care is exceptional for a nonclinical population, approaching that of clinic-referred children. Children in residential care have more mental health problems than those in family-type foster care, while those in kinship care have fewer problems. Children manifest complex psychopathology, characterized by attachment difficulties, relationship insecurity, sexual behaviour, trauma-related anxiety, conduct problems, defiance, inattention/hyperactivity, and less common problems such as self-injury and food maintenance behaviours.Children in care have complex symptomatology that is not well represented in present classification systems. There is a need for research into the characteristics and meaning of these complex presentations, and some re-appraisal of present taxonomies. Clinicians should consider these difficulties in their entirety, rather than as discrete disorders. It is recommended that assessment and intervention are provided by clinical teams that have specialist knowledge of children in care, and that use an ecological approach to assessment.