Young people’s perspectives of foster
placement instability: A grounded theory
approach
Ruth Hunter
Submitted for the Degree of
Doctor of Psychology
(Clinical Psychology)
School of Psychology
Faculty of Arts and Human Sciences
University of Surrey
Guildford, Surrey
United Kingdom
July 2015
1
Abstract
This qualitative grounded theory study aimed to explore experiences of placement moves for
young people in foster care, an area neglected in previous studies. For young people these
moves were distressing experiences of loss and uncertainty that they frequently lacked
support to manage. Consequently the young people felt the need to be self-sufficient for their
emotional needs. However this self-sufficiency often increased instability and distress as they
struggled to influence others or withdrew in self-protection. Despite this, the young people
displayed resilience and were hopeful for a better life after care.
2
Acknowledgements
To all those who have played a role in my path up to this point, thank you. This achievement
is partly yours. Unsurprisingly this encompasses a large number of people in my personal
and professional life. But I would particularly like to thank God, my parents, my family and
those closest to me. Thank you sounds so simple but I hope you realise just how grateful I
am.
3
Contents
MRP Empirical Paper
5
MRP Empirical Paper Appendices
64
MRP Proposal
104
MRP Literature Review
124
Brief Overview of Clinical Experience
192
Table of all Academic Assessments
195
4
MRP Empirical Paper
Young people’s perspectives of foster placement instability: A
grounded theory approach
By
Ruth Joanne Hunter
Submitted in partial fulfilment of the degree of Doctor of Psychology (Clinical
Psychology)
School of Psychology
Faculty of Arts and Human Sciences
University of Surrey
May 2015
5
Abstract
This qualitative grounded theory study aimed to explore experiences of placement moves for
young people in foster care, an area neglected in previous studies. For young people these
moves were distressing experiences of loss and uncertainty that they frequently lacked
support to manage. Consequently the young people felt the need to be self-sufficient for their
emotional needs. However this self-sufficiency often increased instability and distress as they
struggled to influence others or withdrew in self-protection. Despite this, the young people
displayed resilience and were hopeful for a better life after care.
Introduction
Globally, young people in care are one of the most at-risk groups for a range of negative
outcomes both in childhood and later life (Minty, 1999; Barber & Delfabbro, 2003; Tapsfield
& Collier, 2005; Ford, Vostanis, Meltzer & Goodman, 2007) as a consequence of early-life
experiences (Newton, Litrownik, & Landsverk, 2000; Rubin, O’Reilly, Luan, & Localio,
2007).
Placement instability, including unplanned changes, is a major predictor of negative
outcomes from care (Rostill-Brookes, Larkin, Toms, & Churchman, 2011). The literature
6
refers to such changes using terms such as ‘breakdowns’, ‘moves’ and ‘disruptions’ (Unrau,
2007). Research indicates that multiple placements are associated with an increased risk of
emotional, behavioural and mental health problems and also future placement breakdowns
(Rubin, Alessandrini, Feudtner, Mandell, Localio, & Hadley, 2007; Strijker, Knorth, & KnotDickscheit, 2008; Stott, 2011). An understanding of what influences placement stability is
key in developing effective interventions to address this and minimise negative outcomes.
Understanding of Placement Stability
The views of all stakeholders need to be included in a comprehensive understanding of
placement breakdowns and efforts to reduce these (Wilson, Sinclair & Gibbs, 2000). There is
an acknowledged lack of sufficient perspectives of young people, foster carers and social
workers, as well as birth families and other professionals (Rostill-Brookes et al., 2011; Khoo
& Skoog, 2013). The majority of research into placement instability has used quantitative
methods (Unrau, 2007; Rock, Michelson, Thomson & Day, 2013), highlighting risk factors
such as child problem behaviours, longer time in care; older age of child; multiple social
workers; and separation from siblings (Koh, Rollock, Cross & Emblen-Manning, 2014; Rock
et al., 2013). These quantitative approaches have frequently relied on psychometric or
standardised measures, often failing to reliably represent the viewpoints of children or
professionals (Unrau, 2007) and the broader systemic inter-relationships and interactions that
may impact stability. Consequently the complexity of the psychological wellbeing of the
7
young person has also been overlooked.
Perspectives of those involved in foster care
When perspectives of key stakeholders have been considered, the use of labels for behaviour
such as 'difficult' or 'problematic' highlights a dominant adult perspective. This perspective
has likely been influenced by the need to retain foster carers through understanding and
supporting them (Sellick, 2006). This focus is reinforced by research showing that the
distress and sense of failure from placement breakdowns reported by foster carers can lead to
reluctance to offer future placements (Nutt, 2006). Unfortunately, this focus on foster carers
has resulted in a lack of appreciation of the child's voice and child and foster carers'
interpersonal dynamics.
Some attempts to obtain the perspectives of young people have occurred, but the success of
these has been limited by the approaches used. Some researchers have attempted an indirect
approach through seeking foster carers’ and social workers’ perspectives on the young
people’s feelings and experiences (Unrau, 2007). Sommer, Pramling and Hundeide (2010)
highlighted that gaining valid insight into the experiences of young people relies on going
beyond a 'child perspective' to also include a 'child's perspective'. A ‘child perspective’ is the
adult’s perception on children’s actions and experiences and perceptions. In contrast a ‘child’s
perspective’ relates to the child’s view on their actions, experiences and perceptions based on
8
what they view as important.
Obtaining ‘a child’s perspective’
Despite acknowledged difficulties in obtaining young people's perspectives on care and more
specifically placement stability (Gilbertson & Barber, 2002), an increasing number of studies
have attempted to address this gap of knowledge from the 'child's perspective'. However,
these have often focussed on young people's perspectives of what leads to placement
breakdowns and the impact of the breakdown, neglecting the process. For example, Hyde and
Kammerer (2009) found that adolescents in care reported mis-matches between themselves
and foster carers, leading to placement breakdowns. An earlier study by Butler and Charles
(1999) found young people reported difficulties forming relationships with new carers
following placement changes. This gap in understanding the process has begun to be
acknowledged and explored; Unrau, Seita and Putney (2008) found that foster alumni
remembered breakdowns as significant losses that continued to impact upon relationship
success. However, this study included alumni who had left care up to 5 decades previously,
whose experiences likely differ from those going through care services today. It is also likely
that their perceptions will have changed over time. Another study into the process of moves
highlighted that young people (9-15 years) wished for the placement process to be more
inclusive and transparent in order to help them prepare for transitions, both emotionally and
practically (Rostill-Brookes et al., 2011).
9
Despite this progress, these studies remain at the individual descriptive level, failing to
develop a theoretical understanding of the process and impact of placement moves for young
people. Research needs to go beyond simply obtaining the ‘child’s perspective’ to responding
meaningfully to this: Building a coherent understanding of the experiences and perspectives
of young people, grounded in theory to inform a more comprehensive understanding of
placement instability. This can then inform more effective evidence-based practises to reduce
the negative impact of placement instability and improve the well-being of fostered young
people. This study therefore set out to address this gap and ascertain what are young people’s
perspectives of the process and impact of foster placement moves?
Approach
Glaser and Strauss’s (1967) Grounded Theory approach was adopted due to the suitability of
this approach for the broad research question as Grounded Theory is designed to explore
phenomena of which little is known. Furthermore, the inductive approach of Grounded
Theory facilitates the 'discovery' of processes that unfold and give meaning to social
interaction, going beyond merely descriptive accounts of phenomena (Charmaz, 2006).
Stance of the researcher
Given the approach adopted, an avoidance of a priori assumptions was supported through a
10
non-theoretical stance adopted at the outset of the research. The gap in the area of research
was identified but an exploration of potential applicable theories through a detailed
exploration of the literature was avoided. The aim was to avoid the development of
assumptions and preconceived theories that could increase bias in the exploration of the data
and evolution of the consequent theory. Consequently, the research question was broad. 1
Aim
This study aimed to explore the process and impact of placement moves from the perspective
of young people in foster care to develop a preliminary foundation of understanding
regarding the psychological processes and behaviour related to these perspectives. This work
will also aim to provide an early platform for other researchers to further develop a coherent
and theoretically-based account of these phenomena.
Method
The limited knowledge around young people’s perspectives of placement moves determined a
qualitative methodology for the research. It was considered that young people would recount
1
The researcher’s stance and consequent impact on the process are discussed within the method
11
their experiences in relation to the social meaning they had attributed to the events,
influenced by their social context. This social constructionist ontological position adopts a
perspective that reality is influenced by social narratives rather than being fixed, with one
'truth'. This approach enables consideration of how different perspectives may be located in
wider frameworks such as social, familial, cultural and political contexts. Greig, Taylor and
MacKay (2007) described this as particularly valuable for research involving children, to
enable ethical and useful research that is completed 'with' young people rather than being
'about' them. Historically, the voices of young people in foster care have been overlooked or
moderated by adults and legal frameworks. Therefore the value of an approach that enables
young people's voices to retain their own narratives in research is clear.
Data Analysis: Abbreviated Grounded Theory
Grounded Theory does not only aim to collect these experiences but to develop a framework
of understanding. Indeed Glaser and Strauss (1967) designed the methodology to enable new
theories to 'emerge' whilst retaining grounding in the context of the data. Further
development to this approach has acknowledged the impact of the researcher’s role in the
process (Willig, 2008) resulting in Charmaz's (2006) Social Constructionist version of
Grounded Theory. This version acknowledges that the actions and influence of the researcher
led to an interpretation of reality rather than a positivist 'true theory'. Furthermore, this study
aimed to take an inductive approach. It was acknowledged that prior to this study, an
12
appreciation of the wider topic area was gained from scoping the research. It was understood
that such exploration of the literature could influence the researcher's analysis of the data,
alongside the researcher's previous experience and values. Reflections were used to help
identify and minimise this influence.
Previously highlighted difficulties with recruiting young people successfully for studies about
foster care led to an anticipation that recruitment was likely to be difficult in this study
(Gilbertson & Barber, 2000), which would have potential consequences for being able to
saturate the data. Therefore Willig's (2008) Abbreviated Grounded Theory approach was
adopted to enable development of a preliminary framework despite these anticipated
limitations. It ensures analysis goes beyond descriptive accounts, though is more limited in its
ability to broaden and refine the analysis through obtaining further data than a full Grounded
Theory approach2. It was hoped that this project would work as a 'foot-in-the-door' study
(Burger, 1999) developing understanding upon which to develop and direct further research.
Ethics
The University of Surrey Faculty of Arts and Human Sciences Ethics Committee gave a
favourable ethical opinion for the study (See Appendix A). The research was also undertaken
in line with British Psychological Society (BPS) and Health and Care Professions Council
2
See limitation section for discussion of key limitations.
13
(HCPC) guidelines (BPS, 2010; HCPC, 2012).
Inclusion & Exclusion Criteria
Inclusion criteria were broad, as an appropriate starting point for collection of data in a
Grounded Theory study. Some criteria aimed to contain the parameters of exploration, given
the small scale of the study. The exclusion criteria mainly focussed on ethical considerations,
to prevent inappropriate participation in the study from causing distress or harm.
Inclusion Criteria:

Young people who experienced a placement breakdown in foster care after the age of
11 years, to avoid confounding placement transition issues with school transition issues.

Young people 12-21 years of age. This ensured placement breakdowns had been
experienced after age 11 but also gave recent care leavers an opportunity to share their views.

Young people who were in mainstream schooling. Interviewing individuals with
additional needs would have increased the likelihood of engagement difficulties and the risk
of emotional distress that could arise.
Exclusion criteria:

Young people who experienced a placement breakdown only in kinship foster care,
14
due to the different arrangements associated with this form of foster care.

Young people currently receiving mental health support. This was to avoid risking
causing further distress to individuals potentially already distressed.

Young people who had experienced a placement breakdown within the last six months
or were at imminent risk of breakdown, due to the increased distress or difficulties that could
result from discussion of placements.
Sampling strategy and recruitment
Given the historical difficulties in recruiting to studies regarding care experiences, theoretical
sampling of participants was anticipated to be difficult. Due to time and resource constraints,
selective sampling was used, based on the inclusion and exclusion criteria.
A number of strategies were used to recruit participants used. This included: using a social
networking site, Twitter, to advertise to young people directly and to charities and
organisations working with young people; emailing agencies and social service teams
working with young people in and just after leaving care.
In total 48 organisations were emailed. 108 followers on Twitter were obtained, including
organisational and personal accounts. On Twitter, one young person was recruited from seven
expressions of interest. Six further participants were recruited, from a charity and two social
15
care organisations.
As only seven participants were obtained it was not possible to be selective in choosing
which individuals to interview, limiting opportunities to discover further concepts, variations
among concepts and gain further detail in relation to categories. Therefore the findings of this
study remain preliminary and tentative.
The process of recruitment ensured that participants had time to consider their involvement.
Professionals passed the study information to young people, who then contacted the
researcher directly to discuss the study and consider participation. Young people on Twitter
contacted the researcher directly.
Recruitment methods aimed to reduce perceived pressure to participate and facilitate young
people to express their views freely. Consequently, young people were only contacted directly
if they initiated contact or initial agreement to participate had been gained through associated
adults. Accessible information to obtain informed consent; time to decide whether to
participate; explicit opportunities to withdraw and to ask questions were all elements which
supported the non-pressurising agenda.
Careful consideration was given to issues of confidentiality, informed consent and
maintaining participant wellbeing. Participants could withdraw from the study at any time. To
manage wellbeing, the exclusion criteria excluded individuals currently experiencing distress
16
and after the interview, written and verbal debriefs were given (Appendices B & C). Followup contacts to monitor wellbeing were provided, with six choosing to access this from the
support worker or social worker, and one from a direct follow-up contact with the researcher.
Participant characteristics
Seven participants aged 16-21 were included in the study: three females and four males. Six
were White British and one was Romany-Gypsy. Six had left care in the last three years and
one was just about to leave foster care. Demographic details are in Appendix D. One potential
participant felt too nervous about participating and seven young people did not meet the
criteria.
Procedure
Pilot interview and subsequent development of the interview schedule.
To ensure the interview questions appropriately supported the collection of the young
people’s perspectives on the research topic a consultation with a care leaver was undertaken.
This provided confidence that the questions were clear and open and did not reinforce issues
17
of power3 (See Appendix E for the initial interview questions). Feedback resulted in the rephrasing of the questions: The term ‘placement breakdown’ was replaced with ‘unplanned
placement moves’,4 understood as placements ending earlier than agreed in the child’s care
plan (Rostill-Brookes et al., 2011).
The initial interview questions were broad to ensure participants were able to raise the issues
they perceived to be relevant. Additional interviews had more specific questions that arose
from analysis of the data after each interview. (See Data Analysis section for further detail).
(See Appendix F for later interview schedule). For example, some of the early interviews
highlighted a reactive element to the experience of placement moves but later interviews
explored what determined or influenced this reaction. (See Appendix G for example of how
analysis contributed to interview schedule). The broad questions were retained in the
schedule to ensure opportunities for further areas of relevance to arise in the interviews.
Although all seven participants had multiple experiences to report on, analysis suggested that
data saturation was not fully achieved. Some areas of data appeared saturated. These tended
to be those that had arisen from the start and were discussed in each consequent interview, for
example the impact of support on the experience and appraisal of the moves. However areas
such as hopefulness (factors that influenced this) and impact on biological family
3
The intention was to support the young people to perceive themselves as an expert of their experience in the
interview. Therefore, using terminology that the young people associated with authorities over them or found
oppressive or biased were removed.
This term was preferred by the consultee as it was perceived as more common language and
that 'placement breakdown' was a more research-based term. Though the terminology was
changed in the interviews, unfortunately this consultation occurred after advertisement and
therefore the language of the recruitment material reflected previously used terminology. The
term was defined at the start of the interview.
4
18
relationships appeared lacking in richness and depth at the end of the process. Questions
remained about these areas and exceptions and disconfirmations were continuing to arise in
the last interviews.
Informed consent
All participants were aged over 16 and able to provide consent. Written consent was obtained
at the start of the interview following reiteration of the study details. (See Appendix H & I for
Information and Consent sheets).
Interviews
Six face-to-face interviews were undertaken. The seventh interview was a phone interview at
the request of the young person. The young people chose when and where to undertake the
interview. The interviews lasted between 35 and 55 minutes and comprised demographic
questions and a semi-structured interview.
Data Analysis
19
The data were analysed using Willig's (2008) Abbreviated Grounded Theory approach, based
on Charmaz's (2006) full version. (See Appendix J for a comprehensive description of the
data analysis).
Each interview was recorded and transcribed verbatim by the researcher. (See Appendix K for
example of transcript and coding). Before the next interview, transcripts were coded line by
line to identify initial codes, using the language in the transcripts to stay grounded in the data
and limit interpretation. These codes were built up into themes by identifying similarities and
links between these to build theoretical codes. (To maintain a stance that allows theories to
emerge from the data, more prescriptive elements of some approaches to Grounded Theory
were not used, such as ‘conditional matrices’ or an ‘axial coding paradigm’ (Strauss &
Corbin, 1990)).
Memos were used to explore questions and reflections that arose from the coding process.
This helped the researcher to identify gaps of information (detail) to explore in future
interviews. Theoretical sampling was also used to help direct further comparisons within the
data.
The memos also facilitated the researcher’s reflections on the data, to help identify reactions,
assumptions and biases that could lead data collection and analysis in directions unintended
by the young people. The approach of the interview was to acknowledge the young people as
the expert of their experience. Clarifications and summaries were used to help ensure the
20
interviewer understood what was being shared by the young people and reduce the influence
of researcher assumptions.
Additional data from each interview enabled further exploration and validation of the
theoretical codes that were emerging from the analysis. The aim was to help the researcher
stay grounded in the data whilst developing a comprehensive understanding of concepts that
would facilitate movement towards theoretical integration and allow for the development of a
theoretical framework.
Theoretical credibility was built through ensuring analytical credibility, using comparative
analysis to build the initial and theoretical codes. Despite not being able to be more selective
about future participants to expand on concepts and categories, systematic follow-up of
elements in future interviews aimed to improve theoretical credibility of the relationships that
emerged. However, the inductive approach of allowing participants to choose the stories they
shared before focussing in on more specific lines of inquiry also helped to ensure additional
experiences were not overlooked in favour of identified gaps from theoretical sampling (Dey,
1999).
Following recommendations by Yardley (2000), supervision from a senior researcher was
used throughout the analysis in order to build and maintain theoretical credibility, seeking
guidance and feedback on the emerging codes and framework. This input also provided a
space for reflection and transparency on the thought processes which influenced, and were
21
developed from, the data analysis.
Results
The following model (Figure 1) represents what the young people said about their move
experiences, which centred around two main themes: Understanding and Survival. The main
theme of ‘Understanding’ contains two subthemes of ‘Experience’ and ‘Support’. The
‘Survival’ theme contains three subthemes of ‘Action to Influence’, ‘Self-protection’ and
‘Future Focus’. The two main themes influence each other. However, not all the subthemes
directly link to all others but are influential on a meta-level to the other main theme and the
subthemes within it. It is emphasised that full saturation of the data was not achieved and
therefore these results may lack some additional relevant details.
Figure 1: Model of results
22
Understanding of placement moves was constructed from appraisals of past experience and
influenced by the presence or absence of support. Experiences used in these appraisals were
those from both within care and before care. 'Understanding' shed light on reasons for
placement move experiences and informed expectations of the future. These informed
survival responses subsequently. 'Survival' responses included active strategies intended to
influence events or self-protective strategies to manage what was perceived as inevitable and
hopeless (as informed by the ‘Understanding’ of placement moves). Hopelessness was also
managed through a future focus on getting to the end of the care system.
Reflecting on their experiences informed their understanding of the moves, which influenced
the actions taken to survive them. The results of these actions impacted their subsequent
experiences and support received, which in turn influenced future understanding and survival
23
responses. This highlights the cyclical nature of the model. The main purpose of this cycle
appeared to be for the young people to reduce their distress, particularly from loss and lack of
support.
In the following sections the model will be illustrated by highlighting the key elements and
then drawing attention to the links between the themes and subthemes.5,6
Understanding
Accounts of placement moves were predominantly highly negative. Loss was highlighted as
one of the most distressing elements of placements moves, exacerbated by the fact that they
were frequently multiple and varied.
“Absolutely horrible. I was crying … I just felt like all my life was gone between my feet.”
(Amy)
5
6
Pseudonyms have been used to protect confidentiality.
Appendix M examples a finding evidenced by multiple interviews.
24
The participants’ accounts emphasised their constant appraisals regarding their placement
moves. These appraisals informed some emotional responses to the moves and expectations
for the future.
“Why is this happening? These are the things that were going through my mind. ‘What have I
done that’s so wrong for me to deserve this?” (Lisa)
Key in influencing these appraisals were their experiences; both pre-care and in-care. In
addition, there was a clear emphasis on the influence of support on their appraisals.
Experience
Attempts to understand the events of placement moves were informed by previous
experiences: the young people drew upon their pre-care experiences as well as prior
experiences in care (if applicable).
25
“They don't really listen to you.…. So... they kind of do what they want and put you wherever
you are and you can't really control [any of what happens].” (Rich)
Pre-care experiences influenced the young people’s sense of responsibility around difficulties
with placement moves. Those who entered care later had a greater understanding of the
responsibility of adults to provide care for them and consequently attributed some of the
responsibility for difficulties with moves to the professionals around them. Anger arose from
perceptions that appropriate care was not being provided.
Those who understood the responsibility of adults to provide appropriate care adopted an
active stance to influence these adults. They also felt less guilt around the ‘disruptive’
behaviours used to achieve this.
In contrast, the participants who entered care at a younger age took greater responsibility for
difficulties associated with placement moves, acknowledging difficulties engaging with the
process and giving greater credence to this as the reason for distressing placement moves
rather than to adults around them.
26
“…’ where do you want to live?’ ‘Well, I don’t really know. I don’t really know what foster
care is’... So a lot of the time I was just like ‘I don’t mind”. (Rich)
Their own perceived failings led to a sense of hopelessness about being able to influence
future move experiences and a tendency to focus on self-protection to minimise distress from
future events.
“I would love my choice to be increased but until I hit eighteen everyone's always trying to
tell me what to do because in their eyes I'm still a child...” (Sian)
Other pre-care experiences had a more negative impact on the move process. A common
example of this was experiences of abuse creating difficulties in young people’s abilities to
communicate their needs or dissatisfaction to those with power over their care. Such
reflections only occurred in their later years in care, resulting in an increased sense of
responsibility for difficulties with placement moves in the meantime.
“I never felt…able to say to my social worker what I wanted …if you relate it to like my
childhood, where I was abused... a lot of kids, they daren’t say something… about their
parent figure as they feel that they’re going to get hurt.” (Jake)
27
This sense of responsibility and feeling unable to influence the situation was linked to
attempts to protect themselves from anticipated future negative experiences, feeling unable to
act to change these.
“I got too attached and it really hurt when I left’… So I became very ‘to myself’ and I was
like … ‘I’m not gonna talk to [foster carers]’.’’ (Amy)
Experiences of being unable to make their needs known in care highlighted that in-care
experiences also influenced appraisals of placement moves.
Information from previous experiences in care was used to understand the actions of those
influencing placement moves. For example, experiences of being ignored by social workers
when trying to make their views heard or feeling their foster carers didn’t genuinely care
about them were used to understand why they felt unprotected and uncared for during moves.
“… I'd often overheard the stuff that [foster carer] would say like; 'Oh we wish we'd never
taken her on' and all of this... I came back one day and [foster carer]’d packed my stuff and I
just felt as if she was like, 'Yes, she's going. Let's get rid of her'.” (Lucy)
28
Such experiences consequently influenced expectations of future care moves, for example
that their wellbeing would continue to be overlooked in favour of saving money and
professionals could not be trusted to behave otherwise.
“Participant: I was just so angry that my welfare… comes second to money. Like, it might be
a job to them, like having to move me and you know, paying for it, but it’s my life.
Interviewer: Did that have any impact on you?
Participant: I didn’t trust Social Services… that was one.”(Adam)
A hopeless sense of future care and issues of mistrust of professionals and foster carers were
common and frequently followed by a sense of need for self-sufficiency; the need to take
action to survive placements moves.
“Social Services... they work to ensure my wellbeing. If they're not going to work to ensure
my wellbeing then I damn well am.”(Jake)
29
Support
Young people felt repeatedly rejected and unwanted from the experiences of moving
placements and, with a lack of emotional and practical support, felt alone and afraid. Lack of
support and information given influenced the conclusions around placement moves as young
people frequently relied on their own experiences and interpretations.
Positive support around understanding placement moves was uncommon and frequently selfblame was experienced. This went beyond a contextual conclusion regarding their behaviour
to an integrated part of their identity.
“Participant: I didn’t really have anyone talking to me about it, just, ‘You’re moving.’ … It
really shocked me...What have I done that’s so wrong for me to deserve this?
Interviewer: And what were the answers you came up with at the time?
Participant: I was naughty. I was a naughty person.” (Amy)
The lack of perceived entitlement to good care that resulted meant that such individuals
attempted to survive care more often by taking personal responsibility. They adopted self-
30
protection strategies rather than acting to influence others, even though these strategies could
be harmful (isolation, low mood, reduced access to support).
“I didn’t want to focus on my day-to-day life so…I learnt to block things out...when I first
went I didn’t know how to block so I just started trying to hurt myself...because I thought I
was to blame for everything that went wrong in my life.”(Sian)
However, one young person displayed no self-protective strategies despite a sense of
responsibility around care moves, due to a more prominent sense of hopelessness.
"I felt like ‘what’s the point in doing anything anymore,’ like, I started to give up on
myself.”(Lisa)
Negative views of themselves also came from adults around them in care, and influenced
future expectations of their care. A particular sense of hopelessness along with self-blame
followed these incidents.
“They were like …‘You know no one’s going to want to foster you with your referral, you
know that.’ So… everybody knew that… no foster placement would have me…”(Rich)
31
This profound sense of hopelessness was linked to attempts to self-protect and place a sense
of hope in the end of their time in care.
When positive support was received, the contrast in their understanding and consequent
emotional and practical responses was very evident. Such support was often informative,
empathetic and caring, providing both instrumental guidance and also a mindful awareness of
the young person’s situation.
In addition, young people’s understanding of their moves facilitated descriptions of what
support would improve these experiences.
“I think they should be allowed...they can keep in contact with them... it is like leaving your
family...It's really sad. It's traumatic.” (Jake)
Relational losses were repeatedly highlighted as the most distressing elements of moves.
However, young people emphasised that support around this was only helpful when the
professional (social worker, foster carer, other professional) supporting them knew them well.
32
“... I met my Social …on the day that I left…She was trying to comfort me because I was
upset and I felt a bit... I felt a bit like she was intruding...”(Lucy)
Positive support reduced the need to self-protect, providing emotional support and confidence
to influence placement moves. Initially it also appeared that positive support relieved a sense
of responsibility around placement moves.
“My CAMHS worker said to me, ‘It’s not because you’re naughty, it’s because people don’t
understand you.’ And then, that’s how I figured out that they obviously don’t understand
me.” (Sian)
However on exploring this in consequent interviews it became apparent that regardless of
previous experiences, and whether they had fostered a sense of self-value, all participants
appeared to feel some sense of responsibility for the difficulties they experienced around
placement moves. When combined with a lack of support, this perception of responsibility
led the young people to articulate that they had to survive by being self-sufficient as no one
else would prioritise their emotional needs.
33
“… if I hadn't had that, like the strong will to do what was best for me and been articulate
enough to tell everybody that that was what I wanted and been determined enough to fight for
it, then I probably wouldn't have gotten what I needed.” (Lucy)
However, this was the only participant to indicate that they felt they had got some of their
needs met. Others indicated that their actions had only reduced distress.
Relational losses were often of those who were supporting them, whether carers, biological
family or friends. This reinforced the need for self-sufficiency to protect against these
significant loss experiences. They invested less in these relationships as a self-protective
device, which also reduced opportunities for future support to manage other distresses.
“Cause I could have got closer to them…and it could have hurt me a lot… I was like, ‘No.
I’m gonna cut all the ties…and not talk to any of them.”(Amy)
Overall, the young people’s ‘understanding’ of placement moves frequently led to a
conclusion that they needed to be self-sufficient to manage the distress resulting from
placement moves and to minimise anticipated future distress. This came from a pervasive
34
lack of support during the moves, throughout and prior to care. The young people’s careful
appraisals of placement moves influenced their beliefs around self, others and the future.
These consequently informed their ideas about how to manage future experiences: how to
survive placement moves.
Survival
As highlighted previously, whilst in care the young people’s understanding of their placement
moves informed their survival responses; these centred on managing their current distress,
and future anticipated sources of distress, and fell into three themes. ‘Action to Influence’
aimed to influence future events to negate distress whereas ‘Self-protection’ aimed only to
limit the negative impact of what they were to experience. The third theme, ‘Future Focus’
centred on hope for the future. A focus on self-sufficiency was prevalent in all these themes,
a clear result of the lack and loss of consistent support leading young people to depend on
themselves.
35
“I would have been incredibly unhappy….But I wanted to fight for what was best for me
rather than just…having adults tell me what to do.” (Adam)
These attempts at ‘survival’ influenced future experiences: how the participants engaged with
support; how they viewed their placement moves; their subsequent approach to surviving the
experience. This illustrates the cyclical nature of the process whereby experiences and
evaluations affected actions, which in turn influenced experiences and evaluations and so on.
What was clear was the ‘no win’ situation the young people found themselves in, with
attempts to reduce distress often creating alternative distress. A focus on the future after care
provided a hopeful outlook in the midst of these dilemmas. Initially, the descriptions of
survival responses appeared to be an ‘either/or’ scenario regarding the use of actions to
influence. However further exploration in subsequent interviews identified that some young
people engaged in both of these response approaches during a move. For example, they
refused to engage with foster carers to reduce distress but also ran away from placements to
influence their move.
Less-distressing experiences were appraised as requiring fewer survival responses. For
example, young people who felt known by, and who trusted, their social workers were more
36
accepting and less anxious of the placements chosen for them. They did not feel the need to
run away from or refuse these placements (at least initially).
“I could really tell how excited she was for me and that got me excited, ‘cause I was like
‘[she] knows me really well and I’ve got a good relationship with her.” (Rich)
For these young people there was less of a need to be self-sufficient, giving more
opportunities for their needs to be met by others and reinforce the benefits (and drawbacks)
of this. In contrast, some of the young people were clear that the lack of positive support
compromised their success in placements.
“…you know if they'd have said ‘you're here for so long’…then I could have taken that in and
gone ‘ok, I know my time here is limited’ I think I would have been a lot calmer... and stood a
good chance of staying in the placement.”(Sian)
However some responses were reactive rather than based on appraisals of the moves, such as
becoming aggressive towards their social workers during the process of being moved. The
young people then thought about the consequences of these actions and used these appraisals
to decide whether to act the same way again in future.
37
“...That move was obviously immediate ‘cause I ran away to my dad’s… But then it
changed...‘Cause the reason I [would] run away was …would be a lot of the time because I
wasn’t being listened to.”(Rich)
Action to Influence
For some young people there was a motivation to survive and reduce distress that culminated
in actions to achieve their desired improvements. Attempts to influence moves often focussed
around the high level of distress associated with loss of relationships. Actions were intended,
for example, to obtain better support from the social worker.
Actions were often aimed at those whom they perceived had control over their placement
moves: Social Services, foster carers, etc. They included direct negotiations regarding
placement moves, ‘kicking off’, running away and refusal behaviours. Attempts to influence
those in ‘control’ also included gaining support from other professionals to oppose a move.
38
“...She... listened to my Psychiatrist and listened to me… she overruled everything that [the
social worker] said and I managed to stay in the place...” (Amy)
Whilst young people’s actions to influence were generally meant to create positive change,
they had mixed results. In fact, a key negative consequence of some behaviours intended to
influence moves was the negative perception of the young person that resulted. This was part
of a context of experiences of negative perceptions of young people in care that was prevalent
in the accounts: actions that risked reinforcing these were heavily justified. For example, one
young person attributed their ‘kicking off’ to their mum’s emphasis that they should fight to
get their needs met, thereby reducing their sense of shame at being aggressive towards their
social worker.
“My mum raised me …that I was... like, responsible for my own wellbeing.”(Sian)
Such examples repeatedly highlighted that the need to be self-sufficient rarely provided the
young people with ‘ideal’ solutions to reduce future distress, and frequently resulted in
cognitive dissonance. The individual from the quote above believed she was of value and
entitled to receive good care but did not perceive she was receiving this. To resolve this, she
ensured she gained the care she needed by ‘kicking off’ to get those around her to listen and
respond to her requests. Though this succeeded, further cognitive dissonance arose from her
39
perceiving herself as a ‘bad person’ that conflicted with her belief that she deserved good
care. This reinforced her need to justify herself, both whilst in care and afterwards to manage
this dissonance. The need to continue to justify herself in the present highlighted the on-going
fear of being perceived negatively, that had started in her childhood and not yet been
resolved.
However, though some behavioural responses proved effective at influencing individuals and
circumstances, ineffective behavioural responses engendered a sense of hopelessness and led
to an alternative approach of self-protection from the perceived inevitable future difficulties.
An exception to this was one young person, who became self-protective before her first
move, following failed attempts to engage foster carers in fighting for her to be allowed to
stay in the placement.
Self-protection
Young people with greater perceptions of hopelessness and self-blame for the difficulties
with moves engaged in more self-protective strategies. This was also reinforced by previous
failed attempts to influence placement moves. The intention of these behaviours was to
minimise distress, most frequently around relationships and loss. This included denial at the
loss of relationships as well as reluctance to engage in new relationships.
40
“I didn’t wanna…make new friends ‘cause I already had friends over here. So I didn’t really
wanna go out and make a new circle of friends and end up losing them again...” (Lisa)
Although these self-protective responses were perceived to be somewhat effective at reducing
future hurt, the young people acknowledged that they often brought with them isolation and
depression. This further reduced opportunities to obtain support, leading to further
hopelessness and reinforcing the need to engage in self-protective behaviours.
“I become really depressed. I didn’t want to go out. I didn’t talk to anyone.” (Lucy)
The dissonance caused by these negative outcomes was resolved by some of the young
people justifying that these experiences made them emotionally stronger.
“It’s made me stronger.…. I don’t think anyone else realizes how strong it actually does
make young people.” (Jake)
41
Acceptance of acting to survive as best they could was common throughout the narratives,
though disruptive and aggressive behaviours were often discussed with a sense of
embarrassment. However an exception to this was one young person who expressed ongoing
regret at engaging in self-protective approaches: She felt that had she ‘acted to influence’
those in charge of her care that she would have avoided the depression and consequent
educational failures that she attributed to taking a self-protective approach. This perspective
existed despite an acknowledgement of the hopelessness that had led her to take a ‘selfprotective’ approach.
“I definitely think … I don't want to sound like I wanted to cause trouble… I should have
fought my corner more. But yeah, I just never said: I just felt so on my own like no-one would
listen to me at all.” (Sian)
An acknowledged positive outcome of self-protective behaviours for all the young people,
was the avoidance of shame often associated with more active and disruptive strategies,
stereotyped to be common amongst young people in care. This reinforced their use in future
care moves.
Future Focus
42
Another approach utilised by the young people was one of focussing on life beyond care;
hoping that life would improve after care. The young people identified their time in care as a
discrete chapter in their lives, enabling them to be hopeful about the future; a time beyond the
trials and tragedies of care. Reflections after care maintained this perception of care as a
discrete chapter that impacted on their achievements and successes, and continued to limit
their lives.
“[Social workers] did whatever they [wanted]…I just went along with it and then as soon as
I was independent…I was like ‘…It’s time to get all the things I’ve wanted to do.’ So it was
quite a relief...”(Rich)
This focus on the future enabled individuals to separate themselves from the behaviours they
had engaged with in care and give the care system responsibility for this, rather than perceive
themselves as fundamentally ‘bad’. However narratives contained repeated emphasis on this
separation, highlighting an on-going fear of being perceived negatively as a child in care.
“I'm not violent now or nothing like, I’ve left it behind” (Amy)
43
Despite the acknowledged difficulties and distresses with placement moves, the young people
all perceived themselves as survivors, though acknowledging some of their on-going
difficulties as a result of these experiences.
“It’s in the past and I’ve tried to keep it that way. To be reminded of it.. It makes me feel
…quite low about myself. .. I mean I’ve made myself the person I am today… It’s made me
stronger... I don’t think anyone else realizes how strong it actually does make young people.”
(Jake)
What was clear across the narratives was a sense of survival and relief at leaving care, or
hopeful anticipation of it for those still within the care system. However, what was unclear
was the extent to which negative perceptions about themselves were concealed, in a wish to
distance themselves from the ‘bad’ image of a child in care.
Within the overall theme of ‘survival’, the majority of the young people engaged in both
active and self-protective strategies, rather than just one or the other. Switching most
commonly occurred from active to self-protective strategies, as actions to influence failed or
hope around better experiences and support disappeared. However, alongside
acknowledgement of the insufficiency of these approaches to prevent future distress, the
young people highlighted the double bind they were caught in: act to improve their situation
44
and risk being stigmatised further, or focus on protecting the self and risk isolation and
depression.
In summary, the results of this study indicate a cycle of appraisal and response in relation to
placement moves, to reduce distress. Placement move experiences were appraised and
informed consequent responses, which then influenced placement moves and led to further
evaluations to inform future responses. Sometimes losses were averted and support was
provided through these responses, but often responses came with drawbacks as well as
successes. The need for self-sufficiency indicated in the appraisals led to responses that often
furthered isolation and reduced opportunities for support that could have relieved distress.
Consequently, further distress from multiple placement moves led to a sense of hopelessness
and the young people ‘survived’ this by focussing on their future beyond care, as they
recognised their needs but were unable to get them met sufficiently.
Discussion
This study aimed to explore the process and impact of placement moves from the perspective
of young people in foster care to develop a preliminary foundation of understanding
regarding the psychological processes and behaviour related to these perspectives. It was
45
intended that this work would function as an early platform for other researchers to further
develop a coherent and theoretically-based account of these phenomena, to inform effective
and evidence-based interventions.
The themes to emerge from the data highlight the attempts of young people to understand and
survive these experiences in order to manage their distress and minimise the development of
future trauma. In their reflections, they were mindful of the impact of these experiences on
their lives, with the consequential benefits of acquired resilience as well as the considerable
difficulties. The landscape was filled with multiple losses, with a backdrop of lack of
information, uncertainty, and lack of support. The themes of understanding and survival
encapsulate the young people’s process to manage their experiences. Their ability to
recognise their own and others’ contribution to the systemic problem of the moves was
articulated in multiple layers focussing on economic, emotional and social values.
This discussion will explore how the results of this study fit with theoretical models and
previous research with young people in care, highlighting areas that require further
exploration or indicating areas for intervention within care services. Theoretical models
focussed on will include trauma, learning, attachment and resilience. These models have been
included due to their relevance to the results. Other theories have been rejected due to a lack
of congruence with the results. For example, psychoanalytical developmental models have
46
not been included here due to the lack of evidence in the results to substantiate such
congruence or divergence of the findings of this study with such a theory7.
Resolving Trauma
The narratives in this study clearly fit with the criteria for Developmental Trauma (Van der
Kolk, 2005) (Figure 2), drawing into sharp focus that instead of providing nurturance, care
system moves played a role in maintaining and exacerbating early trauma that young people
often bring with them into care (Takayama, Wolfe & Coulter, 1998). Secure bases, necessary
for the development of attachments and sustaining relationships, were lacking. Such
experiences explain the young people’s need to ‘understand’ and ‘survive’ placement moves
and indicate a need for trauma-based support.
Figure 2: Developmental Trauma
7
Appendix N examples a search based on the result
47
Advocation of trauma-based support for young people in care is not a new idea (Hyde &
Kammerer, 2009; Thomas & Philpot, 2009; Webb, 2006; Cairns, 2002). For example, Hyde
& Kammerer advocated trauma-based support for young people after finding that young
people brought behaviours resulting from their trauma to placements, that carers were then
unable to manage, resulting in further breakdowns. The results of this study advocate the
implementation of such support, given the findings that placement moves themselves were
traumatic and resulted in behaviours to reduce associated distress that then risked increasing
further trauma from additional moves.
48
Fight, Flight or Freeze
The results also highlight the stress response of the young people. Though their attempts to
‘survive’ placement moves were attributed mainly to appraisals, the narratives indicated the
stress response present in these experiences. For example, the ‘flight’ of the young man to his
father’s house at the threat of being moved. Though this later came to be a strategy of
influence for him, it indicated the trigger of the stress response during moves. Younger
children are less able to engage in ‘fight’ and ‘flight’ strategies and therefore more frequently
engage in ‘freeze’ (Lowenthal, 2012). In addition to having a reduced sense of entitlement to
care, this may shed further light on why children who entered care at a younger age engaged
with professionals in charge of moves by actions such as becoming emotionally unavailable
(freeze). Such inferences are supported by previous propositions about foster children’s
responses to psychological stress (America Academy of Paediatrics (AAP), 2000).
Understanding New Worlds
The narratives highlight that placement moves were often a learning process for the young
people: they did not know what to expect from the moves initially and consequently often
had to piece together information and experience themselves to make sense of them. Their
49
conclusions then informed their responses (particularly to manage distress). Often, the stress
responses undertaken in the immediate moment were also retained in the considered
responses: aggression and running away (fight and flight) were associated with ‘action to
influence’ whereas withdrawal (freeze) encapsulated self-protective strategies. Stress impacts
the ability to learn (Thompson, 2014) and it may be that this chronic and ongoing stress
limited the effective appraisal and response decisions for the young people in regard to their
placement moves.
However the responses often increased the distress of the young person. For example they
withdrew from relationships to avoid further loss but also missed out on support. These
unsuccessful actions to reduce distress can be understood in the context of a learning process:
children try to make sense of tasks and experiences (identify the meaning of them) and errors
occur when social contexts are unfamiliar as the young person has no framework or scaffold
to inform their actions (Donaldson, 1984). The lack of framework for placement moves
highlighted by the young people in this study emphasises the ‘disembedded’ thinking of the
young people and helps to understand their difficulties in comprehending and responding to
their experiences in a way that benefitted them.
Errors due to a lack of framework highlight the dependency on adults around them to help
them navigate unfamiliar situations successfully by providing information from a ‘child
perspective’ (Donaldson, 1984) in order for young people to appraise situations correctly and
50
respond constructively. Local and national approaches support this principle of including
young people in decisions about their care (Wright, Turner, Clay & Mills, 2006.), but it is
employed to a limited extent according to this study’s participants. The on-going lack of
support and the reactive nature of the placement moves prevented preparation or meaningful
discussion. Consequently dysfunctional scripts were not corrected and young people
continued to respond in ways that compromised their future needs being met.
Attachment and Emotion Regulation
The participants described a lack of support and consistency of relationships, alongside
distress from loss, feelings of abandonment and associated vulnerability. These are consistent
with the emotional responses expected when an individual has experienced insecure or
disorganised attachments (Prior & Glaser, 2006). Such attachments are prevalent in young
people who have been fostered, due to trauma in pre-care attachments and/or during care
(Wekerle & Wolfe, 1998; McCarthy & Taylor, 1999; Crittenden & DiLaila, 1988). However
the youth in this study highlighted how their experiences of relationships around placement
moves (rejection, lies, absence of support when needed) influenced their ability to engage in
relationships with those caring for them. Lack of trust and repeated loss of relationships led to
distrust and perceptions of ‘carer’ relationships as harmful and to be protected against, which
51
were characteristics of young people in care also found by Unrau et. al. (2008). This suggests
a process by which insecure or disorganised attachments may be exacerbated by care events.
Developed by Bowlby (1951), attachment theory proposes that the relationship between
infant and mother forms the basis of a sense of security for the infant, informs emotional
development and future relationships. Further work distinguished privation (no attachments
formed) from deprivation (loss or damage to attachments) (Rutter, 1981; Hodges & Tizzard,
1989). The need to self-protect against relationships, thereby reducing opportunities for
attachment relationships to develop highlights how foster care can increase this risk of
privation.
Moderate difficulties with affect regulation during the interviews also drew attention to
attachment difficulties (Fahlberg, 1991), given that emotional regulation develops through
secure attachment relationships. For many of the young people, their emotions appeared
disorganised, unregulated, absent or masked. Strategies to manage these difficulties included
suppression, minimising or dismissing their experience of emotions, changing the topic and
actively stating this was in the past. Emotional regulation is adaptive for helping young
people achieve their goals and fostering a positive sense of self, a characteristic largely absent
in the young people in this study, despite efforts to conceal difficulties in the present time.
52
Though the need for positive, stable relationships in order to facilitate secure attachment in
foster care is acknowledged in theory, research and practise, implementation appears to
remain problematic (Luke & Coyne, 2008; Samuels, 2009). Given the development of secure
attachments will not only significantly reduce distress and instability in care (through
preventing harmful self-protective or active strategies) but also improve multiple outcomes
beyond care, associated with secure attachment relationships (Prior & Glaser, 2006), this
needs to be a priority.
Internal representations
Rather than their placement moves being conceptualised as the result of specific externally
driven factors, the young people related them to internal global attributions which impacted
on the development of their self-identity. In light of the loss of relationships and role models
early in life it is unsurprising that many of the young people had poorly-attuned internal
working models (IWMs), demonstrated by the way they viewed themselves and others.
Bowlby (1973) explained that mental representations of the parent-child relationship, built
through interactions with primary caregivers contain expectations of caregiver behaviour in
the future, such as availability or responsiveness. They also contain a ‘complementary and
mutually confirming view of the self as worthy or unworthy of care’ (Bowlby, 1973 p, 238).
53
Clear negative examples of this came from participants in this study: unavailability or
rejection from carers and professionals and consequent insecurity and lack of trust led to selfreliance for care needs and a negative sense of self, occasionally partially negated by positive
experiences of care and support. Kools (1997) and the AAP (2000) emphasised the negative
impact of foster care on the development of young people’s identity, resulting from poor
treatment from professionals around them.
Resilience
Within this study the focus on survivorship of the traumatic experiences of placement moves
indicated resilience. Newman and Blackburn (2002, p3) describe resilient children as
‘equipped to resist stress and adversity, cope with change and uncertainty, and to recover
more successfully from traumatic events or episodes’. Originally described by Rutter in 1990,
resilience is a dynamic process of managing experiences of adversity and learning how to
adapt and accommodate to these life challenges to achieve effective adult adjustment (Luther,
Cicchetti & Becker, 2000). Resilience in young people in foster care has gained great
attention in recent years, given the ability of some young people to achieve favourable
outcomes despite the traumatic experiences of their lives prior to and within foster care
54
(Cameron, 2007; Pryce & Samuels, 2010; Wilson, Sinclair, Taylor, Pithouse & Sellick,
2004).
In this study, survival often took the form of self-reliance, as the young people took it upon
themselves to address their emotional needs by reducing distress from moves. This finding
was also ascertained by Samuels and Pryce (2008) who explored reflections of young people
ageing out of foster care. As in this study, they also identified that whilst self-reliance could
be a source of resilience it could also interfere in accessing and developing supportive
relationships associated with positive outcomes in adulthood.
The young people who retained optimism highlighted problem-solving skills, maintained a
sense of autonomy over their situation and engaged in more hopeful responses to improve
their situation. These are three of four attributes of resilient children highlighted in research
by Bernard (1995) and ascertained to be factors related to positive outcomes in young people
in foster care (Edmond, Auslander, Elze & Bowland, 2006; Hass & Graydon, 2009).
However within this research, optimism often appeared to be influenced by sense of
autonomy and positive sense of self, highlighting an area to be explored further.
A focus on the future was one method of survival identified by the young people, alongside
attempts to reduce distress. AAP (2000) highlighted that adults cope with impermanence by
55
building self-reliance and focussing and preparing for a time of greater constancy, an
approach that appeared to be adopted by many of the young people in this study and
facilitated their resilience.
A distinction between life in care and after care enabled young people to separate themselves
from previous ‘bad’ behaviour and retain (or develop) a positive sense of self. The majority
of the young people interviewed reported improvements in mood, behaviour, relationships
and achievements after care, despite the intense difficulties experienced previously. It is
unclear what facilitated this resilience. However, all of the young people reported one key
positive source of support (usually not linked to care services) before, during or after care.
One main positive source of support was identified as a key factor in resilience for children
by Newman & Blackburn (2002) and supported in consequent research, highlighting the
significance of this.
A few young people who entered care expressed some entitlement to having their needs met.
This appeared to be associated with greater resilience to care move events as they internalised
less responsibility for difficulties with care moves. Such findings suggest that these
individuals entered care with an (at least partly) positive IWM (though the majority did not).
These were the young people that entered care later, having had time to develop these (AAP,
2000). This indicates that positive IWMs may potentially be a source of resilience for young
people in care and highlights the consequent need to facilitate these.
56
Resiliency theory highlights the important of having some autonomy or knowledge over the
breadth of changes occurring, in order to be able to prevent these experiences hindering
young people’s development (Newman & Blackburn, 2002). Young people themselves were
aware of specific elements of support that could have reduced the trauma of moves. For
example, social and contextual factors such as having a trusted consistent relationship with an
adult, knowing what to expect, being able to prepare for moves and having some control to
ensure the decisions taken met their needs. Therefore this study supports other work which
challenges the exclusion of young people from decisions and information, not just to reduce
distress but to aid development of resilience. In addition, the alignment of the young people’s
identification of their needs with theory about resilience adds weight to the argument to listen
and respond to young people individually: they can be accurate experts of their needs.
Areas for intervention
Despite the tentative nature of the findings of this research, through the triangulation of the
findings with theory the need to address support for trauma, attachment, resilience and
emotional regulation in placement moves has been indicated. However, much of this fits with
the work being undertaken by those such as Golding (2004; 2007; 2008; Golding & Hughes,
57
2004.) and Hughes (2004; 2006; 2007, 2009.) to develop approaches to address trauma and
attachments in young people in care. Further evidence for the effectiveness of these
approaches is still required to justify broader implementation.
Limitations
This study aimed to explore young people’s experiences of UK foster placement moves. The
applicability of this research is limited by the restricted variation in the participants’ ethnic,
cultural and social backgrounds. These are important elements given that in the UK, African
Caribbean and mixed African Caribbean and white heritage children are overrepresented in
foster care (Thoburn, 2007) and locations such as Scotland have care systems run by their
own government.
A greater number of participants may have led to a greater depth and breadth of information
around the process of managing placement moves. It may also have facilitated fuller
saturation of the data, which has consequently rendered the results a preliminary
understanding of placement moves. However, participants’ experiences of multiple moves at
least partially compensated for the small number of participants. Furthermore, though general
guidelines suggest numbers of 20-30 participants for Grounded theory studies (Charmaz,
58
2006; Creswell, 1998) justification of these numbers is lacking. Guest, Bunce and Johnson
(2006) found that they had generated 34 of their 36 codes within the first six interviews of
their study, with all 36 generated by interview 12. This also suggests the small number of
participants may not be as significantly limiting as may first appear. The small number of
participants also prevented theoretical sampling which may have rendered data more fully
saturated with a small number of participants.
Conclusion
This research has enabled the development of a preliminary understanding of the key
elements of placement moves from the ‘child’s perspective’. It has highlighted the process
used to inform young people’s attempts to survive the often-traumatic experiences of
placement moves: past experiences inform future expectations and consequent responses to
minimise future distress. Frequently a lack of support compounds the trauma of placement
moves and results in a need to be emotionally self-sufficient. However, these self-sufficient
responses often have a negative impact on distress and stability.
It is acknowledged that these results require further exploration to obtain further
understanding of factors that influence resilience and distress from placement moves.
59
However, the findings of this study support current attempts to develop and evaluate
interventions to: facilitate consistent and positive relationships; aid the young people in
development of resilience; and manage and reduce trauma in foster care. Despite the largely
negative descriptions of care moves, this study has highlighted the pervasively resilient
nature of young people in care. But this must not be an excuse to overlook the shortcomings
of care.
The present research has also found that (at least some) young people are able and willing to
report on difficult experiences from foster care. This emphasises that there is no excuse to
neglect a ‘child’s perspective’ in research or in practice.
60
References
American Academy of Paediatrics. (2000). Committee on Early Childhood, Adoption and
Dependent Care. Paediatrics, 106, 1145-1150.
Barber, J., & Delfabbro, P. (2003). Children in foster care. New York: Routledge.
Bernard, B. (1995). Fostering Resilience in Children. San Francisco: Far West Laboratory for
Educational Research and Development.
Bowlby, J. (1951). Maternal care and mental health. World Health Organization Monograph,
3, 355-534.
Bowlby, J. (1973). Attachment and loss, Vol. II: Separation. New York: Basic Books.
The British Psychological Society. (2010). Code of Human Research Ethics. Leicester:
Author.
Burger, J. (1999). The foot-in-the-door compliance procedure: A multiple-process analysis
and review. Personality and Social Psychology Review, 3, 303-325
Butler, S. & Charles, M. (1999). 'The past, the present, but never the future': Thematic
representations of fostering disruption. Child & Family Social Work, 4, 9-19.
61
Cairns, K. (2002). Attachment, trauma and resilience: Therapeutic caring for children.
London: British Association for Adoption and Fostering.
Cameron, C. (2007). ‘Education and Self-Reliance among Care Leavers’. Adoption &
Fostering, 31, 39-39.
Charmaz, K. (2006). Constructing grounded theory. London: Sage.
Cresswell, J. (1998). Qualitative inquiry and research design: Choosing among five
traditions. London: Sage.
Crittenden, P. (1985). Maltreated infants: Vulnerability and resilience, Journal of Child
Psychology and Psychiatry, 26, 85-96.
Crittenden, P. & DiLalla, D. (1988). Compulsive compliance: The development of an
inhibitory coping strategy in infancy. Journal of Abnormal Child Psychology, 16, 585-599.
Dey, I. (1999). Grounding Grounded Theory: Guidelines for Qualitative Enquiry. London:
Academic Press.
Donaldson, M. (1984). Children's Minds. London: Fontana.
Edmond, T., Auslander, W., Elze, D. & Bowland, S. (2006). Signs of resilience in sexually
abused adolsecent girls in the foster care system. Journal of Child Sexual Abuse, 15, 1-28.
62
Fahlberg, V. (1991). A child'’s journey through placement. Indianapolis: Perspectives Press.
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.
Gilbertson, R. & Barber, J. (2002). Obstacles to involving children and young people in
foster care research. Child and Family Social Work, 7, 253–258.
Glaser, B. & Strauss, A. (1967). The Discovery of Grounded Theory. New York: Aldine
Publishing Company;
Golding, K. (2004). Fostering Attachments in Looked after Children: Further Insight into the
Group-Based Programme for Foster Carers. Adoption & Fostering, 32, 64-76.
Golding, K. (2007). Developing group-based training parent training for foster and adoptive
parents. Adoption & Fostering, 31(3), 39-48.
Golding K. S. (2008). Nurturing attachments. Supporting children who are fostered or
adopted. Jessica Kingsley Publishers.
Golding, K. and Picken, W. (2004). Group work for foster carers caring for children with
complex problems. Adoption & Fostering, 28, 25-37.
Greig, A., Taylor, J. & MacKay, T. (2007). Doing Research With Children. London: Sage.
63
Guest, G., Bunce, A. & Johnson, L. (2006). How many interviews are enough: An experiment
with data saturation and variability. Fields Methods, 18, 59-82.
Hass, M. & Graydon, K. (2000). Sources of resiliency amongst successful foster youth.
Children and Youth Services Review, 31. 457-463.
Health Care Professions Council. (2012). Guidance on conduct and ethics for
students. London: Author.
Hodges, J. & Tizard, B. (1989) Social and family relationships of ex-institutional adolescents.
Journal of Child Psychology and Psychiatry, 30, 77-97.
Hughes, D. (2004). An attachment-based treatment of maltreated children & young people.
Attachment & Human Development, 6, 263 –278.
Hughes, D. (2006). (2nd ed.) Building the Bonds of Attachment: Awakening Love in Deeply
Troubled Children, Maryland: Rowman & Littlefield Publishers Inc.
Hughes, D. (2007). Attachment: Focussed family therapy. Norton: New York.
Hughes, D. (2009). Attachment-Focused Parenting: Effective Strategies to Care for Children.
New York: Norton.
Hyde, J. & Kammerer, N. (2009). Adolescents' Perspectives on Placement Moves and
Congregate Settings: Complex and Cumulative Instabilities in Out-of-Home Care. Children
and Youth Services Review 31, 265-273.
64
Khoo, E. & Skoog, V. (2013). The road to placement breakdown: Foster parents’ experiences
of the events surrounding the unexpected ending of a child’s placement in their
care.  Qualitative Social Work, 13, 90-104.
Koh, E., Rolock, N., Cross, T. & Eblen-Manning, J. (2014). What explains instability
in foster care: Comparison of a matched sample of children with stable and unstable
placements. Children and Youth Services Review, 37, 36-46.
Kools, S. (1997). Adolescent Identity Development in Foster Care. Family Relations, 46,
263-271.
Lowenthal, B. (2012). Child Maltreatment: Effects on development and learning. Child
Maltreatment, 17, 365-371.
Luke, N. & Coyne, S. (2008). Fostering self-esteem: exploring adult recollections on the
influence of foster parents. Child & Family Social Work, 12, 402-410.
Luthar, S., Cicchetti, D. & Becker, B. (2000). The construct of resilience: A critical
evaluation and guidelines for future work. Child Development, 71, 543–562.
McCarthy, G., & Taylor, A. (1999). Avoidant/Ambivalent attachment style as a mediator
between abusive childhood experiences and adult relationships. Journal of Child Psychology
and Psychiatry, 40, 465–477.
Minty, B. (1999). Annotation: Outcomes in Long-term Foster Family Care. Journal of Child
Psychology and Psychiatry, 40, 991-999.
Newman, T. & Blackburn, S. (2002). Transitions in the Lives of Children and Young People;
Resilience Factors. Scotland: Scottish Executive Education Department.
65
Newton, R., Litrownik, A., & Landsverk, J. (2000). Children and youth in foster care:
Disentangling the relationship between problem behaviours and number of placements. Child
Abuse and Neglect, 24, 1363-1374.
Nutt, L. (2006). The lives of foster carers: Private sacrifices, public restrictions.
London: Routledge.
Prior, V. & Glaser, D. (2006). Understanding attachment and attachment disorders: Theory,
evidence and practice. London: Jessica Kingsley Publishers.
Pryce, J. & Samuels, G. (2010). Renewal and Risk: The duel experience of motherhood and
ageing out of the child welfare system. Journal of Adolescent Research, 25, 205-230.
Rock, S., Michelson, D., Thomson, S. & Day, C. (2013). Understanding foster placement
instability for Looked After Children : A systematic review and narrative synthesis of
quantitative and qualitative evidence. British Journal of Social Work, 43, 1-27.
Rostill-Brookes, H., Larkin, M., Toms, A. & Churchman, C. (2011). A shared experience
of fragmentation: Making sense of foster placement breakdown. Clinical Child Psychology
and Psychiatry, 16, 103-127.
Rubin, D., Alessandrini, E., Feudtner, C., Mandell, D., Localio, R. & Hadley, T.
(2004). Placement Stability and Mental Health Costs for Children in Foster Care. Paediatrics,
113, 1336-1341.
Rubin, D., O’Reilly, A., Luan, X., & Localio, A. (2007). The impact of placement stability on
behavioural well being for children in foster care. Paediatrics, 119, 336-344.
66
Rutter, M. (1981). Stress, coping and development: some issues and some questions. Journal
of Child Psychology and Psychiatry, 22: 323–356.
Rutter M. Psychosocial resilience and protective mechanisms. In (eds): Rolf, J., Masten, A.,
Cicchetti, D., Nuechterlein, K., & Weintraub, S. (1990). Risk and protective factors in the
development of psychopathology. New York: Cambridge.
Samuels, G. (2009). Ambiguous loss of home: The experience of familial (im)permanence
among young adults with foster care backgrounds. Children and Youth Services Review, 31,
1229-39.
Samuels, G. & Pryce, J. (2008). What doesn't kill you makes you stronger: Survivalist selfreliance as resilience and risk among young adults ageing out of foster care. Children and
Youth Services Review, 30, 1198-1210.
Sellick, C. (2006). ‘United Kingdom’, in Colton, M. & Williams, M. (eds), Global
Perspectives in Foster Family Care. Lyme Regis: Russell House.
Sommer, D., Pramling, S. & Hundeide, K. (2010). Child Perspectives and Children’s
Perspectives in Theory and Practice. London: Springer.
Stott, T. (2011). Placement instability and risky behaviours of youth ageing out of foster
care. Child and Adolescent Social Work Journal, 29, 61-83.
Strauss, A. & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures
and techniques. California: Sage.
67
Strijker, J., Knorth, E., & Knot-Dickscheit, J. (2008). Placement history of foster children: A
study of placement history and outcomes in long-term family foster care. Child Welfare, 87,
107–124.
Takayama, J., Wolfe, E. & Coulter, K. (1998). Relationships between reason for placement
and medical findings among children in foster care. Pediatrics, 101, 201–207.
Tapsfield, R., & Collier, F. (2005). The cost of foster care: investing in our children's future.
London: British Agencies for Adoption and Fostering/ Fostering Network.
Thoburn, J. (2007) Globalisation and child welfare: Some lessons from a cross-national
study of children in out-of-home care. Norwich, UEA Social Work Monographs.
Thomas, M. & Philpot, T. (2009). Fostering a child's recovery: Family placement for
traumatized children. London: Jessica Kingsley.
Thompson, R. (2014). Stress and child development. Future Child, 24, 41-59.
Unrau, Y. (2007). Research on placement moves: Seeking the perspective of foster
children. Children and Youth Services Review, 29, 122-137.
Unrau, Y., Seita, J. & Putney, K. (2008). Former foster youth remember multiple placement
moves: A journey of loss and hope. Children and Youth Services Review, 30, 1256-1266.
Van der Kolk, B. (2005). Developmental Trauma Disorder: Toward a rational diagnosis for
children with complex trauma histories. Psychiatric Annuals, 35, 401-408.
68
Webb, N. (2006). The impact of trauma on youth and families in the child welfare system. In:
Webb, N. (Ed.), Working with traumatized youth in child welfare (pp. 13-26). New York:
Guilford Press.
Wekerle, C., & Wolfe, D. (1998). The role of child maltreatment and attachment style in
adolescent relationship violence. Developmental Psychopathology, 10, 571−586.
Willig, C. (2008). Introducing qualitative research in psychology. England: Open University
Press.
Wilson, K., Sinclair, I. & Gibbs, I. (2000). The trouble with foster care: The impact of
stressful events on foster carers. British Journal of Social Work, 30. 191-209.
Wilson, K., Sinclair, I., Taylor, C., Pithouse, A. & Sellick, C. (2004) Fostering success: An
exploration of the research literature in foster care. Social Care Institute for Excellence.
Wright, P., Turner, C., Clay, D. & Mills, H. (2006). The participation of children and young
people in developing social care. Practice guide 6.
Yardley, L. (2000). Dilemmas in qualitative health research. Psychology and Health,
15, 215–228.
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Appendix A: Ethics Approval
70
71
Appendix B: Debrief Statement
72
Thank you for your help with this study. Here is a debrief sheet that has my contact details if you have
any further questions that you would like answered about the study or decide you would like a copy of
the report that I produce when I have completed the study. I would also like to call you a in a few days
to ensure that you are ok from having discussed these difficult topics today. May I ask how you are
feeling after the topics we discussed today...? What support or what do you think may be helpful for
you after today…?
Thank you again for your help with this study.
73
Appendix C: Debrief sheets
74
Debrief Sheet: Young Person
A study of the experience and impact of foster placement breakdowns: the
young people in foster care’s perspective
Debrief
This study has investigated how individuals who experienced breakdowns in foster care placements
viewed these situations and their views on what support they felt helped or didn't help during these
experiences.
Placement breakdowns are often difficult experiences. Research in the past has asked foster carers and
social workers about the experience but not young people in foster care and young people. This was
sometimes because they did not want to upset young people by talking about these sad or difficult
changes in foster care. This study aimed to ask your views in order to help services understand how to
support you and other young people in foster care better during these times.
We are very grateful for your help with this study and being willing to talk about possible difficult memories. If
taking part in this research has made you feel upset you may wish to talk to someone further. You could contact
one of the following organisations for support by telephone or online via email.
Childline
0800 1111
http://www.childline.org.uk/Pages/Home.aspx
The Samaritans
08457 90 90 90
jo@samaritans.org
75
Support Line
0208 554 9004
info@supportline.org.uk
Alternatively, if you feel very upset you should speak to your foster carer or social worker
who may take you to your GP to get some more support.
This website also has information for young people on mental health and feeling well emotionally:
http://www.youngminds.org.uk/
76
Debrief Sheet: Young Person (18+)
A study of the experience and impact of foster placement breakdowns: the
young people in foster care’s perspective
Debrief
This study has investigated how individuals who experienced breakdowns in foster care placements
viewed these situations and their views on what support they felt helped or didn't help during these
experiences.
Placement breakdowns are often difficult experiences. Research in the past has asked foster carers and
social workers about the experience but not young people in foster care and young people. This was
sometimes because they did not want to upset young people by talking about these sad or difficult
changes in foster care. This study aimed to ask your views in order to help services understand how to
support you and other young people in foster care better during these times.
We are very grateful for your help with this study and being willing to talk about possible difficult memories. If
taking part in this research has made you feel upset you may wish to talk to someone further. You could contact
one of the following organisations for support by telephone or online via email.
The Samaritans
08457 90 90 90
jo@samaritans.org
Support Line
0208 554 9004
info@supportline.org.uk
77
Alternatively, if you feel very upset you may wish to speak to your GP for some further
support.
This website also has information for young adults on mental health and feeling well emotionally:
http://www.mind.org.uk/
If you have any other questions about this study you can contact me or my university supervisor. Our
details our listed below.
78
Appendix D: Participant Demographics
79
Table 1: Participant Demographic Information
Participant
Age
Gender
Ethnicity
No. of foster
placements
(not
residential)
No. of placements
after (moved into)
12 years of age
Still in Care
1
20
Male
White
British
Multiple
2
No
2
19
Male
White
British
2
2
No
3
21
Male
White
British
9
6
No
4
20
Female
White
British
2
2
No
5
19
Female
RomanyGypsy
2
1
No
6
17
Female
White
British
3
3
Yes
7
17
Female
White
British
1
1
No
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Appendix E: Initial Interview Schedule
81
Initial Interview Schedule
1)
I wonder if you could tell about one of your placements where there was an
unplanned ending? (about what happened when it ended?)
2)
Could you tell me about what happened next? (In terms of going to your next
placement)?
3)
Can you tell me what it was like when your placement was ending/ ended?
These were broad initial prompt questions that were intended to get the interview started,
build rapport and lead to a focus on the experience of the placement breakdown and
consequences /impact/views on this. Further questions followed the young person’s lead in
relation to these issues, feelings and experiences they highlight in relation to the placement
breakdown from their perspective in line with Willig’s (2008) Abbreviated Grounded Theory
Approach.
Interview were then transcribed and analysed, identifying key elements and components to
explore further that then impacted the schedule of future interviews as they were prioritised
and explored further. This process was in line with Willig’s Abbreviate Grounded Theory
approach (2008).
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Appendix F: Later Interview Schedule
83
Later Interview Schedule
1.
I wonder if you could tell me about one of your placements where there was an
unplanned ending? (about what happened when it ended?)
2.
Could you tell me about what happened next? (In terms of going to your next
placement?
3.
Can you tell me what it was like when your placement was ending/ ended?
4.
What did you know about what was going to happen when you moved? How did you
find this out?
5.
Why do you think the move process happened like this / this way? How did you
understand what happened
6.
How did you react/respond to what happened? Why?
7.
Can you tell me about your other placement moves when the placement had an
unplanned ending?
8.
(If any,) what was the impact of these experiences?
9.
What did you expect in future placement moves? Why do you think you expected
this?
10.
Can you tell me what was important to you when you moved placements and why?
11.
How do you think placement moves should be done? / What do you think should be
done differently?
NB: These questions were often not asked in an ordered and structured way; sometimes the
answers came up in discussions about the process and were offered without being directly
asked. Sometimes questions were repeated within an interview in relation to different
placement moves experiences.
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Appendix G: Example of analysis producing interview schedule changes
85
Example of transcript analysis:
Participant: They'd just say, ‘oh you're going to a new
place’.
Interviewer: And did you get much warning?
Limited explanation
No, they'd just show up
Participant: No, they'd just show up.
Interviewer: Oh okay, and then you'd go with them
immediately?
Participant: Yeah. Pretty much. I was living out of black
Go immediately
Living out of black bin bags
No hope in permanency
No stability
No security
Always ready in case
Fear of losing things
Yeah. Pretty much (go
immediately)
I was living out of black
bin bags
It got to point
where I literally didn't even
bother taking my clothes
out of the bin bags or
anything like that.
‘cause I knew that I'd be…
I could go at any time
so was just a case of keep
my stuff in there,
where I can just grab it
bin bags. It got to point where I literally didn't even bother
taking my clothes out of the bin bags or anything like that.
‘cause I knew that I'd be… I could go at any time and so
was just a case of keep my stuff in there, where I can just
grab it.
Interviewer: Okay, so you just started living as if they
were going to turn up any time?
Participant: Yeah
Confidence knocked
Constantly settling and
moving
Impact on now – difficulty
settling
Used to play on mind
it's knocked my confidence
because, I’d settle down
somewhere
then you get moved again.
You settle down again, you
get moved again,
it just is like a vicious
circle
It’s why it's like now, why I
find it hard to settle in
it’s not always in the back
of my mind now
but it was a few years ago
like, I know I'm going to
move again soon
Interviewer: And how do you think that kind of affected
you, kind of thing?
Participant: Well, it's knocked my confidence. Just
because, I’d settle down somewhere and then you get
moved again. You settle down again, you get moved
again, it just is like a vicious circle. It’s why it's like now,
why I find it hard to settle in, cos it’s, it’s not always in
the back of my mind now, but it was a few years ago, it
was in the back of my mind like, I know I'm going to
move again soon........
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Associated memo – written after initial coding:
***** seems to be really impacted by this constant moving and lack of preparation for doing
so. I wonder if others also experienced this lack of warning in moving and the effect it had on
them – how did they respond, does it still affect them as it does *****. For ***** it seemed
that he took on looking after himself in relation to being prepared to move, a kind of
independence and I wonder if others responded the same or differently. There is a great
protectiveness over his items that he also mentioned earlier in the interview and this process
triggered risks of losing his items as well as reinforced beliefs that he would be moved
without warning repeatedly. There is a sense that he has to look after himself and his
belongings, given this lack of information (warning) about moving. I realised I did not ask if
he felt not unpacking his belongings had any effect on the placement he moved to and I
wonder if I felt nervous to ask too many questions about this particularly emotional and
distressing part of the account for him. I wonder if others responded in this practical way of
not unpacking their items if they perceived they would always move. Did they perceive they
would always move and anticipate placements would not work out as ***** appears to?
Outcome:
The reflections from after the interview, the coding and memos helped identify further
question to add to the interviews. In this example, the questions added included:
•
What did you know about what was going to happen when you moved? How did you
find this out? - and how did you respond to this? / did this effect you ? – how?
•
What did you expect in future placement moves? Why do you think you expected
this?
•
Can you tell me what was important to you when you moved placements and why?
87
Appendix H: Participant Information Sheet
88
Participant information sheet
(Young person 16+)
The experience and impact of foster placement breakdowns: The young person’s perspective
A research project
Please will you help with my research?
This sheet gives some information about the project to help you decide if you would like to participate
in this study.
Who am I?
My name is Ruth Hunter and I am training to become a Clinical Psychologist. I am undertaking a
study and would like to invite you to participate in this. This information sheet is designed to help you
understand what the project is about and what would be involved in participating in this.
What is the research?
89
My research is looking into collecting the views of individuals who have been in foster care and
experienced placement breakdowns during this time.
Why is the research being done?
Placement breakdowns in foster care are distressing times for young people but research into how
individuals would like to be supported during these times has often focussed on only asking adults
around the young person their views rather than asking the young people themselves. This has led to
people not knowing exactly how it feels for young people to experience a placement breakdown and
the impact it has on them. We also do not know young people’s views on what could help make it
better. This research aims to begin to fill in these gaps in information in order to help guide
professionals to better support young people during placement breakdowns.
What will my participation involve?
I am looking to meet with individuals to ask them some questions about their last placement
breakdown; what this experience was like for them and what the impact of it has been; how young
people reacted and responded to this event. I would like to meet to ask you these questions but can ask
these over a telephone conversation if this is easier, or over email. I will only need to do this once and
it will not take more than one hour.
You will be offered a £15 iTunes voucher for participating in the study to thank you for giving up
your time to meet with me.
Who will be in the project?
I am hoping to meet with individuals between 12 and 21 years of age who are or have been in foster
care and experienced a placement breakdown after the age of 12.
What will happen with my information?
I will record the interview I undertake with you to help me remember what we discussed and then
transcribe this. Your information will be anonymised before I analyse what you say and when I write
this up. It will be put with data from other young people to help us understand young people’s
experiences. My supervisor, a transcriber and I will be the only people that see all of your data. Some
of other work colleagues may see other sections of the transcribed interview, just to help check that I
90
have collected all that I can from the information. They will only see completely anonymised parts of
your interview. Your information will be treated confidentially by all of these people.
How do I take part or let you know if I do not want to?
If you would still like to take part, I would be very grateful if you could email me to inform me of this
(r.hunter@surrey.ac.uk) and I will arrange to meet with you, call you or email you to answer any
further questions you may have. If you are under 16 years I will need your Guardian’s consent for you
to participate. I will ask you to sign a form that you are willing to take part in the study. If you agree
to take part I will then arrange to meet with you again to ask you about your experiences. If you are
interested then I can contact you again at the end of the study to inform you of what I have found from
my research.
Could there be any problems for me if I take part?
Placement breakdowns can be unpleasant and / or difficult experiences. It is possible that thinking
and talking about these experiences may be upsetting. If you feel upset when we are talking about
them then you are welcome to stop and have a break and then continue or you can stop all together. I
will give everyone written information of people and organisations that are available if you feel there
are feelings or experiences you would like support in thinking more about. Your information will be
treated confidentially but if you share information that you or someone else is at risk of harm then I
will need to share this information with an appropriate individual, but I will discuss this with you first
if I need to do this.
How will doing the research help?
When your answers are put together with all the other participants I hope it will tell us something
about young people's views of foster placement breakdowns and how they would like support during
such times. I will write a summary of these findings to help those who work with young people to
understand what I have found out. Your privacy will be respected and your data will be used
anonymously: No one will know that you have taken part aside from me and my supervisor (and if
you are 16 or younger, your Guardian).
91
Appendix I: Consent form
92
Consent to participate in research: Young Person
Researcher: Ruth Hunter, Trainee Clinical Psychologist
Supervisor: Mary John, Registered Clinical Psychologist, HCPC registered
Project: What is the experience and impact of foster placement breakdowns from the perspective
of the young person?
 I agree to take part in this study and to be audio recorded in the interview. (If undertaking a
telephone or face-to-face interview).
 I agree for my data (what I say and talk about) to be used in this study and understand that my
data will be treated confidentially and stored safely.
 I understand that my help in this study is my choice and I have the right to withdraw from the
study within two weeks of undertaking the interview. I understand that after this it will not be
possible to withdraw my information.
 I understand that the results of this study may be published at a later stage but information
that may identify me will not be included.
I have read and understand the statements above and agree to take part in this study
93
Signature:……………………………………… Date:……………………
Appendix J: Description of Analysis - Willig’s (2009) Abbreviated Grounded Theory
Approach
94
Coding
Coding aims to break down the data into component parts. Initial codes were given first, to identify
important words or groups of words in the data. Both categories and In vivo codes were labelled using
the language of the young people to aim to reduce the risk of the 'child's perspective' becoming a
'child perspective' (Soderback, Coyne & Harder, 2011).
Intermediate coding followed later (though the concurrent nature of data collection and analysis
means the researcher moves between the initial and intermediate coding stages). This involved
connecting sub-categories but also linking categories, exploring the range of properties and
dimensions of these.
Memos
Memos are written records of the thinking of a researcher during the process of undertaking a
grounded theory approach that aim to help with data comparison, guide data gathering and enable the
exploration of relationships between categories. Short, explicit memos were used here as well as the
exploration of more detailed memos encompassing reflections and questions for further exploration.
They helped guide further exploration and data collection as well as began to synthesise the
comparisons and categories into a more cohesive understanding of the data, moving towards
developing a framework. An example of this memo is listed in Appendix J.
Theoretical sampling
Theoretical sampling helped give focus and direction to the constant comparative actions and analysis
of the data by the researcher. It helped identify when more information is needed for categories to
become saturated. The Memos were important in helping direct the decisions as to where to obtain
this information.
Theoretical Saturation and Theory generation
Due to limited participants and resources, full theoretical saturation was not achieved and therefore
only a developing framework was produced from the data. Visual diagrams were produced of the
findings, highlighting the complex relationships between the concepts and categories that emerged
through data analysis.
95
Participant validation
The findings were presented to participants to obtain their feedback and ensure that they perceived
that the model represented their experiences. Following feedback, further analysis occurred and
impacted the developing theory.
Credibility
Analytic credibility in Grounded Theory is improved by the emergent and interactive approach to
coding leads to analysis that is influenced but not wholly determined by the researcher. Comparative
analysis by the researcher aimed to help ensure the usefulness and robustness of the codes.
Theoretical Credibility is dependent on analytical credibility. In itself it is improved by the systematic
use of theoretical sampling to explore and develop understanding of properties of tentative categories.
Allowing participants to choose the stories they shared before focussing in on more specific lines of
questioning by the researcher also helped to ensure neglect of information and a focus on specific
information by the researcher (Dey, 1999). Though in this case, it was not possible to return to
participants for multiple interviews, systematic follow-up of elements highlighted in previous data
analysis aimed to improve theoretical credibility.
Yardley (2000) proposed four principles to help improve credibility further in the study. These
included the researcher ensuring sensitivity to the context by staying close to the data and reviewing
literature to (when appropriate) build theoretically upon the work of previous researchers. Supervision
throughout data analysis alongside seeking guidance on the analysis process aimed to improve the
competence of the researcher. Within this, supervision ensured and enhanced the transparency of the
process, as well as monitored the fit of the theory with the method, key for credibility of the study.
The beginnings of a coherent framework of the subject area highlight presence of the fourth key
element from Yardley (2000) of impact and importance, important in a credible study.
96
Appendix K: Example of Transcript and Coding
97
Focussed Coding /
Intermediate Coding
Line by Line coding /
Initial coding
Transcript
Interviewer: Ok. And when you
were going to move, kind of,
between the two placements… How
did that go? What was it like? What
happened?
Moving placements
was horrible
Sister chose to leave
placement without
them





Bond with brother
was important
Couldn’t stand being
moved away from
brother



Bad relationship
with foster carer
impacted on access
to see brother
it was horrible
my sister, she left
that family when
she was sixteen to
move in with her
mates’ mum who
fostered her
me and my brother
had that bond and
moving away from
him was horrible.
I couldn’t stand it.
. I was depressed as
soon as I moved to
[town2].
]. I weren’t allowed
to go to his, to go
see him ‘cause I’d
fell out with my
foster carers
it all just happened
so quick.
Too much to handle
in my … in a few
days
Participant: Oh, it was horrible. It
was actually horrible because
obviously … my sister, she left that
family when she was sixteen to move
in with her mates’ mum who fostered
her and me and my brother had that
bond and moving away from him
was horrible. Absolutely horrible. I
couldn’t stand it. I was depressed as
soon as I moved to [town2]. I weren’t
allowed to go to his, to go see him
‘cause I’d fell out with my foster
carers. And it all just happened so
quick. Too much to handle in my …
in a few days.
Move happened too
quickly too handle
Interviewer: And how ... and when
98
did you find out the placement was

Found out moving
through being told
they’d packed her
bags
They didn’t. They
told me they’d
packed my bags.
ending, relative to when you were
then moved?
Participant: They didn’t. They told
me they’d packed my bags.
Moved on the day
she found out




On the day
No warning
they’d obviously
been planning it for
a few weeks
they just didn’t tell
me.
No warning to being
moved
Interviewer: Ok. So it was on the
day?
Participant: Mmhhmm
Interviewer: There was no warning?

Placement move
planning was kept a
secret from her

Stuff was packed
without her knowing
- secrets
Yeah, while I was
away for the
weekend.
Participant: Mmmhhmm. So they’d
obviously been planning it for a few
weeks and they just didn’t tell me.
So I’d come back to
find all my stuff
packed and then
later that day I was
being moved to
[town].
Interviewer: Ok. And they’d packed
your stuff… and things?
Participant: Yeah, while I was away
Moved same day
found out moving No preparation
for the weekend.



Foster carers told
They couldn’t
handle my
behaviour anymore.
cause I was a pretty
angry child.
Interviewer: Ok.
Participant: So I’d come back to
find all my stuff packed and then
later that day I was being moved to

In a way I was glad
99

Told by foster carer
they couldn’t handle
her behaviour
anymore


‘cause the way like I
found they treated
me
obviously unhappy
as I counted them as
my mum and dad.
they was there for
everything, helped
me like grow up and
all that lot
I’m back in contact
with them now. We
still talk
occasionally.
[town].
Interviewer: And then what did they
say to you... was it the foster carers
that told you or your social worker
or…?
Participant: Foster carers. They
couldn’t handle my behaviour
anymore. Erm…. Yeah and all that,
‘cause I was a pretty angry child.
Interviewer: Ok. And how did you
Mixed feelings about
moving
feel ….
Participant: Erm… I don’t know
Glad to leave
because of way
treated
really. I, like, …. In a way I was glad
‘cause the way like I found they
treated me but obviously unhappy as
Lost what she viewed
as her mum and dad
who had been
helping her grow up


Now back in contact
with foster carer


Not wanted at foster
obviously they
didn’t want me
staying there
anymore
I had to get hold of
my social worker
and the fostering
agencies to find me
a new place
they done pretty
much straight away.
obviously from 18 I
had to sort my own
place out but from
I counted them as my mum and dad.
Like they was there for everything,
helped me like grow up and all that
lot…… I’m back in contact with
them now. We still talk occasionally.
Interviewer: Ok. And who moved
you? (Rattling in the background).
100
carer home anymore

Had to contact SS
herself to sort where
she was going.

going from erm, one
foster family to the
other, obviously
social services had
to be involved,
, the fostering
agency had to be
involved
I couldn’t say
anything about it.
Sorry about that noise.
Participant: That’s alright. Erm,
well obviously they didn’t want me
staying there anymore so obviously I
had to get hold of my social worker
and the fostering agencies to find me
SS acted immediately
to find a new place
a new place… which they done
pretty much straight away.…
obviously from 18 I had to sort my
Had to sort own
place from 18
own place out but from going from

erm, one foster family to the other,
So that was all done
behind my back.
Next thing I know
I’m moving out.
SS responsible for
her until 18 and had
no choice about this

Being moved was a
secret and a surprise
Foster carers talked
about (planned) her
leaving before they told
her.
obviously social services had to be
involved, the fostering agency had to
be involved and I couldn’t say
anything about it.
Deceit – ‘behind my
back’
Interviewer: No?
Participant: So that was all done


They didn’t even
tell me really.
They just said
‘you’re going. We
can’t have you no
more’.
behind my back. Next thing I know
I’m moving out.
Interviewer: Ok, so they’d already
joined up and talked about it?
Decisions made
about her without
her
101
Participant: Mmmhhmm.
Interviewer:..by the time the foster
No detailed
explanation for move
given.
carers told you?
Participant: Yeah.
Interviewer: Ok. Ok.


. My foster carer.
Took me
They helped me
unpack my stuff
from the car, gave
me a cuddle and
then left.
Foster carer took to
new placement
Participant: They didn’t even tell
me really. They just said ‘you’re
going. We can’t have you no more’.
Interviewer: Ok
Participant: And then they took me
Foster carer helped
her to move and then
left – (practical
support only)




It was horrible.
. I was crying …
felt like all my life
was gone between
my feet
Moving to some
house that I didn’t
really know.
Moving to [town],
an area that I didn’t
know.
to [town2].
Interviewer: And who took you?
Participant: My foster carer. They
helped me unpack my stuff from the
car, gave me a cuddle and then left.
Interviewer: And how.. how was
Upset about moving
that, having them …
Felt had lost
everything ‘all my
life was gone’
Participant: It was horrible.
Absolutely horrible. I was crying …
everything. I just felt like all my life
102
All new situation at
new foster carer’s
was gone between my feet. Moving
to some house that I didn’t really
know. Moving to [town], an area that
I didn’t know.
103
Appendix L: Memo Examples
104
Theoretical Memo: Second level – Acceptance of others’ views
Rich reports the fact that he is told he is ‘unfosterable’ without question. He reported no emotional
response to being told this, no attempt to argue or disagree with social workers appearing to already
believe this perspective himself. This was in contrast to his opposition in being moved to particular
placements or the boundaries and instructions from foster carers, to which he reports he ‘acted out’.
From the way Rich reports being told he is unfosterable it could be surmised that he was aware of this
perspective long before it was verbalised to him. He report’s himself as ‘angry’ and ‘bad’ when he
was in care and there appears no expectation that others should want him this way. It appears the
information the social workers are sharing about the fact that he is unfosterable fits with how Rich
views himself as a boy with characteristics that make him not wanted by others. There is a distinct
lack of positive attributions of himself in Rich’s account, highlighting only his ability to be
independent which is a strength in light of the rejection from adults in a position to offer care to him.
Rich does not challenge the view of the social workers, nor does he expect them to search further to
find a placement for him. There is a finality and a pervasive hopelessness of the situation that he is an
unwanted child because he is naughty, something he also believes. He has no sense of entitlement to
be wanted, again a mirror of the apparent attitude of the social workers in giving up on seeking a
placement for him. It is unclear with whom this narrative started, whether it emerged from Rich, the
social workers or others who cared for him. But it appears that there is now a cycle of this belief
between Rich and his social workers.
Reflections:
In reflecting on this situation for Rich I felt a strong reaction of sadness, both in him being told such
cruel information but also that this appeared to be true; that no foster parents would take him in and
care for him. I found myself considering what message this must be giving Rich about his worth and
his value. I feel some anger at the way this information was given by social workers; in an apparently
blunt and consequently almost cruel way without clear consideration or acknowledgement of how this
news may impact Rich. Consequently I was aware of feeling quite protective of Rich. His lack of
emotional response struck me. I found myself considering how this apparent ‘mature response’ in
accepting this piece of information could well be in contrast to the true undercurrent of feelings and
whether the sense of hopelessness openly reported in other elements of his narrative was contributing
to the lack of emotional expression spoken of here. There was a brief acknowledgement that maybe it
was not appropriate for social workers to have shared this information with him in the way they did,
but this was quickly followed by a focus on his maturity. I wondered whether previous descriptions of
himself as ‘bad’ meant he felt he was responsible for events and could not disagree with social
workers’ decisions to tell him what he perceived was the truth. And furthermore, a truth he felt
responsible for.
105
106
Appendix M: Example of a finding evidenced across interviews
107
Evidence: Why the need for self-sufficiency response
- Lack of support
-could not rely on social worker












All my Social Workers have been incredibly hard to get hold of. Obviously I do appreciate
that they have a huge workload but when you need someone then and now, it is important that
you can get hold of them. (Sian)
They actually abused my Children’s rights. Because they made decisions without asking
me… my opinion first. They did lots of things wrong. I really hated her. She was
incompetent. Like she’d come along and say ‘We need to do this, this, this and this and these
things’ and then wouldn’t do them herself. (Rich)
‘Cause they try and suit you with the best placement but some Social Workers don’t know
their young people well enough to be able to choose that. So they end up putting them in the
wrong placement and they just self-destruct. (Lisa)
I'm sure Social Workers get all the time 'I want to be moved. I don't like these people' and
then it's just like one thing, like they were allowed, I don't know, a bar of chocolate or
something. So I think it's, like, understandable that they were, erm, a bit 'We don't want to
move them' 'cause it's a lot of hassle. But at the same time, because I'd said it so many times
they never listened to me. (Sian)
I never ever thought as if they were like seriously considering it. They just said, 'We'll see
how it goes in a few weeks.' And I was just at such a low point. (Adam)
Like, Ok their Social Workers supposed to…. but my Social Worker's supposed to be on my
side. I didn't want it to be sides but like, they were supposed to be like helping me and
erm...and I always felt as if it was like reasoning with [Foster carer] and never … it was never
like what I wanted to happen. (Rich)
I felt really hurt and tricked…cheated, if you know what I mean? I thought ‘Yeah this is it.
I’m gonna stay here for a while.’ But no. I felt cheated and that. (Lucy)
I think it was because it was just too much effort. It always felt like they were just like 'Oh
another problem.' They probably have like so many kids to deal (Jake)
I just felt so on my own like no-one would listen to me at all. (Lisa)
I would love my choice to be increased but until I hit eighteen everyone's always trying to tell
me what to do because in their eyes I'm still a child, whether I have enough maturity to take
responsibility for myself or not. So whether I wanted my choice to be heard... sometimes they
make decisions that were completely wrong for me, like completely wrong for who I am.
Like, not what I would be happy doing but obviously they put me into a box; I'm a child and
this is best for children so we're going to do this and it's not (Sian)
I was just so angry that my welfare… you know, like a child’s welfare comes second to
money. I think that’s disgusting. Like it’s somebody’s life, it’s not just somebody’s job. Like,
it might be a job to them, like having to move me and you know, paying for it, but it’s my
life, rather than something that they can make decisions about, like half-heartedly. And like,
they can cut corners and save money and that’s what’s important rather than my wellbeing.
(Adam)
Like, it’s my wellbeing but they don’t care about that. All they cared about money. (Jake)
108







Because my... I met my Social … my new Social Worker on the day that I left. I didn't really
know her. Like, I couldn't... Like, she was trying to comfort me because I was upset and I felt
a bit... I felt a bit like she was intruding... Like, I felt like, 'This is not for you. This is
something that is very private for me.' (Lucy)
I didn’t feel like I had anybody there for me, like, to talk to about it.I mean I couldn’t talk to
my Social Worker; They was always busy with their other cases. (Amy)
They don't really listen to you. You're still treated as a child and like, you're not given
responsibility for yourself and that you're not... you're not trusted to … to make responsible
decisions for yourself. So... they kind of do what they want and put you wherever you are and
you can't really control.... (Sian)
‘Cause if I had a choice I don’t think I would have gone there. But you don’t really get a
choice in where you end up. That’s Social Services that. (Amy)
It's constantly criticising yourself. And like, in Social Services, the children are always being
criticised. They always have to have goals to achieve. Like, they have plans to make
themselves better. (Rich)
They actually told me that that’s why they were trying to move me; because they couldn’t
afford it and that they thought it would be better for me to be up near lots of people I knew
and my family. But it wasn’t actually at the time. (Rich)
I felt safe there and I was getting better and Social Services just pushed me and pushed me to
go somewhere that I didn’t want to go. (Lisa)
109
Appendix N: Example of search for triangulation of results
110
Database:
Psychinfo
Search terms:
Foster* AND Surviv* AND Child* OR Young Pe* OR
adolescen* OR teen* OR
2005-2015. Peer-reviewed.
Results:
111
Relevant results:
34
Key elements
Resilience, Adversity, Thriving, trauma-related beliefs,
highlighted in
Self-reliance
results:
Future, Psychodynamic adjustment (ego)
Destruction (as a means of survival)
Reactive attachment disorder,
111
MRP Proposal
Impact of disrupted placements on the well-being of children
who are accommodated
By
Ruth Joanne Hunter
School of Psychology
Faculty of Arts and Human Sciences
University of Surrey
August 2012
112
Introduction
Background and theoretical rationale
In March 2011, just under 60,000 children were in foster care in the UK (British Association
of Adoption and Fostering, 2011) and three times more likely to experience mental health
difficulties than the general youth and child population. Despite these statistics, research into
interventions and support for these fostered individuals is largely based on US populations
with limited validation of applicability to individuals in the UK. In 1997, Berridge identified
only 13 UK foster care based studies. Although this has increased recently, understanding
from studies centres only around how to support foster carers, what effective foster care is
and the benefits of 'joined-up' service delivery in supporting foster children. (Sellick, 2006).
UK (but also international) research has frequently ignored the experiences and views of
fostered children themselves, focusing largely on the perspectives of foster carers and other
adults involved in their care and support. This lack of information from the young people
themselves is not only unethical when determining what care they received but also risks
providing care and resources that are less effective or at worst ineffective at meeting their
needs and wishes. (DOH, 2009).
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On top of the increased risk of mental health difficulties for young people within foster care,
breakdown of placements creates further risk for development of emotional, behavioural and
mental health problems, (Rubin et al, 2004) highlighting an important area for understanding
and appropriate support. The Children's Act (1989) highlights a duty of professionals to
facilitate contact between children in care and their biological parents, but it is an area with
on-going debates as to the costs and benefits of this. Leathers (2003) identified that some
children experienced conflicts of loyalty between biological and foster families and this could
lead to problems of adjustment. Brown & Bednar's (2006) found higher conflict loyalty was
associated with greater emotional and behavioural problems, difficulties that have been wellestablished as positively associated with greater risk of placement breakdown. It seems clear
that the views of foster children in how they manage these relationships is important and
currently missing (Leathers, 2003), not just in successful placements but the views of those
who have experienced placement breakdowns and are consequently at greater risk of
emotional and behavioural and mental health problems.
In summary, we lack knowledge and understanding of how young people themselves
experience placement breakdowns in the UK and manage their relationships with their
biological families during these difficult transitions and experiences and consequently what
support they would appreciate at this time. Understanding of resilience and needs must go
further than registering percentages of children without problems and measuring behaviour or
asking only the opinions of parents and professionals to asking the young people themselves.
(Singer et al, 2004). If not, working in the best interests of the child, as encouraged by current
114
policy risks riding on incomplete information and assumptions of what they want and need.
(Sempek & Woody, 2010). This study aims to begin to explore this area in order to build an
understanding that could help inform professionals involved in supporting young people
during this time in the most effective way.
Research Question
What are the psychological and social impacts of disrupted placements on the well-being of
children who are accommodated?
Method
Participants
Between fifteen and twenty participants will be recruited in order to gain enough information
to produce a meaningful understanding of the topic in question.
115
Inclusion Criteria
1. 21-30 years: To help ensure they are sufficiently distanced from the experiences of
disrupted placements that they are less distressed reflecting on their experiences but
recent enough to be able to remember their experiences well.
2. Have been in foster care for at least one year*
3. One placement breakdown minimum*
4. Contact with biological parents for at least one year on entering foster care
5. Grew up in the UK
*. These experiences will have been occurring at or after the age of 7, though individuals may
have entered foster care earlier. The reasoning for this age cut-off is due to children’s
information processing capacity and reliance on verbal recollection in data collection. Piaget
(1983) proposed that prior to seven years children have less organised logical thought, are
more egocentric and have fewer abstract thinking abilities which will impact on recall of
these memories. Cordon et al (2004) highlighted experiences prior to language development
will be difficult to recall linguistically.
116
Exclusion criteria
 Individuals who were in solely kin placements as Messing (2006) proposed that they
do not feel the trauma associated with being removed from one's family.
 Individuals with specific difficulties such as Learning Disabilities or developmental
conditions that may make participation in the study difficult due to potential
impairments in intellectual disability and communication.
 Individuals currently seeking help from mental health services or with a diagnosed
mental health difficulty due to the possible negative impact of the subject on them,
although there is awareness that some individuals may have mental health difficulties
that have not been formally diagnosed and / or treated.
Feasibility of recruitment
It is anticipated that adults who have experienced challenging experiences as children will
want to share their experiences for a variety of motivations. Some may want to share their
thoughts for altruistic reasons to ensure that other young people have the benefits of services
more able to respond effectively whilst others may wish to share their frustrations.
Recruitment Strategy
117
Participants will be recruited through advertisements in the British Association for Adoption
and Fostering, local newspapers (in the Guildford area) and advertisements on University
Supervisors’ website (Ms Mary John, Programme Director PsychD Clinical Psychology). A
PhD forum that advertises studies needing participants will also be used alongside using the
University of Surrey’s research scheme that advertises studies to students (targeting mature
students or those 21-30 years).
A brief piece of information about the study will be given and participants will be asked to
contact via email, phone or text if interested in participating. More detailed information will
then be sent and a meeting will be arranged answer any questions and ensure the participant
meets the inclusion criteria. Following this, written consent will be discussed and obtained if
the individual wishes to participate in the study, ensuring this is a minimum of 24 hours after
receiving the detailed information sheet about the study. If consent is given, a meeting to
undertake data collection and the interview will be arranged.
Design and proposed data analysis
118
Given the lack of research in this area specifically with individuals who have experienced
placement breakdowns and disruptions, a theory of how this is viewed and managed by
individuals is lacking. Therefore this study will be a qualitative interview study using a
Grounded theory approach in line with Charmaz (2006) in order to enable new theory to
emerge in an area that has little current understanding and no current theory specific to this
context. The focus on process and change within the Grounded Theory approach
acknowledges that what is studied is a dynamic and socially constructed version of events
and experiences which sits well in studying the concept of 'impact' in relation to placement
breakdowns. Consequently, conclusions and findings will be acknowledged as an
interpretation of the concepts explored rather than a 'true' portrayal.
IPA is not being used as it has a narrower focus than Grounded Theory, looking at
experiences for individuals rather than enabling a wider understanding to be developed.
(Willig, 2008).
An abbreviated version of Grounded Theory will be used due to time and resource constraints
and a likely limited number of participants. If possible however, some initial analysis will be
undertaken between interviews to look for emerging categories to help direct further
interviews more effectively. (Willig, 2008).
119
It is hoped that further research may be able to explore the theory that will be developed
through this study and its application to clinical practise to support children experiencing
placement breakdowns and disruptions in foster or adoptive care.
A narrative approach will be used in the event that few participants are able to be recruited
for the study.
Measures
 Advertisements will be designed with the University of Surrey Co-ordinator of
Service User and Carer Involvement.
 Information sheet. (See Appendix A*).
 Consent form*
 Demographics. The following will be collected through brief questions: current age,
gender, ethnicity, age at entry to foster care, reason for leaving biological family,
number and length of placements, number of disrupted placements / unsuccessful
placements and when these were, details of contact with biological parents during
care, presence of biological siblings in placements, current contact with biological
family
 The Kinetic Family Drawing. Developed in 1970 by Burns and Kaufman, this test
120
requires the participant to draw a picture of his or her entire family. This picture is
meant to elicit the individuals’ attitudes toward his or her family and the overall
family dynamics.
 Introduction to Data collection. (See Appendix B*).
 Debrief sheet. (See Appendix C*)
 Audio recording equipment to record the interviews.
*These items will all be amended following consultation with service users who have been in
foster care previously but may not meet all criteria for the study, arranged in conjunction with
the Co-ordinator of Service User and Carer involvement.
Procedure
The participants will be interviewed alone. It will be undertaken preferably in a room that is
quiet and with limited distractions. Interviews will be audio recorded for the purposes of
transcription and in line with Grounded Theory are likely to reduce in length as the study
progresses, starting at approximately 50 minutes. Telephone interviews will also be offered if
preferred or more convenient for the participant.
121
Data collection:
1. Introductions, including reminding the participants of the purpose of the study as well
as what to expect from the interview. Confidentiality will also be discussed and the
participants will be given the opportunity to ask any questions. They will be reminded
that they can stop the interview at any time or not answer questions that they do not
wish to. This session will not be recorded to avoid identifiable information being
recorded.
2. Demographic data will be collected through short fixed questions. This will not be
audio recorded to help protect confidentiality.
3. The Kinetic Family Drawing. Once drawn, the drawing is then discussed with the
individual to help ascertain why they have drawn the picture in the way they have. In
this scenario the drawing will be extended to include those involved in the individual's
childhood – both biological and foster / adoptive family. Administration of this test
will also not be audio recorded to avoid recording identifiable information but paper
notes will be taken regarding the details of the discussions. Confidentiality will be
protected by the allocation of a letter to the participant and only first names will be
recorded on the drawing. Alongside eliciting information about the individuals view
of those involved in their childhood it will provide a platform from which to develop
122
engagement and rapport and help the participant feel at ease prior to undertaking the
interview.
4. Semi-structured interview: In line with abbreviated Grounded Theory, the interview
will start with explorative general questions about the research topic and the interview
schedule may change as the participants raise topics that may appear valuable to
pursue with later participants.
This part of the study will be recorded and transcribed in adherence to University
policy for the recording, transportation and storage of audio recordings.
5. Debrief / Ending
A debrief sheet will be given and the participant will be given the opportunity to ask
any questions they have about the study in general or the interview and task they have
just completed.
6. Follow-up
Participants will be asked if they would like to see and give feedback on the data
collected. A follow-up call will also be offered to ensure participants' questions have
been answered and they are directed to services for further support if required.
123
Ethical Considerations
Application will be made to the Faculty of Arts and Human Sciences Ethics Committee as
this study involves recruiting individuals who are potentially vulnerable and discussion of a
sensitive and potentially distressing subject. Below is a list of potential ethical considerations
in relation to this study:
1. Discussing relationships and potentially distressing experiences of separation and
placement breakdowns from the past is a topic to be handled sensitively and
empathetically to ensure distress is minimised. Highlighting their right to opt out of
answering questions or withdraw their consent at any time aims to help protect the
participants from feeling obliged to discuss subjects or share information they do not
wish to. Discussion prior to consent will highlight the subject topic and support the
participants in identifying whether it is a subject they feel able to discuss without too
much distress. The debrief discussion and information sheet and follow-up call aims
to help provide a space for the participant to reduce distress if this occurs during the
interview. The interview will also take place in a setting that is private and free from
disturbances to help reassure the participant that their privacy and feelings discussing
potentially difficult subjects are being respected.
2. Confidentiality will be discussed in the first meeting and at the start of the interview.
If disclosures emerge through the interview, it will be ascertained whether these have
124
been addressed in the past and advise of the option to discuss the matter with the
police. It will also be explored whether any other children may still be at risk and
Safeguarding procedures will be followed if appropriate.
3. Disseminating the research is important in ensuring the participants are not subjected
to discussing private and potentially distressing issues without purpose. The research
aims to help inform support of young people experiencing placement breakdowns
rather. . Opportunities to share the findings of the research and publish the work will
therefore be sought.
4. Individuals may feel obliged to participate due to the demand characteristics of
helping others which may lead to a sense of social compliance, an awareness of the
lack of children’s voices in this area and wanting to help other foster children be
better supported. They may not want however, to discuss such difficult topics.
Discussing the study in detail before and giving time to consent will aim to try and
combat this and ensure the participants are as informed as possible before agreeing to
do study.
Researcher concerns
The researcher is aware of lone working policies and a risk assessment will be undertaken
with the supervisor. The University lone working policy will be followed with the supervisor
being informed of the venues and meeting time commencement and ending.
125
R&D Considerations
Not required.
Service User and Carer Consultation / Involvement
Consultation will be sought from the Co-ordinator of Service User and Carer Involvement at
the University of Surrey over the design of the adverts that will be placed on the internet and
in the newspapers to ensure appropriate wording and explanation. Further consultation will
be sought with two service users as to the questions that will be used in the interview to
ensure they are being asked in the most appropriate, sensitive and respectful manner. They
will be amended as appropriate following this.
Feasibility Issues
126
1. Difficulties in recruiting participants may arise from the reluctance to discuss such a
private and potentially distressing topic or accessing them. Individuals may withdraw
participation from the study once the interview has started. Benefits of participating in
the study will be shared, such as helping inform professionals from the child's
perspective of how to more effectively support children experiencing placement
breakdowns in the UK will be highlighted.
2. It has been found that foster children often keep their status private to avoid stigma
and feelings of difference (Finkelstein et al, 2002) and this may continue into
adulthood and lead to a reluctance to express an interest in the study. For those that do
express an interest, reassurance will be given in relation to confidentiality and a nonjudgemental stance of the interview, as well as the value of their opinions.
3. Despite the multiple methods, it may be difficult to recruit the number of participants
required. If this occurs, narrative evaluation will be employed rather than Grounded
Theory to analyse the data collected.
4. Some individuals may find it difficult to remember some of the demographic data
required if they had numerous placements from an early age.
127
5. Participants may find it difficult to talk openly about their feelings about both their
foster and biological families. Individuals may feel loyal to those that cared for them
and struggle to report more negative aspects of their thoughts and feelings about their
experiences. Reassurance about the value of all their views and opinions will be given
and loyalty issues will be taken into consideration.
Dissemination strategy
Publication will be sought alongside finding other appropriate arenas such as conferences to
share the findings and help potentially inform clinical practise and encourage further
exploration of this area.
Proposed Study Timeline
Ethics Submission:
10/12
Data collection start:
01/13
128
complete:
Data analysis start:
complete:
08/13
08/13
10/13
Complete draft: Results / Discussion :
12/13
Submit complete draft:
02/14
129
References
Berridge, D. (1997). Foster care: A research review. London: HMSO.
British Association of Adoption and Fostering. (2011). Retrieved from:
http://www.baaf.org.uk/res/stats
Brown, J., & Bednar, L. (2006). Foster parent perception of placement breakdowns. Child
and. Youth Services Review, 28, 1497–1511.
Burns, R. C., & Kaufman, S. H. (1970). Kinetic family drawings (K-F-D): An introduction to
understanding children through kinetic drawings. New York: Brunner/Mazel.
Charmaz, K. (2006). Constructing Grounded Theory. London: Sage.
Cordon, I. M., Pipe, M., Sayfan, L., Melinder, A., & Goodman, G. (2004).
Memory
for traumatic experiences in early childhood. Developmental Review, 24, 101-132.
Department of health. (2000). Children Act 1989. London: HMSO.
http://www.legislation.gov.uk
Retrieved from:
Department of Health. (2009). Promoting the health and wellbeing of looked after children –
revised statutory guidance. London. TSO.
130
Finkelstein, M., Wamsley, M., & Miranda, D. (2002). What keeps children in foster care
from succeeding in school? Views of early adolescents and the adults in their lives. Vera
Institute of Justice. United States.
Leathers, S. (2003). Parental visiting, conflicting allegiances, and emotional and behavioural
problems among foster children. Family relations, 52, 53-63.
Messing, J. (2006). From the Child’s Perspective: A qualitative analysis of kinship care
placements. Children and Youth Services Review, 28, 1415-1434.
Piaget, J. (1983). "Piaget's Theory". In P. Mussen (Ed.) Handbook of child
psychology. Wiley.
Rubin, D., Alessandrini, A., Feuddtner, C., Mandell D., Localio, R. & Hadley, T. (2004).
Placement stability and mental health costs for children in foster care. Paediatrics, 113, 13361341.
Sellick, C. (2006). From famine to feast: A review of the foster care research literature.
Children & Society, 20, 67-74.
Singer, E., Doornenbel, J. & Okma, K. (2004). Why do children resist or obey their foster
parents? The inner logic of children’s behaviour during discipline. Child Welfare league of
America, 83, 581-610.
Willig, C. (2008). Introducing qualitative research in psychology. Open University Press:
England.
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132
Literature review
UK evidence for interventions to improve the psychological
wellbeing of foster children: A systematic review
Year 1
April 2012
133
Abstract
Statistics from the UK highlight that foster children and young people are more than three
times more likely than those in the general youth and child population to experience mental
health difficulties. (Meltzer et al. 2003, 2004). The majority of interventions to improve foster
children's psychological wellbeing have been developed and validated in the US yet some of
these are being used in the UK. This systematic literature review looked at the research on the
effectiveness of interventions to improve the social, emotional and behavioural wellbeing of
foster children in the UK. It was a concern that few papers were found and all had substantial
methodological weaknesses that highlighted a large gap for good quality detailed research to
be undertaken to ensure professionals are appropriately and effectively supporting this
vulnerable group of individuals, directly or indirectly with the interventions they use. Future
research needs to address these methodological issues, build on current research, identify
interventions for difficulties other than behavioural problems and consider issues of diversity
and difference within this vulnerable group.
Key words: Foster, children, young people, UK, interventions, review, outcomes
134
Introduction
Foster children in the UK
Statistics from Department for Education 2011 National Statistics showed that over 48,000
children were in foster care in the UK on March 31st 2011. Children and youth in foster care
have higher rates of mental health difficulties than those in the general population. Ford et al
(2007) highlighted that the results of a number of studies by Meltzer et al (2000, 2003,
2004a) emphasised that even compared to the most disadvantaged children outside the care
system, the mental health of children looked after by local authorities was significantly
worse. These studies all involved interviewing carers, teachers and children (between 11-15
years) and using the International Statistical Classification of Diseases and Health Related
Disorders (ICD-10) to identify a prevalence of a mental health disorder. This was defined by
Meltzer et al (2000) as “a clinically recognisable set of symptoms or behaviours associated
with considerable distress and substantial interference with personal functions”. Meltzer et al
(2003) found that ‘mental disorders’ were present in 40% of the fostered population in
England compared to just 13% and 10% for boys and girls between 11 and 15 years
respectively and a prevalence of 6% for children between 5-10 years in the general
population. (Meltzer et al. 2000). Meltzer et al (2004a, b) found similar prevalence rates for
foster children in Scotland and Wales. On top of this, Meltzer et al (2003) highlighted that for
looked after children in England, mental health problems (that did not reach criteria for a
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disorder) was reported for over two fifths of the children included in the study by their carers.
A study by Ward et al (2008) found that 70-80% of foster children and young people require
specialist emotional and behavioural support. Tapsfield & Collier's (2005) study reported a
37% prevalence of conduct disorder in looked-after children in the UK, which was almost
three times higher than that of the general population. Meltzer et al (2004a) identified that
after conduct disorders, emotional disorders (specifically anxiety disorders), were the most
common mental disorders in looked-after children in Scotland, England and Wales. This was
followed by hyperkinetic disorders and depression. Such increased prevalence rates highlight
the importance of effective and appropriate psychological support and interventions for foster
children.
Being healthy, staying safe, enjoying and achieving, making a positive contribution and
economic wellbeing were the five outcome aims for children proposed by the government in
2003 (Department for Education and Skills. 2003). If foster children are to be supported to
achieve the 5 outcomes then, given their increased risk and vulnerability to mental health
difficulties previously detailed then clearly a greater level of mental health support is needed
for these individuals. Best practise is to use evidenced based interventions and support when
undertaking any type of psychological support, to ensure at worst that no harm is being done,
providing the best outcome possible for the intended individuals and that the time and
resources of professionals, foster carers and foster children are not being wasted. (National
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Institute for Clinical Excellence. 2001). Cutbacks and changes in health and social services
mean that there are even fewer resources available to promote wellbeing, making it even
more essential that the interventions and psychological support being implemented are not
only the most effective, but effective for the most needy as well as those with less intense
difficulties.
Established evidence
A basic search of Ebsco, Psychinfo, Medline highlights a wealth of foster care literature and
research from the United States (US). Reviews of this research highlight interventions and
approaches to mental health care that have the best evidence base so far. Landsverk et al's
(2009) work is the most recent published review and they reviewed the evidence for
psychosocial interventions for the most prevalent conditions found in foster children in the
US. They highlighted that for post-traumatic stress disorder, abuse related trauma, depression,
substance abuse and disruptive behaviour disorders, interventions that addressed symptoms,
behaviour and functioning had the best (and indeed a 'strong') evidence base. It is beyond the
scope of this review to detail all the interventions found by Landsverk et al (2009) to be
promising interventions for each of these difficulties. But they found that most interventions
were brief and usually more effective when the caregiver was actively involved. Interventions
varied between involving multiple professionals, the child and the carer, being community
based or clinic based, and of course, the theoretical basis for the approach, highlighting the
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breadth of approaches that have been found to be effective in the US.
UK programmes being implemented
Indeed some of these US evidence-based approaches have already begun to be implemented
in the UK. McAuley & Davis (2009) identified that ten local authorities have implemented
Multi-systemic therapy (MST) programmes for young people aged 11-17 and their families
who are on the edge of custody and an additional site piloting MST specifically for children
who have experienced abuse or neglect. MST is a US developed intensive home-based family
based intervention that acknowledges the role of the family environment on difficulties
experienced by the child and the family. Landsverk et al (2009) identified this as an
intervention with promise, concluding from critiquing 10 studies into MFT that it was
particularly promising for working with foster children to address substance abuse and/or
disruptive behaviours. They concluded it was positively associated with a reduction in
aggressive behaviours in foster children and fewer placements. McAuley & Davis (2009) also
identified 14 local authorities implementing Multi-dimensional Treatment Foster Care
(MTFC) programmes for adolescents aged 11-17 years, six programmes for 3-6 year-olds and
eight sites for children aged 7-11 years. McAuley & Davis (2009) highlighted initiatives to
cascade the programme out to other local authorities. MTFC is a US established programme
based on social learning theory that aims to reduce problem behaviours and promote
developmentally appropriate and prosocial behaviour through a multifaceted, multiple setting
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based approach. This includes foster parenting in the home using specific behavioural
techniques, skills training and supportive therapy for the foster child, school consultations
and family therapy (Moore & Chamberlain. 1994). The other approach identified as being
developed when McAuley & Davis (2009) published their research was a cognitivebehavioural programme called the Fostering Changes Programme, which focussed on helping
foster carers manage children and was developed by Pallett et al (2002). The Fostering
Changes Programme (FCP) was the only intervention to be highlighted by McAuley & Davis
(2009) as having been developed and trialled in the UK prior to being rolled out. It is based
on 'The Incredible Years' programme (Webster-Stratton, 1998), which was developed in the
US, and aimed to promote positive parenting and reduce children's behavioural difficulties
and improve their problem solving and social skills. The FCP trial found carers reported
improvements in their foster children's behaviour, but results from their other measures were
less supportive of this. Through their study, McAuley and Davis (2009) highlighted an
apparent drive to pilot interventions in the UK that had been shown to have a strong or
emerging evidence-base in the US in relation to effectiveness. They discussed hopes that
these pilots would reinforce the value of evidence-based commissioning and gave an
acknowledgement of the need to obtain evidence of the effectiveness of these interventions
for the UK foster population. No detail however, as to how or why these interventions may or
may not be applicable in the UK was addressed in the study: Details that seem fundamental to
the predictions of whether these interventions are likely to be effective for the UK foster
population. Services in the UK increasingly acknowledge the diversity of the UK population
itself and the impact that these differences in culture and background may have on
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psychological interventions and support. Also, foster children in themselves vary on a
multitude of issues: their history, reason for entering care, length of time in care, ethnic
background, religion, culture, etc. Identifying and acknowledging some of these differences
may provide insight into how and why the effectiveness of interventions with an evidencebase in the US may differ in the UK and guide appropriate adjustments or changes and the
appropriateness of implementing or testing these.
US and UK foster care
In 2007, Thoburn published a study comparing statistics about children in out-of-home care
across a number of different countries. She noted a number of similarities and comparisons
between the US and the UK in her analysis of the statistics she collated. Thoburn (2007)
identified that a fewer percentage of those entering care were 16-17 year olds in the UK than
the US, 7% and 20% respectively and the UK had a higher percentage entering at 10-15 years
(40% to 25% respectively) but that for those under 12 months the percentages were very
similar, (17% and 15%). Thoburn's (2007) data identified that in the USA over 90% of
children were taken into out-of-home care as a result of abuse or neglect, whereas this was
only 48% for England, with other factors listed as parental disabilities or illness (8%),
disability or problems of the child (9%), abandonment (11%) and relationships or other
family problems (24%). Wales also had similar percentages to England. Thoburn (2007) also
hypothesised that using performance targets to control welfare spending was linked to seeing
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out-of-home care as something to be avoided; a similarity for the USA and the UK.
Differences between the USA and the UK care system were also highlighted in the report
through comparing the legal status of children entering care on one particular day: For the
USA, over 95% entered into care as a result of a court decision, compared to only 33% in the
UK. The USA and UK had similar average lengths of time spent in out-of-home care: 1.8
year and 2.1 years respectively and both countries had a 5% adoption rate. Also, both
countries had similar percentages of children placed in un-related foster family care: Between
47% and 57% for the four UK countries and 46% in the USA.
As highlighted earlier, Landsverk et al (2009) identified post-traumatic stress disorder, abuse
related trauma, depression, substance abuse and disruptive behaviour disorders as the most
prevalent mental health conditions of children in foster care in the US. In comparison,
Meltzer et al (2003) highlighted conduct disorders as the most common disorder experienced
by children in care (not just foster children) in the UK, followed by anxiety disorders and
hyperkinetic disorders. Statistics however do not report on the level of impact of the mental
health difficulties individually which is also likely to impact what types of support and
interventions need to be prioritised by each country.
On top of differences in legislation, characteristics and factors related to children entering
foster care; in both countries, some ethnic minorities are overrepresented in foster care. In the
UK, African Caribbean and mixed African Caribbean and white heritage are overrepresented
in foster care with black Africans overrepresented to a lesser extent. (Thoburn. 2007). In the
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USA, African American and Native American children are overrepresented in out-of-home
care statistics, with Hispanic children increasingly so. (Thoburn. 2007). In the UK however,
Thoburn (2007) highlight the underrepresentation of those of East and South Asian heritage.
Statistics on the percentage of foster carers from ethnic minorities in the UK and the US are
difficult to obtain, likely due to the presence of public and private foster-care employment
agencies and variations in data governance that create difficulties in obtaining statistics from
these. There are a range of other factors such as average number of placements, placements
with siblings, payment of foster carers and a number of other factors that may vary between
the US and the UK. These could all be issues of diversity and difference that may impact the
appropriateness or effectiveness of psychological interventions.
These statistics highlight the breadth and depth of similarities and differences between both
the foster care systems themselves and the characteristics of the children fostered in these
systems and their difficulties. As discussed, there are also likely to be many more. Given
these details, it seems complacent to assume that the evidence for effectiveness of
interventions used in the USA is automatically relevant to the UK. It highlights the
implementation of such evidence-based practises across the UK as a risky and potentially
costly trial, in terms of public money and psychosocial impact on the foster children and their
families if it is an ineffective intervention. Though US research dominates the literature
databases, one would hope that given the extent that programmes such as MST and MTFC
have already been implemented in a number of local authorities, that UK based evidence for
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effectiveness is now guiding practise in the UK more than US evidence. This literature
review will now look at what evidence exists for the effectiveness of interventions for foster
children in the UK.
Method
An electronic systematic literature search was undertaken on Psychinfo, Medline, Ebsco,
Web of Knowledge and Cochrane databases. It included peer-reviewed papers published from
January 2005 to present. The search terms used were “intervention* OR therap*”; “foster*
OR looked after OR accommodated OR” and “UK OR United Kingdom OR Brit* OR Welsh
OR Wales OR Scot* OR Northern Ireland OR Northern Irish OR Engl*”. Papers were
excluded if they did not focus on interventions and outcomes related to children while in
foster care (therefore excluding a focus on transition and adult outcomes of foster care).
Papers were also excluded if they focussed on policies rather than practise, interventions
within education rather than health, or if they focussed specifically on foster children with
additional medical health needs such as Learning Disabilities. These exclusion criteria were
used as they represent specific areas and groups that are above and beyond the scope of this
review. Papers were not excluded based on type of evidence, though consideration as to the
quality of each type of evidence is evaluated in the review in line with guidelines from the
National Institute of Clinical Excellence (NICE, 2006). Papers that discussed a theoretical
approach and used examples such as case studies were included, in order to gain an
understanding of potential areas for developments or changes to interventions.
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The search was performed February 2012 and produced 11 papers that described or evaluated
interventions with foster children in the UK. These were divided into categories for
evaluation based on who was involved in the intervention; 1) foster parents 2) foster children
3) mixed focus (including combinations of foster parents, foster children, social workers,
etc.). The critique of each of the studies was focussed on the methodology, in order to
evaluate the strength and validity of the respective results for each, in order to determine the
strength of the evidence from each paper, rather than the theoretical approach of the
intervention.
Results
Interventions with Parents of Foster Children
Interventions with foster carers are often used as indirect interventions to improve the social,
emotional and behavioural outcomes of foster children; most frequently aiming to equip
foster carers to manage foster children's difficulties, in order to improve placement stability (a
factor that can impact the social, emotional and behavioural outcomes of foster children
(Holland, Faulkner & Perez-del-Aguila. 2005)) and help foster children reach their potential.
(McDaniel et al. 2011).
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Two of the papers from the search focussed on CBT based programmes for foster carers.
MacDonald et al (2005) looked at the effectiveness of CBT training for parents of foster
children with challenging behaviour. They used a randomised controlled trial (RCT) using
groups of foster carers. 117 foster carers (all but 2 of whom were white) opted into the study;
67 of these were in the training group and 50 in the control group. Data was collected before
and after the training and at 6 months follow-up. Results were that foster-carers in the
training group reported increased confidence in ability to deal with behaviour problems and
scored higher on knowledge of behavioural principles compared to those in the control group.
McDonald et al (2005) queried whether the content and length of the course could have led to
disappointing outcomes or a lack of support to help develop the skills learnt. The authors also
suggest the limited effectiveness of the CBT training in the results could have been due to
using carers of extremely 'difficult' children. They proposed the intervention be refined to
deal with the weaknesses identified to ascertain whether in fact the intervention is ineffective
or whether this study failed to identify the effectiveness of it due to its limitations.
Herbert & Wookey (2007) investigated whether a broadly based CBT programme could
indirectly reduce the challenging behaviour of looked-after children and increase placement
stability, through improving carers' self-assurance and behaviour management skills. Their
study used a randomised controlled study, with 67 foster-carers in the experimental group and
50 in the control group. Those in the experimental group were randomly allocated into six
groups, all given the same intervention. Their ages ranged from 32 to 65 and had a mean of
8.68 years of foster experience. The intervention, the Child Wise Programme (CWP) was
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devised by the authors. It is a programme that aims to be collaborative between facilitators
and foster-carers and to empower caregivers by giving them a conceptual framework (CBT
and behavioural principles and techniques) that enables them to resolve problems themselves.
Herbert & Wookey (2007) reported that CWP has obtained positive results when used with
birth parents but had not been validated for use with foster-carers, but this was not referenced
in this paper. Results were a significant increase in carers' confidence, a majority of foster
carers reporting improvements in children's behaviour (but not to a significant level) and that
these were generally attributed to having acquired new behavioural management skills. There
was no reduction found in relation to unplanned placement breakdowns where behaviour
problems were indicated.
Though both these CBT based approaches suggest some promise in supporting foster carers
with children with challenging behaviours in the UK, both studies relied only on parent
reports of child outcomes and failed to identify detailed demographics of the foster-carers and
foster-children involved that could shed light on whom specifically these interventions may
work for. Though they used randomised controlled trials, generalisability of the results for
both studies is limited by relatively small sample sizes and drop-outs of participants, but also
for McDonald et al (2005), by the fact that carers were required to opt into the study. Also,
the study that included a six month follow-up (McDonald et al. 2005) found less positive
results of the study than Herbert & Wookey (2007), which could suggest a CBT-focussed
intervention may have limited long-term effectiveness. Unfortunately a lack of detail about
each of the programmes makes it difficult to identify the similarities and differences between
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the programmes which could be helpful in investigating these approaches further.
Two other papers found looked at the effectiveness of the Incredible Years Basic Parent
(School Age) Programme (IYP) for improving foster parents ability to manage the complex
needs of looked after children by teaching them skills to manage child behaviour and
consequently promote placement stability. The IYP is founded on social learning theory and
was originally developed for use with biological parents. It's protocol includes detailed
session plans and home activities that can be tailored by professionals to the specific needs of
families. McDaniel et al (2011) conducted a pilot programme in Northern Ireland,
implemented by Barnardo's Professional Fostering Service, using a single-group pre-test and
post-test design with 13 foster carers. McDaniel et al (2011) focussed on an age range of 8
and 13, providing some (though limited) information on this. Assessments were carried out
before and immediately after the group training and included a self-report parent rating scale
to measure the degree of conduct and externalising behaviour management problems are
exhibited by children. Results from the study suggested a significant decrease in the intensity
of social, emotional and behavioural difficulties reported by foster carers following the IYP,
and a smaller but not significant decrease in the extent to which foster carers felt their foster
child's behaviour was problematic.
Bywater et al (2008) also looked at the effectiveness of IYP. They emphasised the potential of
IYP to enhance placement stability and help foster carers understand the needs of lookedafter children. Their study focussed on 46 foster carers of children between 2 and 8 years and
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employed controlled randomisation to allocate to the intervention (n=29) and control (n=17)
groups. Foster carers were approached and requested to participate in the study and received
monetary rewards for completing data at baseline and six-month follow-up. The children
ranged between 2 and 17 years at the start of the study. Results suggest that the IYP was an
effective programme for significantly reducing carer depression and reducing challenging
behaviours in the foster children, as rated by the foster carers. Bywater et al (2008)
questioned whether their findings had been limited by using a parent-report scale that they
felt needed to be more sensitive. They also did not use other measures which reduced the
scope of measuring the changes that had occurred.
Again, despite promising findings, evidence of the effectiveness of IYP from both these
studies is limited by their small sample sizes. Bywater (2008) and McDaniel et al (2011) also
relied only on foster-carer reports to identify any impact of IYP on the foster children
themselves, and gave very limited information of the foster children and carers, limiting
understanding of who exactly the IYP appeared to be effective for. McDaniel et al (2011) also
failed to use a control group, which further limits the evidence for whether IYP is a promising
intervention. Additionally, a confounding feature in the study was Barnardo's Professional
Fostering Service provided ongoing support and training to foster carers outside of the IYP
which may have instead resulted, or contributed to the positive changes reported by the
carers. Furthermore, McDaniel et al's (2011) study failed to ascertain whether any reports of
changes or improvements from the intervention were maintained over time. A strength of
these studies was that they used quantitative measures to identify 'significant' improvements.
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Though both McDaniel et al (2011) and Bywater (2009) also failed to detail many
demographics of the foster carers and foster children in their studies that could have aided
understanding of for whom the intervention was most effective (backgrounds, placements,
etc.). Overall, the study provides promising evidence but yet again another tentative start to
identifying the effectiveness of IYP for foster children.
Gurney-Smith et al (2010) used a repeated measures design, (pre, post and three month
follow-up) design to evaluate the impact of a Fostering Attachments Group (FAG) for a
mixed group of foster and adoptive parents. FAG (Golding & Picken. 2004) is based on
social learning and attachment theories and aims to develop parenting skills by educating
about the influence of the social environment on behaviour, with consideration of the need for
responsive and attuned parenting to develop successful attachments. The group comprised of
5 foster carers and 10 adoptive parents and a special guardian; one male and 15 females.
Evaluation data was only collected from 13 participants at all three stages. Inclusion criteria
involved currently experiencing problem behaviour from a child when the group started and
difficulties in attachment relationships for that child. Referrals came from Social workers and
were active cases in the Children, Young People and Families Service. Measures used were
all parent-report tools. Analysis showed that reported parenting skills and understanding
improved to a statistically significant degree which was maintained through to follow-up. A
significant decrease in reported child hyperactivity/inattention behaviours was obtained
between pre-group and follow-up time points. Post hoc tests also found a significant decrease
in overall difficulties of the child reported between pre-group and 3 month follow-up scores.
149
Parenting stress levels were not impacted but children were reported to show significantly
less inhibition.
Similarly to some of the other studies, no control group was used by Gurney-Smith et al
(2010), the sample size was very small, long-term evaluation was limited (only measured at
three months after) and measures used only foster-parent reports to identify any positive
outcomes for the foster children. The relevance of the findings to foster children is also
limited through the study using adoptive parents and a special guardian as well as foster
parents as, despite commonalities of background histories, their situations of temporary and
permanent placements may well impact the social environment quite differently. Again, as
with the other studies, though this study suggests some potential for being effective in
working with foster parents, this study fails to identify whether this approach has a truly
positive impact for the child.
Interventions directly with Foster Children
Loxterkamp (2009) aimed to challenge what she described as the ‘predominant conviction’
(p.423) that regular contact of adopted and fostered children with their biological parents is
always beneficial. Loxterkamp used three cases studies to illustrate her arguments that
contact is not always beneficial (in the short or long-term) and instead can often be the cause
of secondary harm. Though this approach highlights well the points argued by Loxterkamp
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(2009) it does not provide high quality evidence that her hypotheses are valid and that the
experiences of those in her case examples are generalisable to those in the wider population.
For example, she chose the case studies to include as she felt they were representative of the
common attitudes in relation to contact. They were also chosen following therapy, as cases
Loxterkamp (2009) that had highlighted issue of biological contact that supported her
arguments, bias that cannot be ignored. Consequently, this study begins to identify potential
issues of contact but provides poor evidence for these upon which to initiate change in a
matter that has well-established beliefs and practises associated with it.
In contrast, Sen and Broadhurst's (2011) study was a narrative review of studies into
outcomes of foster children as a result of contact with their biological family. However, they
gave little detail of the methods of the studies and detailed no quantitative outcomes. They
highlighted that evidence for the impact of biological parent contact on children's emotional,
behavioural and intellectual outcomes was largely dated and inconsistent with no studies
having employed systematic measures to evidence the effect of contact on child outcomes in
relation to both UK and International studies. The only two main papers discussed in detail in
relation to this were focussed on disruption of attachment formation through contact with
biological parents. But again, little detail of the strengths of the study or the conclusions
found were presented. Sen & Broadhurst (2011) also looked at the impact of biological parent
contact on stability of placements, but failed to link this to identifying psychosocial outcomes
for the child and again, the descriptive style provided limited insight into the strength of the
evidence found from the studies presented. Sen & Broadhurst (2011) suggest a number of
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components for future research that would help improve the quality of evidence found, but
that these conclusions are valid relies on the reader assuming that these components were not
included in the studies discussed by Sen & Broadhurst (2011) based on direct omission of
these details from the review rather than detailed critique of the studies, highlighting these
omissions. Such suggestions included a need for studies using robust outcomes measures
including psychosocial profiling and children's views, sufficiently sized and representative
samples of foster children, prospective and longitudinal designs and based on clear
definitions of contact. A lack of detail and lack of systematic approach to addressing the
literature, alongside the approach used by Loxterkamp (2009) means that evidence for the
outcomes of foster children as a result of contact with their biological parents in the UK is
currently very unclear.
The third study by Wakelyn (2008), looked at the impact of transitional therapy for children
in 'short-term' foster care. This work discussed the theories and used one case example to
illustrate the approach. It shows a promising consideration of developing and detailing new
approaches and ways of working with foster-children that take into account the importance of
well evidenced facets of practises such as multi-disciplinary working. It does not however,
provide evidence for the effectiveness of this intervention on improving the psychosocial and
behavioural outcomes of foster children given the limitations of using a case study, as with
Loxterkamp (2009).
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Interventions with Multiple groups
Staines, Farmer & Selwyn (2011) investigated the effectiveness of a Therapeutic Team
Parenting approach. A prospective repeated measures design was used, involving children
between the ages of 5 and 14 entering new placements organised by one Independent FosterCare Agency. Twenty-three local authorities participated, 450 children were identified and
they, their carers and social workers were sent questionnaires at the start of the placement and
one year into it. Only eighty placements had data from carers and social workers at both time
points which reduced how representative the results are of the placements as a whole. Despite
detailing some demographics of the carers, including ethnicity, age and marital status, the
sample sizes did not allow reliable detailed analysis of the result in relation to these. The
team parenting approach emphasises all team members involved with the child working
collaboratively together, assessing the young person in placement rather than in isolation. The
therapeutic fostering environment views the placement and activities provided as enabling the
fostered individual to learn and develop, based on a systemic approach. Results found high
levels of satisfaction from foster-parents for the therapeutic and team parenting approaches
and the authors concluded that high-quality placements were provided for many of the
challenging children. The authors acknowledged that the approach was not always
implemented as efficiently as intended (delays in service provision following assessment, for
example). But alongside this, due to the small return rate of questionnaires it is difficult to
determine whether this approach positively impacts placement stability or child outcomes or
whom it is particularly beneficial to. On top of this, whether this approach could be effective
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outside the Independent Foster-Care sector could be questioned from debate that Independent
Foster Care Agencies often do not provide placements for the most challenging children in
the care system.
Hibbert & Frankyl (2011) also relied on qualitative analysis and were even more limited by a
small sample size in their study into the impact of a psychology consultation service set up to
support foster carers and social workers. The approach was a consultation model that aimed
to combine clinical expertise and knowledge of psychological interventions for foster
children with the experiences and knowledge of social workers and foster carers in order is to
help foster carers understand the child’s early experience, the impact of this and then adapt
expectations of the child and strategies of working with them accordingly. Social workers
(n=7) were randomly selected but foster carers (n=7) opted into the study. They had between
1 and 6 consultation meetings (3.3 and 4.4 average for foster carers and social workers
respectively). A semi-structured interview about the consultation service was undertaken and
evaluated using thematic analysis. From this analysis, Hibbert & Frankyl (2011) highlighted
that all foster carers had reported an increase in psychological understanding of the child and
in skills for behaviour management, which in turn foster carers reported had led to improved
relationships between carers and their children and more self-confidence from this. Foster
carers also reported feeling emotionally supported. Social workers reported feeling supported
within the wider professional system, able to obtain different perspectives and reflect on
situations, gaining enhanced skills and support with decision making and planning.
Unfortunately, again no long-term investigations or child specific outcome measure were
154
used. Given the qualitative nature of the study and the small sample size, the generalisability
and reliability of the benefits of this approach appear are also clearly limited, though it
suggests a promising potential approach that could be worth investigating further to build on
these findings.
Golding (2010) investigated a multiagency approach to supporting children in foster care,
using an example of an integrated multi-agency service in Worcestershire for Looked-after
and adopted children (ISL). The aim is to maximise placement stability by providing mental
health and emotional well-being guidance and advice based around a consultation process,
supported by additional facets such as network meetings, supporting parenting and providing
education and mental health interventions. The author draws upon professional clinical
experience and states that 'a range of research and audit-based evaluations has confirmed ISL
provides an effective additional level of support for the children, carers and professional
network' (p581. Golding, 2010) but does not detail what these are other than detailing that
service user views and a pilot evaluation were used. Outcomes are detailed only as foster
carers having increased confidence and a changed perception of their children following
consultation leaving a vague understanding of the added value of the team. It is also unclear
as to the value of this work for the foster children's outcomes specifically, long-term benefits
and what components of the approach may be important. Evaluations are needed to identify
this, at least to ensure it is not causing harm, if there are other benefits that motivate services
to employ such an approach.
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Discussion
Overall, there is currently very little evidence for the effectiveness of any particular
intervention to improve the social, emotional and behavioural outcomes for foster children in
the UK. Firstly, interventions involving foster-carers appear to have stronger methodologies,
using control groups and showing some attempts at identifying long-term outcomes of the
approaches used. Results from these studies all appear promising in producing positive
outcomes for carers, but unfortunately all child-related outcomes are based on parent reports
only, leading to a lack of understanding as to whether these interventions are truly have a
positive impact on foster-children. Is it enough to assume positive outcomes for a child if
their parents report being more able to cope with difficult behaviour or reduced problem
behaviours from the child? Placement stability has been evidenced as having a positive
impact on foster children’s social, emotional and behavioural outcomes, but are these studies
making assumptions that if foster parents feel more able to cope then the placement will be
more stable? Further studies need to take these questions into careful consideration.
Demographic details of foster parents and children are also limited in these studies and this
therefore limits understanding for whom these interventions may be effective and when.
Studies that have tried to consider these have been restrained by their sample sizes. Of the
foster-parent based interventions critiqued in this review, all show promise in supporting
foster carers and potentially foster children in relation to challenging behaviour particularly,
but due to methodological issues it is difficult to identify if any show more promise than
156
others currently. Secondly, interventions that directly involve the foster child are currently
lacking in numbers and development: Only Wakelyn (2008) has discussed a specific
approach and Loxterkamp (2009) and Sen & Broadhurst (2011) looked at the common
practise of contact with biological parents. Methods to evaluate these are also weak, with a
lack of controlled trials and use of measures to identify child outcomes. Thirdly, interventions
that include a range of individuals including carers, professionals and sometimes fosterchildren themselves seem to be even more difficult to ascertain whether they are having a
positive impact on foster children's psychosocial wellbeing: All these studies looked at failed
to use control groups and had small sample sizes or relatively high drop-out rates (or
incomplete data). Alongside this, they also relied on parent-report of child improvements and
changes, rather than multiple perspectives further highlighting difficulties ascertaining
whether these approaches truly benefit foster children. The detail of the work undertaken
within each study was also lacking, leading to limited understanding about what in the
approach may have been beneficial and why. Similarly to the parent-focussed approaches,
these studies also had limited demographic data of the foster children and carers involved and
the potential impact of issues of difference and diversity on the effectiveness of the
interventions.
Overall, the approaches that currently appear to have the most established evidence as to their
effectiveness in the UK are the foster parent focussed approaches. (McDonald et al (2005);
Herbert& Wookey (2007); McDaniel et al (2011); Bywater et al (2008); Gurney-Smith et al
(2009)). These however, have much to improve on both in the quality and detail of evidence
157
obtained but also in the fact that they have done more to evidence their positive outcomes for
foster carers than foster children themselves and this needs to be addressed as a priority in
future research with these approaches. What is also worth highlighting, is that these
interventions focus almost solely on issues around challenging behaviours in foster children
and though this is the current most common difficulty for foster children in the UK (Tapsfield
& Collier. 2005), other difficulties and disorders experienced by foster children need effective
and appropriate interventions also.
Limitations
Limitations of this systematic review are that the inclusion of the search terms around
location may have overlooked some papers that have been undertaken in the UK but have not
been explicitly listed as such. Despite this, it is important to consider that professionals or
researchers interested in using UK evidence-based interventions for foster care are likely to
have time pressures that limit them from long database searches to find these. Though this
leads to a potential limitation of this review, it highlights the need to label papers in a way
that facilitates their use by those whom they are most valuable to. A similar limitation may be
the use of peer-reviewed and published articles in this review: It may be that for example, the
local authorities implementing MST as discussed by McAuley & Davis (2009) may have
evaluated the effectiveness of this intervention but not shared the findings through publishing
them, or the findings may have not reached a standard to be published. Again, if such
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information has not been shared or is not able to be accessed, it limits the ability of other
local authorities and services to understand the effectiveness and limitations of these
interventions in the UK and make more informed decisions on how to best support foster
children and families.
Another limitation is the inclusion of papers that have included adoptive parents as well as
foster parents as these may have prevented the review drawing on purely foster-related
research. (e.g., Gurney-Smith et al. 2010). Despite this drawback, given the limited wealth of
research in this area, it was felt including it would enable discussion of a more approaches
being used with foster carers in the UK. The same lack of clarity may apply from having used
papers that group looked-after children rather than focus on fostered children specifically.
(e.g., Golding. 2010) Given that in 2011, 74% of looked after children were in foster
placements suggests that this group is likely to constitute a majority of those used in studies
including all looked after children and is worth considering. (Department for Education.
2011) Studies have found however, that those in residential care are statistically likely to have
greater difficulties (Meltzer et al. 2003, 2004a, b).
Future directions
Given the limited research and weaknesses in methodology discussed in this review, there are
a number of potential directions and considerations for future research. The use of RCT's in
159
some of the research papers critiqued is a promising step towards providing valid and reliable
findings on the effectiveness of interventions for foster children in the UK, but greater sample
sizes and avoiding using samples where individuals have 'opted in' to the study will help
enable stronger conclusions to be drawn from findings. Given the often wide range of
individuals involved in a foster-child's care, control groups are very important in validating
the impact of an intervention and future studies should consider carefully to what extent their
research may be compromised without a control group. Just as the diversity and difference
issues between US and UK foster children, carers and systems need to be considered, so does
the diversity of foster children and their carers in the UK. Acknowledging and investigating
how issues of diversity and difference may impact the effectiveness of interventions may be
key in help identifying what interventions are effective to use in the UK. Studies may need to
investigate specific ethnic groups, children with specific lengths of time in care or particular
histories, etc., or analyse results in more general studies to identify any potential betweengroup differences. Future research looking into supporting foster children with conduct
disorders through foster-parent work needs to build on the work discussed in this review and
study more carefully the outcomes for the foster children to ensure this work is having the
positive impact on the children intended. Studies that look at longitudinal outcomes for
foster-parents and children of these programmes will also be important in understanding the
value of these interventions for the foster-care population. As emphasised earlier, with a
positive and growing focus on evaluating interventions for foster children with conduct
disorder in the UK, evaluations and developments of interventions for other difficulties
experienced by UK foster children, such as emotional and anxiety disorders must not be
160
neglected. (Tapsfield & Collier. 2005). Depending on the focus, future work in this area may
involve developing new approaches, making adjustments to approaches or looking at the
validity and relevance of already established approaches but all done in order to ensure
interventions used with this vulnerable group are safe and effective.
Conclusion
From this review, it is clear that the evidence base for the effectiveness of interventions that
aim to improve the social, emotional and behavioural wellbeing for UK foster children is
limited and weak. Foster-parent focused interventions in the UK show promise in helping
foster carers feel more able to manage difficult behaviour but have done little to evidence
positive outcomes for the foster children themselves. Evidence of the effectiveness for
interventions that address the social and emotional difficulties of foster children in the UK is
lacking. Consequently, there is great scope for studies that use stronger methodologies, larger
sample studies, carefully defined samples, consider diversity implications and consider longterm effects of interventions, whether these be validating the effectiveness of studies
developed elsewhere or developing new ones. What is clear is that with this vulnerable group
of individuals, professionals have a responsibility to support these children and young people
effectively, safely and use resources wisely to do this, to ensure we help both those with the
most need but also as many individuals as possible. In order to do this, we need a greater
understanding of what interventions can enable UK foster children to achieve the best
161
outcomes for their current wellbeing and future.
162
References
Bywater, T., Hutchings, J., Linck, P., Whitaker, C., Daley, D., Yeo, S., &
Edwards, R.
(2010). Incredible Years Parent Training Support for Foster Carers in Wales: A Multi-Centre
Feasibility Study. Child Care Health and Development. 37, 233-243.
Department for Education. (2011). DfE: Children Looked After by Local Authorities in
England (including adoption and care leavers) - year ending 31 March 2011. Retrieved from
Department of Education website: http://www.education.gov.uk
Department for Education and Skills. (2003). Every Child Matters: Presented to Parliament
by the Chief Secretary to the Treasury by Command of Her Majesty, September 2003.
London: Stationery Office. Retrieved from department of education website:
http://www.education.gov.uk
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, 319-325.
Golding, K. (2010). Multi-agency and specialist working to meet the mental health needs of
children in care and adopted. Clinical Child Psychology and Psychiatry, 15, 573-587.
163
Gurney-Smith, B., Granger, C., Randle, A., & Fletcher, J. (2010). ‘In time and in tune’ – the
Fostering Attachments Group: capturing sustained change in both caregiver and child.
Adoption & Fostering, 34, 50–60.
Herbert, M., & Wookey, J. (2007). The Child Wise Programme: A course to enhance the selfconfidence and behaviour management skills of foster carers with challenging children
Adoption & Fostering Journal, 31, 27-37.
Hibbert, G., & Frankl, J. (2011). A psychology consultation service for
social workers and
foster carers in a child and adolescent mental health service. Educational and Child
Psychology, 28, 63-72.
Holland, S., Faulkner, A., & Perez-del-Aguila, R. (2005). Promoting stability and continuity
of care for looked after children: A survey and critical review. Child & Family Social Work,
10, 29-41.
Landsverk, J., Burns, B., Stambaugh, L., & Reutz, J. (2009). Psychosocial interventions for
children and adolescents in foster care: Review of research literature. Child Welfare , 88, 4969.
Loxterkamp, L. (2009), 'Contact and Truth: The Unfolding Predicament in Adoption and
Fostering'. Clinical Child Psychology and Psychiatry, 14, 423-35.
164
Macdonald, G., & Turner, W. (2005). An experiment in helping foster-carers manage
challenging behaviour. British Journal of Social Work, 35, 1265-1282.
McAuley, C & Davis, T (2009) 'The Emotional Well-Being of Looked After Children in
England'. Child and Family Social Work, 14, 147-155.
McDaniel, B., Braiden, H. J., Onyekwelu, J., Murphy, M., & Regan, H. (2011). Investigating
the effectiveness of the incredible years basic parenting programme for foster carers in
northern Ireland. Child Care in Practice, 17, 55-67.
Meltzer, H, Gatward, R, Goodman, R and Ford, T. (2000). The mental health of children and
adolescents in Great Britain: summary report. London: The Stationery Office.
Meltzer, H., Gatward, R., Corbin, T., Goodman, R., Ford, T. (2003). The mental health of
young people looked after by local authorities in England. London: The Stationary Office.
Meltzer, H., Lader, D., Corbin, T., Goodman, R. and Ford, T. (2004a). The mental health of
young people looked after by local authorities in Scotland. Edinburgh: The Stationery Office.
Meltzer, H., Lader, D., Corbin, T., Goodman, R., Ford, T. (2004b). The mental health of
young people looked after by local authorities in Wales. London: The Stationary Office.
165
Moore, K. J., & Chamberlain, P. (1994). Treatment foster care: Toward
development of
community-based models for adolescents with severe emotional and behavioral disorders.
Journal of Emotional and Behavioral Disorders, 2, 22-30.
National Institute of Clinical Excellence. (2001). The guideline development process –
Information for national collaborating centres and guideline development groups. London:
NICE. Retrieved at:
http://www.nice.org.uk
Pallett C, Scott S, Blackeby K, Yule W and Weissman R (2002) Fostering changes: a
cognitive-behavioural approach to help foster carers manage children. Adoption and
fostering, 26, 39-48.
Sen, R., & Broadhurst, K. (2011). Contact between children in out of home placements and
their family and friends networks: A research review. Child & Family Social Work, 16, 298309.
Staines, J., Farmer, E., & Selwyn, J. (2011). Implementing a therapeutic
team parenting
approach to fostering: The experiences of one independent foster-care agency. British
Journal of Social Work, 41, 314-332.
Tapsfield, R., & Collier, F. (2005). The cost of foster care: investing in our children's future.
London: British Agencies for Adoption and Fostering/ Fostering Network.
166
Thoburn, J. (2007). Globalisation and child welfare: Some lessons from a cross-national
study of children in out-of-home care. Norwich: UEA Social Work Monographs.
Wakelyn, J. (2008). Transitional psychotherapy for looked-after children in 'short-term' foster
care. Journal of Social Work Practice, 22, 27-36.
Ward, H., Holmes, L., Soper, J., & Olsen, R. (2008). Costs and consequences of placing
children in care. London: Jessica Kingsley Publishers.
World Health Organisation. (1992). International statistical classification of diseases and
related health problems (ICD-10), 10th revision. Geneva: Author.
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Literature review
UK evidence for interventions to improve the psychological
wellbeing of foster children: A systematic review
By
Ruth Joanne Hunter
School of Psychology
Faculty of Arts and Human Sciences
University of Surrey
April 2012
168
Abstract
Statistics from the UK highlight that foster children and young people are more than three
times more likely than those in the general youth and child population to experience mental
health difficulties. (Meltzer et al. 2003, 2004). The majority of interventions to improve foster
children's psychological wellbeing have been developed and validated in the US yet some of
these are being used in the UK. This systematic literature review looked at the research on the
effectiveness of interventions to improve the social, emotional and behavioural wellbeing of
foster children in the UK. It was a concern that few papers were found and all had substantial
methodological weaknesses that highlighted a large gap for good quality detailed research to
be undertaken to ensure professionals are appropriately and effectively supporting this
vulnerable group of individuals, directly or indirectly with the interventions they use. Future
research needs to address these methodological issues, build on current research, identify
interventions for difficulties other than behavioural problems and consider issues of diversity
and difference within this vulnerable group.
Key words: Foster, children, young people, UK, interventions, review, outcomes
Introduction
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Foster children in the UK
Statistics from Department for Education 2011 National Statistics showed that over 48,000
children were in foster care in the UK on March 31st 2011. Children and youth in foster care
have higher rates of mental health difficulties than those in the general population. Ford et al
(2007) highlighted that the results of a number of studies by Meltzer et al (2000, 2003,
2004a) emphasised that even compared to the most disadvantaged children outside the care
system, the mental health of children looked after by local authorities was significantly
worse. These studies all involved interviewing carers, teachers and children (between 11-15
years) and using the International Statistical Classification of Diseases and Health Related
Disorders (ICD-10) to identify a prevalence of a mental health disorder. This was defined by
Meltzer et al (2000) as “a clinically recognisable set of symptoms or behaviours associated
with considerable distress and substantial interference with personal functions”. Meltzer et al
(2003) found that ‘mental disorders’ were present in 40% of the fostered population in
England compared to just 13% and 10% for boys and girls between 11 and 15 years
respectively and a prevalence of 6% for children between 5-10 years in the general
population. (Meltzer et al. 2000). Meltzer et al (2004a, b) found similar prevalence rates for
foster children in Scotland and Wales. On top of this, Meltzer et al (2003) highlighted that for
looked after children in England, mental health problems (that did not reach criteria for a
disorder) was reported for over two fifths of the children included in the study by their carers.
170
A study by Ward et al (2008) found that 70-80% of foster children and young people require
specialist emotional and behavioural support. Tapsfield & Collier's (2005) study reported a
37% prevalence of conduct disorder in looked-after children in the UK, which was almost
three times higher than that of the general population. Meltzer et al (2004a) identified that
after conduct disorders, emotional disorders (specifically anxiety disorders), were the most
common mental disorders in looked-after children in Scotland, England and Wales. This was
followed by hyperkinetic disorders and depression. Such increased prevalence rates highlight
the importance of effective and appropriate psychological support and interventions for foster
children.
Being healthy, staying safe, enjoying and achieving, making a positive contribution and
economic wellbeing were the five outcome aims for children proposed by the government in
2003 (Department for Education and Skills. 2003). If foster children are to be supported to
achieve the 5 outcomes then, given their increased risk and vulnerability to mental health
difficulties previously detailed then clearly a greater level of mental health support is needed
for these individuals. Best practise is to use evidenced based interventions and support when
undertaking any type of psychological support, to ensure at worst that no harm is being done,
providing the best outcome possible for the intended individuals and that the time and
resources of professionals, foster carers and foster children are not being wasted. (National
Institute for Clinical Excellence. 2001). Cutbacks and changes in health and social services
mean that there are even fewer resources available to promote wellbeing, making it even
171
more essential that the interventions and psychological support being implemented are not
only the most effective, but effective for the most needy as well as those with less intense
difficulties.
Established evidence
A basic search of Ebsco, Psychinfo, Medline highlights a wealth of foster care literature and
research from the United States (US). Reviews of this research highlight interventions and
approaches to mental health care that have the best evidence base so far. Landsverk et al's
(2009) work is the most recent published review and they reviewed the evidence for
psychosocial interventions for the most prevalent conditions found in foster children in the
US. They highlighted that for post-traumatic stress disorder, abuse related trauma, depression,
substance abuse and disruptive behaviour disorders, interventions that addressed symptoms,
behaviour and functioning had the best (and indeed a 'strong') evidence base. It is beyond the
scope of this review to detail all the interventions found by Landsverk et al (2009) to be
promising interventions for each of these difficulties. But they found that most interventions
were brief and usually more effective when the caregiver was actively involved. Interventions
varied between involving multiple professionals, the child and the carer, being community
based or clinic based, and of course, the theoretical basis for the approach, highlighting the
breadth of approaches that have been found to be effective in the US.
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UK programmes being implemented
Indeed some of these US evidence-based approaches have already begun to be implemented
in the UK. McAuley & Davis (2009) identified that ten local authorities have implemented
Multi-systemic therapy (MST) programmes for young people aged 11-17 and their families
who are on the edge of custody and an additional site piloting MST specifically for children
who have experienced abuse or neglect. MST is a US developed intensive home-based family
based intervention that acknowledges the role of the family environment on difficulties
experienced by the child and the family. Landsverk et al (2009) identified this as an
intervention with promise, concluding from critiquing 10 studies into MFT that it was
particularly promising for working with foster children to address substance abuse and/or
disruptive behaviours. They concluded it was positively associated with a reduction in
aggressive behaviours in foster children and fewer placements. McAuley & Davis (2009) also
identified 14 local authorities implementing Multi-dimensional Treatment Foster Care
(MTFC) programmes for adolescents aged 11-17 years, six programmes for 3-6 year-olds and
eight sites for children aged 7-11 years. McAuley & Davis (2009) highlighted initiatives to
cascade the programme out to other local authorities. MTFC is a US established programme
based on social learning theory that aims to reduce problem behaviours and promote
developmentally appropriate and prosocial behaviour through a multifaceted, multiple setting
based approach. This includes foster parenting in the home using specific behavioural
techniques, skills training and supportive therapy for the foster child, school consultations
173
and family therapy (Moore & Chamberlain. 1994). The other approach identified as being
developed when McAuley & Davis (2009) published their research was a cognitivebehavioural programme called the Fostering Changes Programme, which focussed on helping
foster carers manage children and was developed by Pallett et al (2002). The Fostering
Changes Programme (FCP) was the only intervention to be highlighted by McAuley & Davis
(2009) as having been developed and trialled in the UK prior to being rolled out. It is based
on 'The Incredible Years' programme (Webster-Stratton, 1998), which was developed in the
US, and aimed to promote positive parenting and reduce children's behavioural difficulties
and improve their problem solving and social skills. The FCP trial found carers reported
improvements in their foster children's behaviour, but results from their other measures were
less supportive of this. Through their study, McAuley and Davis (2009) highlighted an
apparent drive to pilot interventions in the UK that had been shown to have a strong or
emerging evidence-base in the US in relation to effectiveness. They discussed hopes that
these pilots would reinforce the value of evidence-based commissioning and gave an
acknowledgement of the need to obtain evidence of the effectiveness of these interventions
for the UK foster population. No detail however, as to how or why these interventions may or
may not be applicable in the UK was addressed in the study: Details that seem fundamental to
the predictions of whether these interventions are likely to be effective for the UK foster
population. Services in the UK increasingly acknowledge the diversity of the UK population
itself and the impact that these differences in culture and background may have on
psychological interventions and support. Also, foster children in themselves vary on a
multitude of issues: their history, reason for entering care, length of time in care, ethnic
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background, religion, culture, etc. Identifying and acknowledging some of these differences
may provide insight into how and why the effectiveness of interventions with an evidencebase in the US may differ in the UK and guide appropriate adjustments or changes and the
appropriateness of implementing or testing these.
US and UK foster care
In 2007, Thoburn published a study comparing statistics about children in out-of-home care
across a number of different countries. She noted a number of similarities and comparisons
between the US and the UK in her analysis of the statistics she collated. Thoburn (2007)
identified that a fewer percentage of those entering care were 16-17 year olds in the UK than
the US, 7% and 20% respectively and the UK had a higher percentage entering at 10-15 years
(40% to 25% respectively) but that for those under 12 months the percentages were very
similar, (17% and 15%). Thoburn's (2007) data identified that in the USA over 90% of
children were taken into out-of-home care as a result of abuse or neglect, whereas this was
only 48% for England, with other factors listed as parental disabilities or illness (8%),
disability or problems of the child (9%), abandonment (11%) and relationships or other
family problems (24%). Wales also had similar percentages to England. Thoburn (2007) also
hypothesised that using performance targets to control welfare spending was linked to seeing
out-of-home care as something to be avoided; a similarity for the USA and the UK.
Differences between the USA and the UK care system were also highlighted in the report
175
through comparing the legal status of children entering care on one particular day: For the
USA, over 95% entered into care as a result of a court decision, compared to only 33% in the
UK. The USA and UK had similar average lengths of time spent in out-of-home care: 1.8
year and 2.1 years respectively and both countries had a 5% adoption rate. Also, both
countries had similar percentages of children placed in un-related foster family care: Between
47% and 57% for the four UK countries and 46% in the USA.
As highlighted earlier, Landsverk et al (2009) identified post-traumatic stress disorder, abuse
related trauma, depression, substance abuse and disruptive behaviour disorders as the most
prevalent mental health conditions of children in foster care in the US. In comparison,
Meltzer et al (2003) highlighted conduct disorders as the most common disorder experienced
by children in care (not just foster children) in the UK, followed by anxiety disorders and
hyperkinetic disorders. Statistics however do not report on the level of impact of the mental
health difficulties individually which is also likely to impact what types of support and
interventions need to be prioritised by each country.
On top of differences in legislation, characteristics and factors related to children entering
foster care; in both countries, some ethnic minorities are overrepresented in foster care. In the
UK, African Caribbean and mixed African Caribbean and white heritage are overrepresented
in foster care with black Africans overrepresented to a lesser extent. (Thoburn. 2007). In the
USA, African American and Native American children are overrepresented in out-of-home
care statistics, with Hispanic children increasingly so. (Thoburn. 2007). In the UK however,
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Thoburn (2007) highlight the underrepresentation of those of East and South Asian heritage.
Statistics on the percentage of foster carers from ethnic minorities in the UK and the US are
difficult to obtain, likely due to the presence of public and private foster-care employment
agencies and variations in data governance that create difficulties in obtaining statistics from
these. There are a range of other factors such as average number of placements, placements
with siblings, payment of foster carers and a number of other factors that may vary between
the US and the UK. These could all be issues of diversity and difference that may impact the
appropriateness or effectiveness of psychological interventions.
These statistics highlight the breadth and depth of similarities and differences between both
the foster care systems themselves and the characteristics of the children fostered in these
systems and their difficulties. As discussed, there are also likely to be many more. Given
these details, it seems complacent to assume that the evidence for effectiveness of
interventions used in the USA is automatically relevant to the UK. It highlights the
implementation of such evidence-based practises across the UK as a risky and potentially
costly trial, in terms of public money and psychosocial impact on the foster children and their
families if it is an ineffective intervention. Though US research dominates the literature
databases, one would hope that given the extent that programmes such as MST and MTFC
have already been implemented in a number of local authorities, that UK based evidence for
effectiveness is now guiding practise in the UK more than US evidence. This literature
review will now look at what evidence exists for the effectiveness of interventions for foster
177
children in the UK.
Method
An electronic systematic literature search was undertaken on Psychinfo, Medline, Ebsco,
Web of Knowledge and Cochrane databases. It included peer-reviewed papers published from
January 2005 to present. The search terms used were “intervention* OR therap*”; “foster*
OR looked after OR accommodated OR” and “UK OR United Kingdom OR Brit* OR Welsh
OR Wales OR Scot* OR Northern Ireland OR Northern Irish OR Engl*”. Papers were
excluded if they did not focus on interventions and outcomes related to children while in
foster care (therefore excluding a focus on transition and adult outcomes of foster care).
Papers were also excluded if they focussed on policies rather than practise, interventions
within education rather than health, or if they focussed specifically on foster children with
additional medical health needs such as Learning Disabilities. These exclusion criteria were
used as they represent specific areas and groups that are above and beyond the scope of this
review. Papers were not excluded based on type of evidence, though consideration as to the
quality of each type of evidence is evaluated in the review in line with guidelines from the
National Institute of Clinical Excellence (NICE, 2006). Papers that discussed a theoretical
approach and used examples such as case studies were included, in order to gain an
understanding of potential areas for developments or changes to interventions.
The search was performed February 2012 and produced 11 papers that described or evaluated
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interventions with foster children in the UK. These were divided into categories for
evaluation based on who was involved in the intervention; 1) foster parents 2) foster children
3) mixed focus (including combinations of foster parents, foster children, social workers,
etc.). The critique of each of the studies was focussed on the methodology, in order to
evaluate the strength and validity of the respective results for each, in order to determine the
strength of the evidence from each paper, rather than the theoretical approach of the
intervention.
Results
Interventions with Parents of Foster Children
Interventions with foster carers are often used as indirect interventions to improve the social,
emotional and behavioural outcomes of foster children; most frequently aiming to equip
foster carers to manage foster children's difficulties, in order to improve placement stability (a
factor that can impact the social, emotional and behavioural outcomes of foster children
(Holland, Faulkner & Perez-del-Aguila. 2005)) and help foster children reach their potential.
(McDaniel et al. 2011).
Two of the papers from the search focussed on CBT based programmes for foster carers.
MacDonald et al (2005) looked at the effectiveness of CBT training for parents of foster
179
children with challenging behaviour. They used a randomised controlled trial (RCT) using
groups of foster carers. 117 foster carers (all but 2 of whom were white) opted into the study;
67 of these were in the training group and 50 in the control group. Data was collected before
and after the training and at 6 months follow-up. Results were that foster-carers in the
training group reported increased confidence in ability to deal with behaviour problems and
scored higher on knowledge of behavioural principles compared to those in the control group.
McDonald et al (2005) queried whether the content and length of the course could have led to
disappointing outcomes or a lack of support to help develop the skills learnt. The authors also
suggest the limited effectiveness of the CBT training in the results could have been due to
using carers of extremely 'difficult' children. They proposed the intervention be refined to
deal with the weaknesses identified to ascertain whether in fact the intervention is ineffective
or whether this study failed to identify the effectiveness of it due to its limitations.
Herbert & Wookey (2007) investigated whether a broadly based CBT programme could
indirectly reduce the challenging behaviour of looked-after children and increase placement
stability, through improving carers' self-assurance and behaviour management skills. Their
study used a randomised controlled study, with 67 foster-carers in the experimental group and
50 in the control group. Those in the experimental group were randomly allocated into six
groups, all given the same intervention. Their ages ranged from 32 to 65 and had a mean of
8.68 years of foster experience. The intervention, the Child Wise Programme (CWP) was
devised by the authors. It is a programme that aims to be collaborative between facilitators
and foster-carers and to empower caregivers by giving them a conceptual framework (CBT
180
and behavioural principles and techniques) that enables them to resolve problems themselves.
Herbert & Wookey (2007) reported that CWP has obtained positive results when used with
birth parents but had not been validated for use with foster-carers, but this was not referenced
in this paper. Results were a significant increase in carers' confidence, a majority of foster
carers reporting improvements in children's behaviour (but not to a significant level) and that
these were generally attributed to having acquired new behavioural management skills. There
was no reduction found in relation to unplanned placement breakdowns where behaviour
problems were indicated.
Though both these CBT based approaches suggest some promise in supporting foster carers
with children with challenging behaviours in the UK, both studies relied only on parent
reports of child outcomes and failed to identify detailed demographics of the foster-carers and
foster-children involved that could shed light on whom specifically these interventions may
work for. Though they used randomised controlled trials, generalisability of the results for
both studies is limited by relatively small sample sizes and drop-outs of participants, but also
for McDonald et al (2005), by the fact that carers were required to opt into the study. Also,
the study that included a six month follow-up (McDonald et al. 2005) found less positive
results of the study than Herbert & Wookey (2007), which could suggest a CBT-focussed
intervention may have limited long-term effectiveness. Unfortunately a lack of detail about
each of the programmes makes it difficult to identify the similarities and differences between
the programmes which could be helpful in investigating these approaches further.
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Two other papers found looked at the effectiveness of the Incredible Years Basic Parent
(School Age) Programme (IYP) for improving foster parents ability to manage the complex
needs of looked after children by teaching them skills to manage child behaviour and
consequently promote placement stability. The IYP is founded on social learning theory and
was originally developed for use with biological parents. It's protocol includes detailed
session plans and home activities that can be tailored by professionals to the specific needs of
families. McDaniel et al (2011) conducted a pilot programme in Northern Ireland,
implemented by Barnardo's Professional Fostering Service, using a single-group pre-test and
post-test design with 13 foster carers. McDaniel et al (2011) focussed on an age range of 8
and 13, providing some (though limited) information on this. Assessments were carried out
before and immediately after the group training and included a self-report parent rating scale
to measure the degree of conduct and externalising behaviour management problems are
exhibited by children. Results from the study suggested a significant decrease in the intensity
of social, emotional and behavioural difficulties reported by foster carers following the IYP,
and a smaller but not significant decrease in the extent to which foster carers felt their foster
child's behaviour was problematic.
Bywater et al (2008) also looked at the effectiveness of IYP. They emphasised the potential of
IYP to enhance placement stability and help foster carers understand the needs of lookedafter children. Their study focussed on 46 foster carers of children between 2 and 8 years and
employed controlled randomisation to allocate to the intervention (n=29) and control (n=17)
groups. Foster carers were approached and requested to participate in the study and received
182
monetary rewards for completing data at baseline and six-month follow-up. The children
ranged between 2 and 17 years at the start of the study. Results suggest that the IYP was an
effective programme for significantly reducing carer depression and reducing challenging
behaviours in the foster children, as rated by the foster carers. Bywater et al (2008)
questioned whether their findings had been limited by using a parent-report scale that they
felt needed to be more sensitive. They also did not use other measures which reduced the
scope of measuring the changes that had occurred.
Again, despite promising findings, evidence of the effectiveness of IYP from both these
studies is limited by their small sample sizes. Bywater (2008) and McDaniel et al (2011) also
relied only on foster-carer reports to identify any impact of IYP on the foster children
themselves, and gave very limited information of the foster children and carers, limiting
understanding of who exactly the IYP appeared to be effective for. McDaniel et al (2011) also
failed to use a control group, which further limits the evidence for whether IYP is a promising
intervention. Additionally, a confounding feature in the study was Barnardo's Professional
Fostering Service provided ongoing support and training to foster carers outside of the IYP
which may have instead resulted, or contributed to the positive changes reported by the
carers. Furthermore, McDaniel et al's (2011) study failed to ascertain whether any reports of
changes or improvements from the intervention were maintained over time. A strength of
these studies was that they used quantitative measures to identify 'significant' improvements.
Though both McDaniel et al (2011) and Bywater (2009) also failed to detail many
demographics of the foster carers and foster children in their studies that could have aided
183
understanding of for whom the intervention was most effective (backgrounds, placements,
etc.). Overall, the study provides promising evidence but yet again another tentative start to
identifying the effectiveness of IYP for foster children.
Gurney-Smith et al (2010) used a repeated measures design, (pre, post and three month
follow-up) design to evaluate the impact of a Fostering Attachments Group (FAG) for a
mixed group of foster and adoptive parents. FAG (Golding & Picken. 2004) is based on
social learning and attachment theories and aims to develop parenting skills by educating
about the influence of the social environment on behaviour, with consideration of the need for
responsive and attuned parenting to develop successful attachments. The group comprised of
5 foster carers and 10 adoptive parents and a special guardian; one male and 15 females.
Evaluation data was only collected from 13 participants at all three stages. Inclusion criteria
involved currently experiencing problem behaviour from a child when the group started and
difficulties in attachment relationships for that child. Referrals came from Social workers and
were active cases in the Children, Young People and Families Service. Measures used were
all parent-report tools. Analysis showed that reported parenting skills and understanding
improved to a statistically significant degree which was maintained through to follow-up. A
significant decrease in reported child hyperactivity/inattention behaviours was obtained
between pre-group and follow-up time points. Post hoc tests also found a significant decrease
in overall difficulties of the child reported between pre-group and 3 month follow-up scores.
Parenting stress levels were not impacted but children were reported to show significantly
less inhibition.
184
Similarly to some of the other studies, no control group was used by Gurney-Smith et al
(2010), the sample size was very small, long-term evaluation was limited (only measured at
three months after) and measures used only foster-parent reports to identify any positive
outcomes for the foster children. The relevance of the findings to foster children is also
limited through the study using adoptive parents and a special guardian as well as foster
parents as, despite commonalities of background histories, their situations of temporary and
permanent placements may well impact the social environment quite differently. Again, as
with the other studies, though this study suggests some potential for being effective in
working with foster parents, this study fails to identify whether this approach has a truly
positive impact for the child.
Interventions directly with Foster Children
Loxterkamp (2009) aimed to challenge what she described as the ‘predominant conviction’
(p.423) that regular contact of adopted and fostered children with their biological parents is
always beneficial. Loxterkamp used three cases studies to illustrate her arguments that
contact is not always beneficial (in the short or long-term) and instead can often be the cause
of secondary harm. Though this approach highlights well the points argued by Loxterkamp
(2009) it does not provide high quality evidence that her hypotheses are valid and that the
experiences of those in her case examples are generalisable to those in the wider population.
185
For example, she chose the case studies to include as she felt they were representative of the
common attitudes in relation to contact. They were also chosen following therapy, as cases
Loxterkamp (2009) that had highlighted issue of biological contact that supported her
arguments, bias that cannot be ignored. Consequently, this study begins to identify potential
issues of contact but provides poor evidence for these upon which to initiate change in a
matter that has well-established beliefs and practises associated with it.
In contrast, Sen and Broadhurst's (2011) study was a narrative review of studies into
outcomes of foster children as a result of contact with their biological family. However, they
gave little detail of the methods of the studies and detailed no quantitative outcomes. They
highlighted that evidence for the impact of biological parent contact on children's emotional,
behavioural and intellectual outcomes was largely dated and inconsistent with no studies
having employed systematic measures to evidence the effect of contact on child outcomes in
relation to both UK and International studies. The only two main papers discussed in detail in
relation to this were focussed on disruption of attachment formation through contact with
biological parents. But again, little detail of the strengths of the study or the conclusions
found were presented. Sen & Broadhurst (2011) also looked at the impact of biological parent
contact on stability of placements, but failed to link this to identifying psychosocial outcomes
for the child and again, the descriptive style provided limited insight into the strength of the
evidence found from the studies presented. Sen & Broadhurst (2011) suggest a number of
components for future research that would help improve the quality of evidence found, but
that these conclusions are valid relies on the reader assuming that these components were not
186
included in the studies discussed by Sen & Broadhurst (2011) based on direct omission of
these details from the review rather than detailed critique of the studies, highlighting these
omissions. Such suggestions included a need for studies using robust outcomes measures
including psychosocial profiling and children's views, sufficiently sized and representative
samples of foster children, prospective and longitudinal designs and based on clear
definitions of contact. A lack of detail and lack of systematic approach to addressing the
literature, alongside the approach used by Loxterkamp (2009) means that evidence for the
outcomes of foster children as a result of contact with their biological parents in the UK is
currently very unclear.
The third study by Wakelyn (2008), looked at the impact of transitional therapy for children
in 'short-term' foster care. This work discussed the theories and used one case example to
illustrate the approach. It shows a promising consideration of developing and detailing new
approaches and ways of working with foster-children that take into account the importance of
well evidenced facets of practises such as multi-disciplinary working. It does not however,
provide evidence for the effectiveness of this intervention on improving the psychosocial and
behavioural outcomes of foster children given the limitations of using a case study, as with
Loxterkamp (2009).
Interventions with Multiple groups
187
Staines, Farmer & Selwyn (2011) investigated the effectiveness of a Therapeutic Team
Parenting approach. A prospective repeated measures design was used, involving children
between the ages of 5 and 14 entering new placements organised by one Independent FosterCare Agency. Twenty-three local authorities participated, 450 children were identified and
they, their carers and social workers were sent questionnaires at the start of the placement and
one year into it. Only eighty placements had data from carers and social workers at both time
points which reduced how representative the results are of the placements as a whole. Despite
detailing some demographics of the carers, including ethnicity, age and marital status, the
sample sizes did not allow reliable detailed analysis of the result in relation to these. The
team parenting approach emphasises all team members involved with the child working
collaboratively together, assessing the young person in placement rather than in isolation. The
therapeutic fostering environment views the placement and activities provided as enabling the
fostered individual to learn and develop, based on a systemic approach. Results found high
levels of satisfaction from foster-parents for the therapeutic and team parenting approaches
and the authors concluded that high-quality placements were provided for many of the
challenging children. The authors acknowledged that the approach was not always
implemented as efficiently as intended (delays in service provision following assessment, for
example). But alongside this, due to the small return rate of questionnaires it is difficult to
determine whether this approach positively impacts placement stability or child outcomes or
whom it is particularly beneficial to. On top of this, whether this approach could be effective
outside the Independent Foster-Care sector could be questioned from debate that Independent
Foster Care Agencies often do not provide placements for the most challenging children in
188
the care system.
Hibbert & Frankyl (2011) also relied on qualitative analysis and were even more limited by a
small sample size in their study into the impact of a psychology consultation service set up to
support foster carers and social workers. The approach was a consultation model that aimed
to combine clinical expertise and knowledge of psychological interventions for foster
children with the experiences and knowledge of social workers and foster carers in order is to
help foster carers understand the child’s early experience, the impact of this and then adapt
expectations of the child and strategies of working with them accordingly. Social workers
(n=7) were randomly selected but foster carers (n=7) opted into the study. They had between
1 and 6 consultation meetings (3.3 and 4.4 average for foster carers and social workers
respectively). A semi-structured interview about the consultation service was undertaken and
evaluated using thematic analysis. From this analysis, Hibbert & Frankyl (2011) highlighted
that all foster carers had reported an increase in psychological understanding of the child and
in skills for behaviour management, which in turn foster carers reported had led to improved
relationships between carers and their children and more self-confidence from this. Foster
carers also reported feeling emotionally supported. Social workers reported feeling supported
within the wider professional system, able to obtain different perspectives and reflect on
situations, gaining enhanced skills and support with decision making and planning.
Unfortunately, again no long-term investigations or child specific outcome measure were
used. Given the qualitative nature of the study and the small sample size, the generalisability
and reliability of the benefits of this approach appear are also clearly limited, though it
189
suggests a promising potential approach that could be worth investigating further to build on
these findings.
Golding (2010) investigated a multiagency approach to supporting children in foster care,
using an example of an integrated multi-agency service in Worcestershire for Looked-after
and adopted children (ISL). The aim is to maximise placement stability by providing mental
health and emotional well-being guidance and advice based around a consultation process,
supported by additional facets such as network meetings, supporting parenting and providing
education and mental health interventions. The author draws upon professional clinical
experience and states that 'a range of research and audit-based evaluations has confirmed ISL
provides an effective additional level of support for the children, carers and professional
network' (p581. Golding, 2010) but does not detail what these are other than detailing that
service user views and a pilot evaluation were used. Outcomes are detailed only as foster
carers having increased confidence and a changed perception of their children following
consultation leaving a vague understanding of the added value of the team. It is also unclear
as to the value of this work for the foster children's outcomes specifically, long-term benefits
and what components of the approach may be important. Evaluations are needed to identify
this, at least to ensure it is not causing harm, if there are other benefits that motivate services
to employ such an approach.
Discussion
190
Overall, there is currently very little evidence for the effectiveness of any particular
intervention to improve the social, emotional and behavioural outcomes for foster children in
the UK. Firstly, interventions involving foster-carers appear to have stronger methodologies,
using control groups and showing some attempts at identifying long-term outcomes of the
approaches used. Results from these studies all appear promising in producing positive
outcomes for carers, but unfortunately all child-related outcomes are based on parent reports
only, leading to a lack of understanding as to whether these interventions are truly have a
positive impact on foster-children. Is it enough to assume positive outcomes for a child if
their parents report being more able to cope with difficult behaviour or reduced problem
behaviours from the child? Placement stability has been evidenced as having a positive
impact on foster children’s social, emotional and behavioural outcomes, but are these studies
making assumptions that if foster parents feel more able to cope then the placement will be
more stable? Further studies need to take these questions into careful consideration.
Demographic details of foster parents and children are also limited in these studies and this
therefore limits understanding for whom these interventions may be effective and when.
Studies that have tried to consider these have been restrained by their sample sizes. Of the
foster-parent based interventions critiqued in this review, all show promise in supporting
foster carers and potentially foster children in relation to challenging behaviour particularly,
but due to methodological issues it is difficult to identify if any show more promise than
others currently. Secondly, interventions that directly involve the foster child are currently
lacking in numbers and development: Only Wakelyn (2008) has discussed a specific
191
approach and Loxterkamp (2009) and Sen & Broadhurst (2011) looked at the common
practise of contact with biological parents. Methods to evaluate these are also weak, with a
lack of controlled trials and use of measures to identify child outcomes. Thirdly, interventions
that include a range of individuals including carers, professionals and sometimes fosterchildren themselves seem to be even more difficult to ascertain whether they are having a
positive impact on foster children's psychosocial wellbeing: All these studies looked at failed
to use control groups and had small sample sizes or relatively high drop-out rates (or
incomplete data). Alongside this, they also relied on parent-report of child improvements and
changes, rather than multiple perspectives further highlighting difficulties ascertaining
whether these approaches truly benefit foster children. The detail of the work undertaken
within each study was also lacking, leading to limited understanding about what in the
approach may have been beneficial and why. Similarly to the parent-focussed approaches,
these studies also had limited demographic data of the foster children and carers involved and
the potential impact of issues of difference and diversity on the effectiveness of the
interventions.
Overall, the approaches that currently appear to have the most established evidence as to their
effectiveness in the UK are the foster parent focussed approaches. (McDonald et al (2005);
Herbert& Wookey (2007); McDaniel et al (2011); Bywater et al (2008); Gurney-Smith et al
(2009)). These however, have much to improve on both in the quality and detail of evidence
obtained but also in the fact that they have done more to evidence their positive outcomes for
foster carers than foster children themselves and this needs to be addressed as a priority in
192
future research with these approaches. What is also worth highlighting, is that these
interventions focus almost solely on issues around challenging behaviours in foster children
and though this is the current most common difficulty for foster children in the UK (Tapsfield
& Collier. 2005), other difficulties and disorders experienced by foster children need effective
and appropriate interventions also.
Limitations
Limitations of this systematic review are that the inclusion of the search terms around
location may have overlooked some papers that have been undertaken in the UK but have not
been explicitly listed as such. Despite this, it is important to consider that professionals or
researchers interested in using UK evidence-based interventions for foster care are likely to
have time pressures that limit them from long database searches to find these. Though this
leads to a potential limitation of this review, it highlights the need to label papers in a way
that facilitates their use by those whom they are most valuable to. A similar limitation may be
the use of peer-reviewed and published articles in this review: It may be that for example, the
local authorities implementing MST as discussed by McAuley & Davis (2009) may have
evaluated the effectiveness of this intervention but not shared the findings through publishing
them, or the findings may have not reached a standard to be published. Again, if such
information has not been shared or is not able to be accessed, it limits the ability of other
local authorities and services to understand the effectiveness and limitations of these
193
interventions in the UK and make more informed decisions on how to best support foster
children and families.
Another limitation is the inclusion of papers that have included adoptive parents as well as
foster parents as these may have prevented the review drawing on purely foster-related
research. (e.g., Gurney-Smith et al. 2010). Despite this drawback, given the limited wealth of
research in this area, it was felt including it would enable discussion of a more approaches
being used with foster carers in the UK. The same lack of clarity may apply from having used
papers that group looked-after children rather than focus on fostered children specifically.
(e.g., Golding. 2010) Given that in 2011, 74% of looked after children were in foster
placements suggests that this group is likely to constitute a majority of those used in studies
including all looked after children and is worth considering. (Department for Education.
2011) Studies have found however, that those in residential care are statistically likely to have
greater difficulties (Meltzer et al. 2003, 2004a, b).
Future directions
Given the limited research and weaknesses in methodology discussed in this review, there are
a number of potential directions and considerations for future research. The use of RCT's in
some of the research papers critiqued is a promising step towards providing valid and reliable
findings on the effectiveness of interventions for foster children in the UK, but greater sample
194
sizes and avoiding using samples where individuals have 'opted in' to the study will help
enable stronger conclusions to be drawn from findings. Given the often wide range of
individuals involved in a foster-child's care, control groups are very important in validating
the impact of an intervention and future studies should consider carefully to what extent their
research may be compromised without a control group. Just as the diversity and difference
issues between US and UK foster children, carers and systems need to be considered, so does
the diversity of foster children and their carers in the UK. Acknowledging and investigating
how issues of diversity and difference may impact the effectiveness of interventions may be
key in help identifying what interventions are effective to use in the UK. Studies may need to
investigate specific ethnic groups, children with specific lengths of time in care or particular
histories, etc., or analyse results in more general studies to identify any potential betweengroup differences. Future research looking into supporting foster children with conduct
disorders through foster-parent work needs to build on the work discussed in this review and
study more carefully the outcomes for the foster children to ensure this work is having the
positive impact on the children intended. Studies that look at longitudinal outcomes for
foster-parents and children of these programmes will also be important in understanding the
value of these interventions for the foster-care population. As emphasised earlier, with a
positive and growing focus on evaluating interventions for foster children with conduct
disorder in the UK, evaluations and developments of interventions for other difficulties
experienced by UK foster children, such as emotional and anxiety disorders must not be
neglected. (Tapsfield & Collier. 2005). Depending on the focus, future work in this area may
involve developing new approaches, making adjustments to approaches or looking at the
195
validity and relevance of already established approaches but all done in order to ensure
interventions used with this vulnerable group are safe and effective.
Conclusion
From this review, it is clear that the evidence base for the effectiveness of interventions that
aim to improve the social, emotional and behavioural wellbeing for UK foster children is
limited and weak. Foster-parent focused interventions in the UK show promise in helping
foster carers feel more able to manage difficult behaviour but have done little to evidence
positive outcomes for the foster children themselves. Evidence of the effectiveness for
interventions that address the social and emotional difficulties of foster children in the UK is
lacking. Consequently, there is great scope for studies that use stronger methodologies, larger
sample studies, carefully defined samples, consider diversity implications and consider longterm effects of interventions, whether these be validating the effectiveness of studies
developed elsewhere or developing new ones. What is clear is that with this vulnerable group
of individuals, professionals have a responsibility to support these children and young people
effectively, safely and use resources wisely to do this, to ensure we help both those with the
most need but also as many individuals as possible. In order to do this, we need a greater
understanding of what interventions can enable UK foster children to achieve the best
outcomes for their current wellbeing and future.
196
References
Bywater, T., Hutchings, J., Linck, P., Whitaker, C., Daley, D., Yeo, S., &
Edwards, R.
(2010). Incredible Years Parent Training Support for Foster Carers in Wales: A Multi-Centre
Feasibility Study. Child Care Health and Development. 37, 233-243.
Department for Education. (2011). DfE: Children Looked After by Local Authorities in
England (including adoption and care leavers) - year ending 31 March 2011. Retrieved from
Department of Education website: http://www.education.gov.uk
Department for Education and Skills. (2003). Every Child Matters: Presented to Parliament
by the Chief Secretary to the Treasury by Command of Her Majesty, September 2003.
London: Stationery Office. Retrieved from department of education website:
http://www.education.gov.uk
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, 319-325.
Golding, K. (2010). Multi-agency and specialist working to meet the mental health needs of
children in care and adopted. Clinical Child Psychology and Psychiatry, 15, 573-587.
197
Gurney-Smith, B., Granger, C., Randle, A., & Fletcher, J. (2010). ‘In time and in tune’ – the
Fostering Attachments Group: capturing sustained change in both caregiver and child.
Adoption & Fostering, 34, 50–60.
Herbert, M., & Wookey, J. (2007). The Child Wise Programme: A course to enhance the selfconfidence and behaviour management skills of foster carers with challenging children
Adoption & Fostering Journal, 31, 27-37.
Hibbert, G., & Frankl, J. (2011). A psychology consultation service for
social workers and
foster carers in a child and adolescent mental health service. Educational and Child
Psychology, 28, 63-72.
Holland, S., Faulkner, A., & Perez-del-Aguila, R. (2005). Promoting stability and continuity
of care for looked after children: A survey and critical review. Child & Family Social Work,
10, 29-41.
Landsverk, J., Burns, B., Stambaugh, L., & Reutz, J. (2009). Psychosocial interventions for
children and adolescents in foster care: Review of research literature. Child Welfare , 88, 4969.
Loxterkamp, L. (2009), 'Contact and Truth: The Unfolding Predicament in Adoption and
Fostering'. Clinical Child Psychology and Psychiatry, 14, 423-35.
198
Macdonald, G., & Turner, W. (2005). An experiment in helping foster-carers manage
challenging behaviour. British Journal of Social Work, 35, 1265-1282.
McAuley, C & Davis, T (2009) 'The Emotional Well-Being of Looked After Children in
England'. Child and Family Social Work, 14, 147-155.
McDaniel, B., Braiden, H. J., Onyekwelu, J., Murphy, M., & Regan, H. (2011). Investigating
the effectiveness of the incredible years basic parenting programme for foster carers in
northern Ireland. Child Care in Practice, 17, 55-67.
Meltzer, H, Gatward, R, Goodman, R and Ford, T. (2000). The mental health of children and
adolescents in Great Britain: summary report. London: The Stationery Office.
Meltzer, H., Gatward, R., Corbin, T., Goodman, R., Ford, T. (2003). The mental health of
young people looked after by local authorities in
England. London: The Stationary Office.
Meltzer, H., Lader, D., Corbin, T., Goodman, R. and Ford, T. (2004a). The mental health of
young people looked after by local authorities in Scotland. Edinburgh: The Stationery Office.
Meltzer, H., Lader, D., Corbin, T., Goodman, R., Ford, T. (2004b). The mental health of
young people looked after by local authorities in Wales. London: The Stationary Office.
199
Moore, K. J., & Chamberlain, P. (1994). Treatment foster care: Toward
development of
community-based models for adolescents with severe emotional and behavioral disorders.
Journal of Emotional and Behavioral Disorders, 2, 22-30.
National Institute of Clinical Excellence. (2001). The guideline development process –
Information for national collaborating centres and guideline development groups. London:
NICE. Retrieved at:
http://www.nice.org.uk
Pallett C, Scott S, Blackeby K, Yule W and Weissman R (2002) Fostering changes: a
cognitive-behavioural approach to help foster carers manage children. Adoption and
fostering, 26, 39-48.
Sen, R., & Broadhurst, K. (2011). Contact between children in out of home placements and
their family and friends networks: A research review. Child & Family Social Work, 16, 298309.
Staines, J., Farmer, E., & Selwyn, J. (2011). Implementing a therapeutic
team parenting
approach to fostering: The experiences of one independent foster-care agency. British
Journal of Social Work, 41, 314-332.
Tapsfield, R., & Collier, F. (2005). The cost of foster care: investing in our children's future.
London: British Agencies for Adoption and Fostering/ Fostering Network.
200
Thoburn, J. (2007). Globalisation and child welfare: Some lessons from a cross-national
study of children in out-of-home care. Norwich: UEA Social Work Monographs.
Wakelyn, J. (2008). Transitional psychotherapy for looked-after children in 'short-term' foster
care. Journal of Social Work Practice, 22, 27-36.
Ward, H., Holmes, L., Soper, J., & Olsen, R. (2008). Costs and consequences of placing
children in care. London: Jessica Kingsley Publishers.
World Health Organisation. (1992). International statistical classification of diseases and
related health problems (ICD-10), 10th revision. Geneva: Author.
201
Overview of Clinical Experience
Adult Mental Health
This placement was based in an Adult Community Mental Health Team. The main model of
the placement was Cognitive-Behavioural Therapy (CBT), with some DBT (Dialectical
Behavioural therapy) and Schema therapy. I used these approaches to undertake individual
work with a range of individuals with a variety of difficulties including depression, bi-polar,
personality disorders and a range of anxiety disorders including Obsessive Compulsive
Disorder (OCD), hoarding, generalised anxiety, social anxiety and post-natal depression. I
also undertook joint work with social workers and community psychiatric nurses (CPNs)
doing in-home assessments and interventions as well as joint assessments with the local
substance abuse team. I co-facilitated a CBT group for clients with depression and evaluated
this to inform service developments. The neuropsychological assessments explored queried
Learning Disabilities and brain injuries.
Older People's Mental Health
This placement was based within an Older People's Community Mental Health Team and
Older People's memory service . I undertook cognitive assessments of older adults with
suspected memory loss, to help diagnose the presence dementia, including specifying the
potential type of dementia. This developed my knowledge of dementia profiles as well as the
cognitive changes associated with older age and expanded my skills in neuropsychological
assessment tests. I co-ran a support group for individuals newly diagnosed with dementia and
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their carers and I undertook training for professionals managing behaviours that challenge in
individuals with dementia. I undertook individual therapeutic work with older adults with
depression, anxiety, bereavement difficulties, and personality disorders, often alongside
physical health conditions.
Child and Adolescent Mental Health
This placement was based in a Child and Adolescent Mental Health Service (CAMHS) where
the main approach used by my supervisor was an integrative approach. Due to the nature of
the work, there was a high emphasis on a systemic approach, with elements of CBT, narrative
and psychodynamic elements. I worked with young people and their families who were
experiencing difficulties with depression, generalised anxiety, agoraphobia, PTSD, eating
difficulties, histories of sexual assault and sexual abuse, OCD, psychosis, ASD, ADHD and
Learning Disabilities. These cases expanded my experience of assessment and managing risk,
utilising positive risk management strategies and developed my working knowledge of Child
Protection procedures. I also undertook cognitive assessments of young people with queried
learning disabilities to inform future support as well as therapeutic input. I also participated in
ASD assessments and the family therapy reflecting team.
Learning Disabilities
This placement was based in a Community Team for Adults with Learning Disabilities. It
offered variety in relation to individual work, family group and consultation to staff working
in residential homes. Part of this work included functional assessments to inform behaviour
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plans and staff training as well as CBT for depression, narrative work and complex grief
work. I worked closely with staff and families to carry out assessments with clients who were
referred to psychology for difficulties living with other residents and challenging behaviour.
Whilst on this placement, I was involved in safeguarding meetings and risk assessments,
researching specific behaviours and associated risks of these alongside issues of capacity. I
also provided consultation to staff in relation to managing safeguarding behaviours in
residential homes in the context of limited resources. During this placement I undertook
cognitive assessments for dementia with clients with Down Syndrome, as well as with a
young lady with a queried Learning Disability and ASD.
Advanced competencies
This placement was based in a Paediatric Psychology team within a large hospital. This
service offers Psychological support to children and their families and medical staff. The
predominant models of this placement were systemic, narrative, behavioural models and CBT
as assessments and therapy took into account the impact of medical conditions on all the
areas of the young people's and their families' lives. This placement expanded my
understanding of the contribution of Psychology in a predominantly medical setting.
This service exists within a very diverse community of staff and clients and provided me the
opportunity to develop my skills in working through interpreters. There was a high level of
liaison between medical staff and different medical teams, schools, education services, social
services and community medical teams. This expanded my knowledge and skills of care
coordinating but also developed my awareness of the roles and functions of a wider range of
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child focussed services.
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Academic Assessments
Year I Assessments
PROGRAMME
COMPONENT
TITLE OF ASSIGNMENT
Fundamentals of Theory
and Practice in Clinical
Psychology (FTPCP)
Short report of WAIS-III data and practice
administration
Research –SRRP
Impact on symptoms of depression of a CBT for
depression group
Practice case report
Cognitive behavioural therapy with a middle-aged man
presenting with obsessive-compulsive disorder
Problem Based Learning –
Reflective Account
'Relationship to change'
Research – Literature
Review
UK evidence for interventions to improve the
psychological wellbeing of foster children: A
systematic review
Adult – case report
Assessment, cognitive behavioural formulation and
therapy with a man in his thirties presenting with
severe depression and post-traumatic stress disorder
Adult – case report
Cognitive behavioural therapy with a woman in her
late twenties presenting with anxiety and depression.
Research – Qualitative
Research Project
Trainees’ perceptions and experiences of selfdisclosure in a therapeutic Setting
Research – Major
Research Project Proposal
Impact of disrupted placements on the well-being of
children who are accommodated
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Year II Assessments
PROGRAMME
COMPONENT
TITLE OF ASSESSMENT
Research
Research methods and statistics test
Professional Issues Essay
How do we understand the context of mental health,
mental illness and mental wellbeing when people are
experiencing material poverty? What psychological
frameworks do we have to offer such people?
Problem Based Learning –
Reflective Account
Child protection, domestic abuse, parenting and
learning disabilities and kinship care
Older People – Case
Report
Neuropsychological assessment for a gentleman in his
eighties experiencing some mild memory difficulties
Personal and Professional
Learning Discussion
Groups – Process Account
Personal and Professional Learning Discussion Groups
Process Account
Child and Family– Oral
Presentation of Clinical
Activity
Positive risk management with a mid-teenage girl
Year III Assessments
PROGRAMME
COMPONENT
Research – MRP
Portfolio
ASSESSMENT TITLE
Young people’s perspectives of foster placement
instability: A grounded theory approach
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Personal and
Professional Learning –
Final Reflective Account
On becoming a clinical psychologist: A retrospective,
developmental, reflective account of the experience of
training
Specialist – Case Report
Integrative therapy with a young girl with chronic
constipation and low self-esteem
End of Portfolio.
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