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 PsychologyFaculty of Arts and Human Sciences
University of SurreyGuildford, SurreyUnited 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
ByRuth 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 SurreyMay 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).
6
Placement instability, including unplanned changes, is a major predictor of
negative outcomes from care (Rostill-Brookes, Larkin, Toms, & Churchman,
2011). The literature 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, & Knot-Dickscheit, 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,
7
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 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
8
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 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
9
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).
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
10
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
11
supported through a 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.
Method1 The researcher’s stance and consequent impact on the process are discussed within the method
12
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 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)
13
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
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
14
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 (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
2 See limitation section for discussion of key limitations.
15
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, 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
16
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 care
17
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.
18
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 and after the
interview, written and verbal debriefs were given (Appendices B & C).
Follow-up 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
19
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 of power3 (See
Appendix E for the initial interview questions). Feedback resulted in the re-
phrasing 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 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.
4This 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.
20
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 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).
21
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
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
22
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 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
23
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 developed from, the data analysis.
24
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
25
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.
26
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
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
5 Pseudonyms have been used to protect confidentiality. 6 Appendix M examples a finding evidenced by multiple interviews.
27
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)
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.
28
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).
“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.
29
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.
“…’ 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.
30
“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)
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.
31
“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)
32
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)
33
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 self-blame 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)
34
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-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)
35
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)
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.
36
“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.
“... 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.
37
“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.
“… 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)
38
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 lack of support
39
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.
40
“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.
41
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 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
42
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.
“...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
43
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.
“...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
44
‘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 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.
45
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.
46
“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)
47
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 ‘self-
protective’ 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
48
amongst young people in care. This reinforced their use in future care
moves.
Future Focus
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)
49
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)
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)
50
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 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
51
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 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.
52
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 not been included here due
53
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
54
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.
55
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
56
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 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
57
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 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
58
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 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
59
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.
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,
60
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
61
unworthy of care’ (Bowlby, 1973 p, 238). 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
self-reliance 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).
62
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 (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 &
63
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 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
64
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.
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
65
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, 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.
66
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, 2006; Creswell, 1998)
67
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.
68
It is acknowledged that these results require further exploration to obtain
further understanding of factors that influence resilience and distress from
placement moves. 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.
69
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. 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.
70
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.
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.
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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. 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.
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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. 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.
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.
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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.
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.
74
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 self-reliance 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. 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.
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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.
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
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Appendix B: Debrief Statement
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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.
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Appendix C: Debrief sheets
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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.
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Childline 0800 1111http://www.childline.org.uk/Pages/Home.aspx
The Samaritans 08457 90 90 90 [email protected]
Support Line 0208 554 9004 [email protected]
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/
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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.
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The Samaritans 08457 90 90 90 [email protected]
Support Line 0208 554 9004 [email protected]
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.
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Appendix D: Participant Demographics
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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 Romany-Gypsy
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
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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
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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 happened6. 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
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Example of transcript analysis:
Limited explanation
Go immediatelyLiving out of black bin bagsNo hope in permanency
No stabilityNo securityAlways ready in case
Fear of losing things
Confidence knocked
Constantly settling and moving
Impact on now – difficulty settlingUsed to play on mind
No, they'd just show up
Yeah. Pretty much (go immediately)I was living out of black bin bagsIt got to pointwhere 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 timeso was just a case of keep my stuff in there,where I can just grab it
it's knocked my confidencebecause, I’d settle down somewherethen you get moved again.You settle down again, you get moved again,it just is like a vicious circleIt’s why it's like now, why I find it hard to settle init’s not always in the back of my mind nowbut it was a few years agolike, I know I'm going to move again soon
Participant: They'd just say, ‘oh you're going
to a new place’.
Interviewer: And did you get much warning?
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 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
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
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you expected this?• Can you tell me what was important to you when you moved placements and why?
Appendix H: Participant Information Sheet
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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.
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What is the research?
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?
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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 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 ([email protected]) 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
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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).
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Appendix I: Consent form
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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
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Signature:……………………………………… Date:……………………
Appendix J: Description of Analysis - Willig’s (2009) Abbreviated Grounded Theory Approach
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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
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data. Visual diagrams were produced of the findings, highlighting the complex relationships between the concepts and categories that emerged through data analysis.
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
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element from Yardley (2000) of impact and importance, important in a credible study.
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Appendix K: Example of Transcript and Coding
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Focussed Coding / Intermediate Coding
Line by Line coding / Initial coding
Transcript
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
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
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?
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
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on access to see brother
Move happened too quickly too handle
Found out moving through being told they’d packed her bags
Moved on the day she found out
No warning to being moved
Placement move planning was kept a secret from her
Stuff was packed without her knowing - secrets
They didn’t. They told me they’d packed my bags.
On the day No warning they’d obviously
been planning it for a few weeks
they just didn’t tell me.
Yeah, while I was away for the weekend.
So I’d come back to find all my stuff packed and then later that day I was being moved to [town].
my foster carers. And it all
just happened so quick. Too
much to handle in my … in a
few days.
Interviewer: And how ... and
when did you find out the
placement was ending,
relative to when you were
then moved?
Participant: They didn’t.
They told me they’d packed
my bags.
Interviewer: Ok. So it was
on the day?
Participant: Mmhhmm
Interviewer: There was no
warning?
Participant: Mmmhhmm. So
they’d obviously been
planning it for a few weeks
and they just didn’t tell me.
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Moved same day found out moving - No preparation
Told by foster carer they couldn’t handle her behaviour anymore
Mixed feelings about moving
Glad to leave because of way treated
Foster carers told
They couldn’t handle my behaviour anymore.
cause I was a pretty angry child.
In a way I was glad ‘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.
Interviewer: Ok. And they’d
packed your stuff… and
things?
Participant: Yeah, while I
was away for the weekend.
Interviewer: Ok.
Participant: So I’d come
back to find all my stuff
packed and then later that
day I was being moved to
[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
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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 carer home anymore
Had to contact SS herself to sort where she was going.
SS acted immediately to find a new place
Had to sort own place from 18
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 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.
did you feel ….
Participant: Erm… I don’t
know really. I, like, …. In a
way I was glad ‘cause the
way like I found they treated
me but obviously unhappy as
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). 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
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SS responsible for her until 18 and had no choice about this
Being moved was a secret and a surprise
Deceit – ‘behind my back’
Decisions made about her without her
No detailed explanation for move given.
So that was all done behind my back.
Next thing I know I’m moving out.
Foster carers talked about (planned) her leaving before they told her.
They didn’t even tell me really.
They just said ‘you’re going. We can’t have you no more’.
. My foster carer. Took me
They helped me unpack my stuff from the car, gave me a cuddle and then
find me a new place… which
they done pretty much
straight away.… obviously
from 18 I had to sort my own
place out but from going from
erm, one foster family to the
other, obviously social
services had to be involved,
the fostering agency had to
be involved and I couldn’t say
anything about it.
Interviewer: No?
Participant: So that was all
done behind my back. Next
thing I know I’m moving out.
Interviewer: Ok, so they’d
already joined up and talked
about it?
Participant: Mmmhhmm.
Interviewer:..by the time
the foster carers told you?
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Foster carer took to new placement
Foster carer helped her to move and then left – (practical support only)
Upset about moving
Felt had lost everything ‘all my life was gone’
All new situation at new foster carer’s
left.
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.
Participant: Yeah.
Interviewer: Ok. Ok.
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 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 that, having them …
Participant: It was horrible.
Absolutely horrible. I was
crying … everything. I just
felt like all my life was gone
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between my feet. Moving to
some house that I didn’t
really know. Moving to
[town], an area that I didn’t
know.
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Appendix L: Memo Examples
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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
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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.
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Appendix M: Example of a finding evidenced across interviews
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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
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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)
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)
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Appendix N: Example of search for triangulation of results
122
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
highlighted in
results:
Resilience, Adversity, Thriving, trauma-related
beliefs, Self-reliance
Future, Psychodynamic adjustment (ego)
Destruction (as a means of survival)
Reactive attachment disorder,
123
MRP Proposal
Impact of disrupted placements on the well-being of children who are accommodated
ByRuth Joanne Hunter
School of Psychology Faculty of Arts and Human Sciences
University of Surrey
August 2012
124
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).
125
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 well-established 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.
126
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
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
127
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.
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
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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.
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
129
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
130
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.
131
Design and proposed data analysis
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).
132
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).
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*).
133
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 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.
134
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.
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.
135
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 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
136
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.
Ethical Considerations
137
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.
138
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 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.
139
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.
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
140
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
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
141
express an interest in the study. For those that do express an
interest, reassurance will be given in relation to confidentiality and a
non-judgemental 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.
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
142
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
complete: 08/13
Data analysis start: 08/13
complete: 10/13
Complete draft: Results / Discussion : 12/13
143
Submit complete draft: 02/14
144
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. Retrieved from: http://www.legislation.gov.uk
Department of Health. (2009). Promoting the health and wellbeing of looked after children – revised statutory guidance. London. TSO.
145
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, 1336-1341.
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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147
Literature review
UK evidence for interventions to improve the psychological wellbeing of foster children: A systematic review
Year 1
April 2012
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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
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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
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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.
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
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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
and family therapy (Moore & Chamberlain. 1994). The other approach
identified as being developed when McAuley & Davis (2009) published
their research was a cognitive-behavioural 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
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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 background,
religion, culture, etc. Identifying and acknowledging some of these
differences may provide insight into how and why the effectiveness of
interventions with an evidence-base in the US may differ in the UK and
guide appropriate adjustments or changes and the appropriateness of
implementing or testing these.
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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
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
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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,
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
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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
children in the UK.
Method
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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
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
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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
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
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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
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
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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.
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
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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 looked-
after 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
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)
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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
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.
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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.
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
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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.
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
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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
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
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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
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 Foster-
Care Agency. Twenty-three local authorities participated, 450 children were identified and
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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
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
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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
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,
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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
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,
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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
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 foster-
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children 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
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
173
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
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
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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
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
175
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 between-
group 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
validity and relevance of already established approaches but all done in order to ensure
interventions used with this vulnerable group are safe and effective.
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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 long-
term 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.
177
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.
178
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.
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 self-confidence 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, 49-69.
179
Loxterkamp, L. (2009), 'Contact and Truth: The Unfolding Predicament inAdoption and Fostering'. Clinical Child Psychology and Psychiatry,
14, 423-35.
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.
180
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.
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.
181
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, 298-309.
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.
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.
182
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
ByRuth Joanne Hunter
School of Psychology Faculty of Arts and Human Sciences
University of Surrey
April 2012
184
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.
186
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
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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
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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
and family therapy (Moore & Chamberlain. 1994). The other approach
identified as being developed when McAuley & Davis (2009) published
their research was a cognitive-behavioural 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-
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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 background,
religion, culture, etc. Identifying and acknowledging some of these
differences may provide insight into how and why the effectiveness of
interventions with an evidence-base 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
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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 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
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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, Thoburn (2007) highlight the underrepresentation of
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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
194
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
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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
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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 looked-
after 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
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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
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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.
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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.
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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
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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
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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 Foster-
Care 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
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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
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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
207
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
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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 foster-
children 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
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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
210
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
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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 between-
group 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
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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 long-
term 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.
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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.
214
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.
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 self-confidence 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, 49-69.
215
Loxterkamp, L. (2009), 'Contact and Truth: The Unfolding Predicament in Adoption and Fostering'. Clinical Child Psychology and Psychiatry, 14, 423-35.
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.
216
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.
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.
217
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, 298-309.
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.
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.
218
World Health Organisation. (1992). International statistical classification of diseases and related health problems (ICD-10), 10th revision. Geneva: Author.
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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
220
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
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care coordinating but also developed my awareness of the roles and
functions of a wider range of child focussed services.
223
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 self-disclosure in a therapeutic Setting
Research – Major Research Project Proposal
Impact of disrupted placements on the well-being of children who are accommodated
224
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
ASSESSMENT TITLE
Research – MRP Portfolio
Young people’s perspectives of foster placement instability: A grounded theory approach
225
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.
226
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