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Adoption

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Addressing the Mental Health Needs of Looked after Children Who Move
Placement Frequently
Alison Beck
Adoption & Fostering 2006 30: 60
DOI: 10.1177/030857590603000308
The online version of this article can be found at:
http://aaf.sagepub.com/content/30/3/60

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What is This?

Addressing the mental health needs of looked


after children who move placement
frequently
Research has revealed high levels of mental health
need among children who are looked after. The aim
of this study, reported by Alison Beck, was to compare the mental health needs of looked after children
who move placement frequently with the mental
health needs of those who do not and to consider
how these differences may be addressed in terms of
mental health service planning. Two questionnaires
(including the Strengths and Difficulties Questionnaire SDQ) were sent to the carers of 747 young
people (aged over three years) looked after by one
inner-London local authority, to the young people
themselves if they were aged over 11 years and to a
selected sample of teachers. A third (30 per cent) of
young people had a probable psychiatric diagnosis
using the SDQ. Eleven per cent had moved placement three or more times in the last year and they
were three times more likely to have a probable
psychiatric diagnosis. They were also significantly
more likely to report deliberate self-harm in the last
six months compared to those who had moved
placement less frequently.
Although young people who move placement
frequently are far more likely to develop psychiatric
disturbance than other looked after children, they are
much less likely to access mental health services.
The barriers to service access and practice implications of these findings are discussed.

Alison Beck is
Consultant Clinical
Psychologist, South
West London and St
Georges NHS Trust,
London
Key words: mental
health, looked after
children, frequent
placement moves

60

Introduction
This study compares the mental health
needs of looked after children who move
placement frequently with those in more
stable placements. A number of UK
studies have found high rates of mental
health need among looked after children
(McCann et al, 1996; Dimigen et al,
1999; Minnis and Devine, 2001). These
findings are supported by the results of
the Office for National Statistics (ONS)
survey of the mental health needs of
looked after children.

The foremost recent British study of


the mental health of five to 15-year-olds
in the general population, conducted by
the ONS (Meltzer et al, 2000), found that
one in ten children had a clinically diagnosable disorder (ICD-10) that caused
them distress or had a considerable
impact on their life. More recently, some
of the same authors explored the mental
health of young people looked after by
local authorities in England and found
that 45 per cent of those looked after by
local authorities and aged between five
and 17 years had a mental disorder
(Meltzer et al, 2003).
However, none of these studies specifically considered the mental health
needs of young people who move placement frequently. This is surprising given
the findings of a recent study by McCarthy
(2004), based on a small number of cases,
that reaches a worrying conclusion about
the relationship between movement and
mental health.
The current study looks at this group
and compares them with looked after
children in more stable placements,
scrutinising not only their mental health
but also their access to (and barriers to
accessing) mental health services. A
number of studies have suggested that
looked after children in general have
difficulties accessing mental health services (eg Glisson, 1996; Dimigen et al,
1999; Zima et al, 2000). This article
considers whether frequent placement
moves may impose a further barrier to
mental health service access. Many
factors present a barrier to young people
who move placement frequently accessing
services and these need to be addressed in
planning mental health services. But it
may also be the case that young people
who often move placement experience
different types of mental disorder compared to their more securely placed peers.
These mental health needs may contribute
to frequent placement breakdown and
may be exacerbated by it.

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ADOPTION & FOSTERING VOLUME 30 NUMBER 3 2006

Methods
All 786 young people looked after by
Lambeth local authority who were aged
over three years were included. Social
workers withdrew consent to approach 37
young people and 45 carers/birth parents,
the most common reason being that there
were ongoing care proceedings. Twenty
birth parents withheld consent for their
children to participate in the project.
All looked after children and young
people over the age of 11, for whom
consent was not withdrawn, were invited
to take part (N = 529). In addition, the
main carers of all young people (aged
over three years) in the care of the local
authority were invited to participate (N =
661). All individuals were sent a letter
describing the project and emphasising
that they were under no obligation to take
part, although they were offered a financial incentive of 5 for returning the
questionnaires.
Participants were sent two questionnaires: the Strengths and Difficulties
Questionnaire (SDQ, Goodman, 1997)
and either a Carer or a Young Person
questionnaire. The latter was a nonstandardised tool developed for the study
to obtain demographic details and qualitative information about a variety of aspects
of young peoples lives relevant to their
mental health and access to mental health
services.
The Carer and Young Person questionnaires were developed to provide young
people and their carers with an opportunity to share more descriptive information about factors affecting their mental
health. Questions were therefore largely
open-ended, allowing for the expression
of a broad range of views about placements, about young peoples relationships
with social workers and foster carers, and
about their views of mental health services. Information was also collected
about young people and their carers
perceptions of risk and protective factors for mental ill-health, about their
perceptions of the young peoples emotional and behavioural difficulties, and

about their self-harming behaviour in the


last six months.
All the teachers (N = 8) employed by
the local authoritys looked after children
education service were asked to complete
questionnaires on every young person to
whom they had provided a service over
the last year (N = 25). Information was
not obtained from other teachers as their
details were not available to the research
team.
Results
Demographics
Seven hundred and eighty-six young
people aged over three years were known
to be in the care of the local authority in
July 2001. Three hundred and twentyseven were girls (42 per cent) and 459
boys (58 per cent). Sixty-three (8 per
cent) were aged three to five years, 157
(20 per cent) aged six to ten years, 330
(42 per cent) aged 11 to 15 years and 236
(30 per cent) aged 16 to18 years. Two
hundred and twelve (27 per cent) were
white, 212 (27 per cent) black British
Caribbean, 134 (17 per cent) black British
African and 228 (29 per cent) were from
other ethnic groups. Forty-three per cent
were on full care orders, ten per cent on
interim care orders and 46 per cent
accommodated under section 20 on a
voluntary basis.
Less than one-third (27 per cent) of
young people (N = 212) resided in the
borough in which the study was based, the
remaining 73 per cent (N = 573) living
outside. Approximately 85 per cent (N =
668) lived within Greater London.
The vast majority of young people had
lived in two placements or less in the last
year; only 11 per cent had had three
placements or more. Those who moved
frequently were found to differ statistically from young people in stable placements in a number of important ways.
They were significantly more likely to
live out of borough,1 to be aged between
11 and 15 years,2 to be placed in a residential unit,3 and to be accommodated

X2 = 7.5, p = 0.006
X2 = 11.3, p = 0.001
3 2
X = 21.6, p<0.001
2

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ADOPTION & FOSTERING VOLUME 30 NUMBER 3 2006

61

Table 1
Prediction of psychiatric diagnoses using SDQ
Unlikely

Possible

Probable

Conduct

409 (58%)

120 (17%)

177 (25%)

Emotional

586 (83%)

78 (11%)

42 (6%)

Hyperactivity

459 (65%)

233 (33%)

14 (2%)

Any diagnosis

353 (50%)

141 (20%)

212 (30%)

under section 20 or in the process of


ongoing care proceedings.4 In terms of
gender5 or ethnicity,6 no statistically
significant differences were found between frequent placement movers and
young people who had been in two placements or less in the last year.
Respondents vs non-respondents
One hundred and sixty-two out of the 661
carers (or key workers) who were sent
questionnaires responded (approximately
25 per cent response rate). The equivalent
response for young people aged over 11
years was 109 out of 529 (approximately
21 per cent response rate).
Respondents were not significantly
statistically different from the overall
sample of looked after children in terms
of gender,7 legal status,8 whether they
lived in or out of borough,9 number of
placements in the last year10 or time in
current placement.11 However, a significantly greater proportion of the people
describing themselves as white responded compared to individuals from other
ethnic backgrounds12 and respondents
were more likely to be in foster care (or
foster carers) rather than other types of
placement.13
SDQ results from respondents
One hundred and nine young people (out
of 529) and 162 carers (out of 747)

Protective factors
Six factors were repeatedly mentioned by
carers as protecting the young people in
general from mental health problems.
Furthermore, when those young people
perceived by their carers as having one of
the protective factors were grouped and
compared with those who did not display
these factors, they were less likely to have
a probable psychiatric diagnosis. The
factors were a consistent hobby or
interest,14 somebody they are close to,15 a
sociable and independent nature,16 a
warm and affectionate disposition,17 selfconfidence18 and a sense of responsibility.19 These results must be cautiously
interpreted and causal links cannot be
made. Further studies with longitudinal

11

12

X2 = 4.0, p = 0.05
X2 = 0.4, p = 0.5
6
For example, white vs non-white X2 = 0.08,
p = 0.8
7
X2 = 3.8, p = 0.053
8
For example, full care order compared to
section 20: X2 = 1.8, p = 0.2
9
X2 = 2.5, p = 0.1
10
t (782) = 1.6, p = 0.1

62

returned completed SDQs. All eight


teachers returned completed SDQs in
respect of all the 25 looked after children
with whom they worked. Half of the
looked after children in the study sample
had a possible or probable psychiatric
diagnosis. Thirty per cent fulfilled the
more stringent criteria of probable
psychiatric diagnosis. Twenty-five per
cent had a probable conduct disorder,
six per cent a probable emotional disorder and two per cent a probable hyperactivity disorder. The results are given in
Table 1. The algorithm requires multiinformant data and low teacher numbers
are likely to have substantially reduced
the number of young people meeting the
criteria for a possible and probable
rating of disorder.
When the data were further analysed,
it was found that young people who
moved placement frequently were three
times more likely than others to have any
psychiatric diagnosis and to have a probable conduct disorder. The numbers
were too small to compare hyperactivity
and emotional disorders.

t (782) = 0.85, p = 0.4


X2 = 12.7, p<0.001
X2 = 6.2, p = 0.01
14
t (119) = 2.4, p = 0.02
15
t (96) = 3.0, p = 0.003
16
t (95) = 3.2, p = 0.002
17
t (107) = 3.5, p = 0.003
18
t (93) = 3.5, p = 0.001
19
t (80) = 4.8, p< 0.001
13

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ADOPTION & FOSTERING VOLUME 30 NUMBER 3 2006

design are necessary to explore whether


these factors may protect young people
from the development of mental disorder.
The carers of young people who
moved placement frequently (defined as
three or more times in the last year) were
significantly less likely to report the
presence of two of the six identified
protective factors in the young people in
their care. These factors were a consistent
hobby or interest20 and having somebody
they are close to.21
Self-harm and support from others
Twenty-seven per cent of young people
who responded to the questionnaires
reported having deliberately harmed
themselves in the last six months. Fiftynine per cent believed that their social
worker was not aware of their emotional
or behavioural problems. Young people
who reported self-harm were 24 times
more likely to have a conduct disorder
than those who did not.22 Furthermore,
the carers of young people who often
moved placement were significantly more
likely to report that the young people in
their care had deliberately harmed
themselves in the last six months,23 by
comparison with the carers of more
securely placed young people.
Eleven per cent of carers reported that
the young people in their care (of school
age) were not in school. The carers of
young people who moved placement
frequently were significantly more likely
to report that the young person in their
care was not in school24 than the carers of
young people in more stable placements.
Access to mental health services
The carers of young people who moved
placement frequently were significantly
more likely to report that the young
people in their care had not had any contact with mental health services25 by
comparison with the carers of other
young people.

Discussion
This study confirms previous findings of
high rates of mental health problems in
looked after children and raised levels
among those who move around placements. Young people who had moved
placement three or more times in the last
year seemed to be at particular risk of
developing a psychiatric disorder,
especially conduct disorder. They were
found to be three times more likely to
have a conduct disorder than looked after
children who had moved placement less
often. Young people in the first category
had a number of other distinguishing
characteristics. They were more likely
than children in more stable placements
to live out of borough, to be aged between
11 and 15 years and to be placed in residential units. Further studies are needed
to explore these associations further to
clarify questions of causality.
The high rates of deliberate self-harm
found in this study are extremely concerning and worthy of targeted intervention. Twenty-seven per cent of the young
people reported having deliberately
harmed themselves in the last six months.
As a percentage of the looked after
children in the care of Lambeth, this
translates into 191 young people. Furthermore, children with probable conduct
disorders were 24 times more likely than
those without to report self-harming, and
young people who had moved placement
frequently were significantly more likely
to report self-harm than those in more
stable placements.
It is significant that these results
confirm those of a smaller but similar
study published in Adoption & Fostering
(McCarthy, 2004). McCarthy found that
children who move around placements
display multiple problems before entry to
care, experience a mixture of living
situations in and out of their home area
and get caught up in a negative cycle of
instability that reinforces their

20

X2 = 4.6, p = 0.03
X2 = 4.7, p = 0.03
22
X2 = 11.4, p = 0.001
23
X2 = 5.2, p = 0.02
24
X2 = 5.6, p = 0.02
25
X2 = 5.2, p = 0.02
21

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ADOPTION & FOSTERING VOLUME 30 NUMBER 3 2006

63

psychological and social functioning.


Much of the blame for childrens
multiple placements is attributed to social
workers and carers. This view is implied
in many initiatives to improve childrens
situations, such as Quality Protects and
Performance Targets. But, while it is
certainly the case that poor practice
exacerbates an already dismal outlook,
professionals and carers may find themselves on a hiding to nothing if the underlying mental health problems of these
children and young people remain unaddressed.
Given these concerns, the results of
this study point to a number of opportunities for mental health service planning
and for targeted mental health interventions for looked after children. The high
rates of mental health issues among
young people who move placement frequently clearly highlight the need for
services among this group. However, their
mobility (among other factors) also presents a barrier to their accessing local
child and adolescent mental health services (CAMHS). A stepwise approach to
services may be one way forward to
resolve this problem.
First of all, given the high levels of
often serious self-harm among this group,
it will probably be necessary to provide
crisis support services to all young people
and their carers, screening those particularly at risk for targeted outreach. Secondly, interventions might aim to stabilise
placements. Where this is successful,
young people could be supported to
access their local CAMHS by providing
information and advice about approaching services. Where placements cannot be
stabilised, or the young people do not
wish to access their local CAMHS, a
dedicated team of mental health professionals might provide an outreach service
aimed at helping young people form
lasting relationships with someone they
can feel close to and develop a secure
base (Byng Hall, 1996). This could
operate as a protective factor to future
mental ill-health and also form a blueprint from which the young person could
be encouraged to form other therapeutic
relationships, for example, within local
CAMHS.
64

In parallel with these developments,


there would seem to be a need to promote
an understanding in young people, their
carers and social workers that conduct
disorders are extremely distressing mental
health issues which can be successfully
treated and which constitute a legitimate
basis for referral to mental health services. The results of this study suggest
that, especially among older children,
conduct disorder is not seen by carers as a
mental health problem. It is possible that
lack of service provision has left many
carers simply unable to cope with the
difficulties that the young people in their
care bring with them, and left them with
little alternative than to blame the child.
Study limitations
The current study revealed relatively low
rates of emotional and hyperactivity
disorders: six per cent of the sample had a
probable emotional disorder and two per
cent a probable hyperactivity disorder
compared to 12 per cent of the ONS
sample of looked after children having
conduct disorder and seven per cent being
rated as hyperactive (Meltzer et al, 2003).
However, several factors suggest that the
low rates in the current study may not
accurately reflect the levels of mental
disorder in this population. First of all,
hyperactivity disorders have low base
rates and therefore relatively large study
numbers may be necessary in order to
describe accurately their prevalence.
Furthermore, the algorithm for predicting
hyperactivity disorder from the multiinformant SDQ emphasises the pervasiveness of the disorder across informants.
The low teacher numbers in this study are
likely to have significantly reduced this
score. In addition, emotional disorders
may be relatively less significant for
carers in the context of the difficulties
associated with conduct disorders, leading carers to under-report emotional
problems. Further studies are necessary to
investigate these findings.
A number of other factors limit the
conclusions which can be drawn from the
findings of this study. Significant differences were found between respondents
and non-respondents. Of particular concern is the under-representation of young

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ADOPTION & FOSTERING VOLUME 30 NUMBER 3 2006

people in residential units among the


respondent group. Young people in residential units have been found, in other
studies, to have higher rates of mental
disorder. The under-representation of this
group in the sample is likely to also have
depressed the overall prevalence scores as
well as limiting the generalisability of the
findings. However, there are sufficient
points of concern raised in this initial
study to recommend more elaborate
research to inform the development of
services for children with severe mental
health needs.
Acknowledgements
The author would particularly like to
thank the following: Health Action Zone
and Quality Protects for funding this
research; Jackie Gratton and Dr Orlee
Udwin; Professor Robert Goodman; Dr
Tamsin Ford; Rebecca Collins; Alex
Hunt; Caroline Phillips; and Dr Claire
Diamond. A special dedication is also
offered to Maxwell Magondo Mudarikiri,
whose work on this project was cut short
by his untimely death. The authors also
gratefully appreciate the contributions
made by many others to the successful
completion of this research, not least the
young people and their carers who completed the questionnaires.
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Alison Beck 2006

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