Improving well-being and outcomes for looked after children in Wales: a context sensitive review of interventions

Abstract

Improving outcomes for looked after children and young people has been a longstanding concern in Wales. This article reports the findings of a scoping study which sought to identify interventions aimed at improving outcomes for looked after children that are effective or promising. The study was commissioned by an independent funding body to inform a £5 million investment programme for Wales. It comprised a rapid review of literature, informed through consultation with an expert advisory panel and groups of young people who had been in care. The article outlines the rapid review method, provides details of shortlisted interventions and describes the interventions subsequently approved for investment. It concludes that although there are many promising interventions which address the factors associated with poor outcomes for looked after children, the evidence base is weak. It is argued that decision-making on interventions should be informed by appraisal of the empirical evidence available, but should also be guided by professional judgement that considers the needs, priorities and preferences of service users, carers, practitioners and policy-makers.

Keywords

Looked after children outcomes interventions foster care policy Wales

Introduction

Improved outcomes for looked after children have long been an aim of the UK and Welsh Governments (Berridge, 2012; DCSF, 2009a; 2009b; Welsh Assembly Government, 2004). In Wales, a raft of legislation, statutory guidance and policy directives has been designed to address this issue (see, for example, Children Act 2004, Parts 3–5; Welsh Assembly Government, 2007a; 2007b; 2011). Despite some positive change, improved outcomes have generally remained elusive (CSSIW, 2015; Holland, 2015; Welsh Audit Office, 2012), as is the case elsewhere in the UK (see Coman and Devaney, 2011; Scottish Government, 2015). The extent to which obdurately poor outcomes are due to children’s pre-care experiences, the care system or other factors remains unclear (Forrester, et al., 2009). What is clear, however, is that in Wales the scale of the challenge is growing as the number of children in care has been rising, currently to 91 children in care per 10,000 of the 0–18 population, a ratio that is some one-third higher than that found in England and Northern Ireland (StatsWales, 2014).

In seeking to understand the underlying factors explaining this difference, it is helpful to reflect on the practice context in Wales. The country has been engaged in a process of devolution since the Government of Wales Act (1998) and the transfer of legislative power has created a highly complex practice landscape. Whereas the oversight of education and health has been devolved and led to increasingly idiosyncratic practice compared with the rest of the UK, family and youth justice remain the preserve of the UK Government. Practitioners in Wales are, therefore, frequently faced with having to attend to directives from two governments that place differing emphasis on, for example, respect for the United Nations Convention on the Rights of the Child (see Welsh Assembly Government, 2011). The recent Social Services and Well-being (Wales) Act (2014) has further increased this divergence.

The context of practice in Wales, especially for a mobile population such as looked after children, is further complicated by the relatively large number of municipal authorities, many of which are small. Some argue that this cultivates insular practice which can, in turn, lead to the fragmentation of core services and discontinuity in the provision of care (Williams, 2014). Wales is also a remarkably diverse nation in respect of language, economics and transport networks. Consequently, any strategic attempt to improve outcomes for looked after children must take into account a unique and complex mix of legislative, geographical, economic and cultural factors.

This article details the findings of a commissioned scoping study which sought to identify effective or promising interventions specifically for use with looked after children in Wales. The funding was supplied by the Big Lottery Fund with the expressed purpose of informing decisions about its £5 million investment to improve their life chances.

Initially, the ‘rapid review’ method employed for the study is discussed and details of the shortlisted interventions provided. This is followed by some reflections on the deliberations of the review team in recommending interventions for investment. It will be seen that appraisal of the evidence featured heavily in the process, but that broader issues, such as potential impact and effectiveness with looked after children, were also considered.

Among the questions asked were:

Who should be the target of interventions? Some may be suitable for the majority of looked after children while others may be targeted at particular age groups or those with specialist needs.

Which needs should be targeted? Improved outcomes in certain areas may be particularly desirable as they are likely to have positive ‘knock on’ effects for other areas of the child’s life.

How should interventions be delivered? Interventions may be delivered via a number of agencies and individuals, but the project team was especially interested in the involvement of children.

The needs of looked after children

An understanding of the needs of looked after children is essential in order to carry out a meaningful appraisal of intervention programmes. However, this makes the exercise complex as looked after children are known to experience greater difficulties in a number of areas compared with the general population. These include academic achievement, physical and mental health, behaviour and socialisation. For example, the educational attainment of looked after children in Wales is notably low. In the academic year 2014–2015 only 11% of them obtained five or more GCSEs (A*–C) compared to 58% of the general population (StatsWales, 2015). Two-thirds are reported as having special educational needs (Meltzer, et al., 2004) and they are more likely to be excluded from school (Axford, 2008). Similar disadvantages have been noted for mental health issues (Meltzer, et al., 2004; Sempik, 2010), risks of self-harm and suicide (Furnivall, 2013) and physical needs that require health service support (DCSF, 2009a; 2009b; Meltzer, et al., 2004) due to early pregnancy or substance misuse (Craine, et al., 2014; Panwar and Wilson, 2011). The same situation applies to children’s socialisation, relationship formation and maintenance (Guishard-Pine, McCall and Hamilton, 2007) and subsequent social exclusion (Axford, 2008; Hicks, et al., 2012; NICE, 2010).

It is important to note, however, that many looked after children perform relatively well in key domains and that there is no single difficulty or constellation of presenting problems that is common to every child (Rees, 2013). Similarly, the profile of individual need is always complex and specific to the individual child and his or her circumstances.

Although many of these difficulties affect the wider population, the underlying mechanisms that give rise to difficulties may differ for looked after children as many of them have experienced considerable disruption and trauma at a time when formative attachments were developing. When Jones and colleagues (2011: 621) reviewed 92 studies that mapped intervention outcomes, certain factors stood out as especially significant for such children – namely, placement stability and emotional and behavioural problems, which the authors perceived as ‘key mediators between underlying risk factors and outcomes’. The significance of placement stability has also been stressed by Leve and colleagues (2012) while Rees (2013) has emphasised the importance of regular birth family contact for positive performance in key domains. In the light of this evidence, interventions designed to boost placement stability which are sensitive to fundamental underlying issues of attachment, separation, loss, trauma and birth family relationships seemed to be good candidates for investment.

Reviewing the literature

Having recognised the variety of needs that may be experienced by looked after children, the research team sought answers to the following questions:

What is the range of interventions that meet the needs and enhance the well-being and outcomes of looked after children and which of these are targeted at specific areas, such as education or health, and which are more holistic?

Which interventions have the strongest evidence base and are most likely to be applicable to the Welsh context?

Do interventions which have strong evidence of effectiveness have common elements? If so, what are they?

To get things going, a briefing paper on the study and an invitation to participate as members of an expert advisory group were forwarded to a cross-section of 22 stakeholder organisations involved with looked after children. These organisations were identified by Children in Wales and included representatives from the Welsh Government, statutory services, independent agencies and third sector organisations. Seven young people with experience of being in the looked after system were also invited, and agreed to participate as consultants.

Given the restricted timescale and the success of this method in health and social work evaluations, a review of the literature was undertaken in the autumn of 2013 using a ‘rapid review’ methodology (Shaw and Holland, 2014). Figure 1 gives an overview of the process, decision points and outcomes. This method streamlines the processes of a full systematic review and takes less time, but importantly, shares many of its rigorous procedures by setting inclusion and exclusion criteria and a traceable methodology for database searching and analysing findings (Collins and Fauser, 2005; Shaw and Holland, 2014).

Figure 1.

Chart showing rapid review process, decision points and outcomes.

The initial stage of the exercise involved searching for relevant interventions reported in the literature, especially those involving looked after children. In recognition of the broad spectrum of their needs, the search focused on the three domains of education, mental health and health. In all, 1200 separate keyword searches were performed across 13 academic databases and seven relevant websites.¹ The search strategy is further summarised in Table 1.

Table 1.

Search terms and criteria.

Search terms	Publication	Study design	Population and focus	Deselection criteria
Looked after children, foster care, kinship care, residential care (NOT older people OR elderly OR older adults OR adults), out of home care AND Education, mental health, health AND Intervention, support, child welfare, outcomes	English language Jan 2000–Oct 2013	Empirical	Looked after children and young people < 18 years of age Foster carer/other carers Children in foster care (individual or group interventions) Education and/or mental health (new/additional/ specific interventions)	Statutory services, CAMHS and models of delivery Applicability in Wales limited Care leaver interventions Highly specific interventions (eating disorders among BME youth, youth justice, repetitive self-harm, grandparent carers) Small-scale studies: n = <10 Trial found no positive impact

The search was supplemented by internet trawls, hand searches of journals and reference lists together with suggestions from the expert advisory group, interested organisations and academics. In total, 340 publications were identified. Due to resource constraints, those published before 2000 and/or not in English were filtered out, as were interventions with care leavers and those with a very narrow focus, such as repetitive self-harm. As funders had stipulated that interventions must be additional to or an enhancement of services routinely provided by Welsh local authorities and/or health boards, those patently similar to statutory services were also omitted. In the end, 60 interventions were retained for further examination. The second stage involved reviewing the abstracts and/or summaries of the 60 interventions. Reviewers considered whether they were supported by robust empirical evidence, showed an awareness of underlying issues such as separation or trauma, and appeared suited to the Welsh context. Thirty-two interventions out of the 60 were retained for further consideration.

The 32 studies were then assigned to individual team members for quality appraisal. The National Institute for Health and Social Care Excellence’s (NICE) Quantitative and Qualitative appraisal checklists (NICE, 2012a; 2012b) were used to rate each intervention’s methodology as strong, moderate or weak (see Appendix A) and to scrutinise the underlying theory, study design, measures used, target population, use of intervention/control groups, the analysis and findings, especially those that showed a long-term effect on children’s functioning. Studies that concentrated on community settings, relationships and problem-solving approaches were rated more highly, as were those that directly impacted on the children.

Once this rating exercise was complete, the individual appraisals were shared among the team, who reviewed each summary and agreed the studies to be retained. At the end of this stage, 18 interventions were included (see Appendix B).

In the fourth stage, the 18 interventions were reappraised with heightened attention paid to their potential impact, awareness of underlying issues germane to looked after children, practice relevance and applicability to Wales. There was initial disagreement about the value of four of the 18 interventions but consensus was reached following further discussion. The provisional recommendations for all 18 studies were then discussed by the project team and the advisory panel, who drew up a shortlist of four interventions judged as ‘strong’ and a fifth as ‘weak to moderate’. These can be seen in Table 2. The empirical evidence available on a sixth intervention, Head, Heart and Hands, was rated as weak but members of the Advisory Panel felt that its emphasis on issues highly relevant to looked after children merited recognition.

Table 2.

Interventions shortlisted for recommendation.

Intervention	Target group	Delivery (schedule/by whom)	Description and content	Evidence of impact	Effect size (on key measures)	Evaluation of available evidence
Fostering Changes	Carers of 2–12-year-olds can be adapted for over-12 s.	Weekly, three-hour group sessions, over 12 weeks Delivered by: clinical specialists from a Tier 4 Child and Adolescent Mental Health clinic	Adaptation of the Fostering Changes programme (Pallett, et al., 2005). Targets behaviour and security. Draws on social learning theory, attachment theory and cognitive behavioural techniques.	RCT in UK: intervention group (n = 34) control (waitlist) group (n = 29). Improvement on some scales, including emotional and behavioural difficulties, attachment to carers and carer-defined problems.	SDQ Total. Pre and post main group effect: 0.32 (small)	Strong
Fostering Healthy Futures Programme	9–11-year-olds	Weekly 1.5 hour skills groups for 30 weeks. Delivered by: licensed clinicians together with and graduate student trainees	Developed in Colorado, USA. Targets mental health and related issues. Addresses emotion recognition, problem solving and anger management. Incorporates cognitive behavioural activities. Children mentored by social work students.	RCT with longitudinal follow-up: intervention group (n = 79), control group (n = 77). Statistically significant differences were recorded on mental health (six-month follow-up), quality of life (end of intervention) and placement permanency (one-year follow-up) suggesting the intervention was effective.	Mental Health symptoms: Pre and post intervention (six months). 0.51 (medium)	Strong
Incredible Years for foster carers	Carers (primarily for 2–8-year-olds but has been delivered to carers of young people up to 16)	Group sessions (2 hr) designed for a maximum of 12 carers over 12 weeks. Delivered by two facilitators. Sessions include discussions, videotape modelling and rehearsal of strategies. Delivered by: Incredible Years parenting programme mentors.	Emphasises importance of play, use of incentives, ways to help children learn, effective praise and ways to deal with adverse behaviour.	RCT undertaken in Wales: intervention group (n = 29), control group n = 17). Positive outcomes for intervention group and lower carer depression levels observed. As a parenting programme has been found to be effective in preventing and treating conduct disorders. Endorsed by Welsh and English governments. In use world-wide	SDQ Total and ECBI-I Pre and post intervention (six months). Intervention group: SDQ: 0.56 (medium); ECBI-I 0.67 (large) respectively	Strong
KEEP: Keeping foster and kinship parents trained and supported	Foster and kinship carers (of age groups 3–6, 5–12 and 12–17)	A 16–20-week programme, with sessions lasting 1.5 hours each Delivered by: trained facilitator and co-facilitator	Originated in Oregon, USA. Aims to increase positive parenting skills, improve child outcomes, increase positive placement changes and reduce disruption. Theoretical basis is social learning theory.	Evaluated in USA, RCT (n = 700). The intervention was positively associated with placement stability and ‘positive exits’. Reduction in child behaviour problems and an increase in positive parenting techniques observed.	Externalising behaviour problems (Achenbach). Pre and post intervention (six months): 0.7 (large).	Strong
Paired Reading Literacy Scheme	Foster carer and child	Typical intervention involves: i) training workshops for foster carers, social workers and/or teachers. ii) carer reading with child for a minimum of 20 minutes, three times a week, for 16 weeks. Delivered by: i) training, by Paired Reading lead area co-ordinator and local Educational Psychology Service. ii) paired reading, by carer(s).	The intervention requires the carer and child to read together and this gradually progresses to the child reading alone. Has potential to foster more positive relationships between school staff and foster carers as they make contact on a weekly basis.	Small-scale pre and post evaluation with primary aged looked after children in England, UK. Average reading ability progressed by one year for every month’s participation. On going progress remained uncertain, but findings suggest effective short-term gains. Improvements in children’s confidence and enthusiasm observed by carers.	Not reported	Weak to moderate.

Shortlisted intervention consultation

Having selected the five most robust interventions, the next decision was where to target the investment. Final recommendations about this were informed by the preferences of the expert advisory panel and young people’s group. The former stated a preference for interventions that: target more than one aspect of children’s well-being; include direct work with young people; have originated in or are transferrable to the UK; and have been designed for looked after children and carers. The young people liked interventions that: involve direct work with young people; have a broad focus; can be used with those living in residential and foster care; and include some follow-up element to ensure longer-term sustainability. An additional issue was the extent to which the interventions were compatible with the legislative, political, social, economic and geographical context of Wales, especially the impact on children’s overall well-being – a key principle of the Social Services and Wellbeing (Wales) Act 2014.

Results: Investment for Wales

Following presentation of the findings of the scoping study to the funder, the following selection was approved for investment:

Fostering Changes (revised programme);

follow-up Support Group for Carers;

Fostering Healthy Futures (feasibility study);

piloting of the Fostering Healthy Futures or an adaptation of this programme (determined by the recommendations of the feasibility study).

This selection will involve a five-year investment in Fostering Changes (revised programme) rolled out on a phased basis across Wales for foster, residential and kinship carers, and feasibility studies to explore the process for implementing or adapting the Fostering Healthy Futures programme. The evidence base for both of these programmes is strong. Fostering Changes (Pallett, et al., 2005) has been successfully implemented in parts of England since 2009, is age and placement inclusive and focuses on the key priorities for enhancing the well-being of looked after children. Likewise, Fostering Healthy Futures works directly with looked after children. Both initiatives include provision for ongoing evaluation.

Discussion

It is encouraging that this review was able to quickly identify a large number of interventions specifically aimed at improving the outcomes of looked after children and acknowledge the efforts of practice-oriented researchers from a range of disciplines, who have highlighted the exceptional needs of such children and sought to fashion effective interventions. But despite this welcome increase in attention, this study has indicated that there is some way to go in establishing a sizeable bank of interventions based on robust evidence of efficacy. Many of the studies deselected reported promising results, but had too few participants and/or were focused on too narrow a sub-group to afford confidence in the generalisability of their findings.

Another common reason for deselection was the lack of evidence of positive impact in key areas of children’s functioning. The majority of interventions provided indirect input which was mediated through carers, social workers, care workers and teachers. While positive change on indirect outcome measures such as carers’ knowledge and satisfaction is pleasing, the inability of many studies to demonstrate any significant effect in key areas of the child’s functioning is disappointing.

In recent times the social work profession has been increasingly challenged to demonstrate that its practice is based on sound evidence. Some within the profession have turned, therefore, to evidence-based practice, a scientific model for the appraisal of intervention efficacy that originated in the field of medicine (Straus, et al., 2011). An allure of evidence-based practice is that it offers a purportedly objective appraisal of evidence that may safeguard against criticism of subjectivity and bias. Integral to it is a predetermined hierarchical system of evaluation with meta-analyses of randomised controlled trials (RCTs) and individual RCTs considered the ‘gold standard’ and qualitative case studies regarded as inherently weak. Unsurprisingly, evidence-based practice is among the most contentious issues in contemporary social work (Mullen and Streiner, 2004). Critics argue that it is too mechanistic, narrow in focus, impractical and of low ecological validity and restricts clinical judgement or creative interventions, preferring terms such as ‘evidence-informed practice’ (Nevo and Slonim-Nevo, 2011) or ‘evidence-guided practice’ (Gitterman and Knight, 2013).

This review has shown that this for and against debate is an oversimplification as in reality there is no substantial body of research evidence available to practitioners (Mullen and Streiner, 2004). Few of the interventions scrutinised in this exercise were highly rated against orthodox evidence-based practice criteria, suggesting that empirical research on efficacy in child care is still very much in its infancy, making the current utility of evidence-based practice frameworks, at best, restricted. In addition, as the looked after children population is immensely heterogeneous and the needs of some children can only be met by interventions tailored to meet a child’s specific needs, highly structured interventions have to have some flexibility. Users’ perceptions and wishes can also be important and have to be incorporated somehow.

All of this made the task of the review team especially difficult; it was charged with recommending intervention(s) for funding that required maintaining the integrity of decision-making while employing an eclectic and consultative approach. In one case, an intervention was considered weak scientifically, but some members of the expert advisory group clearly liked it and it was retained until the latter stages of the exercise for the purpose of highlighting a novel and promising intervention, rather than being nominated as a good investment.

This review also reinforced what practitioners know by experience; there is unlikely to be an intervention that will serve as a panacea for all the challenges faced by the looked after population, so it is no surprise that a wide range of outcomes were targeted using a myriad of approaches. Nevertheless, it is remarkable given the context of practice within Wales and the emphasis on reducing the care population (ADSS Cymru, 2013; Welsh Assembly Government, 2016) that so few studies specifically targeted rehabilitation. It is probable that the authors of many small-scale interventions consider such an objective to be beyond the scope of a ‘bolt-on’ intervention and the preserve of social services. Paradoxically, however, any intervention that is not closely aligned with the primary objectives of social services, Child and Adolescent Mental Health Services (CAMHS) and adoption support services may struggle to see meaningful success.

Limitations

This review was, of necessity, undertaken within a short timescale. The use of rapid review methodology provided a helpful framework, but it is acknowledged that the project team could not apply the same degrees of scrutiny to studies as would typically occur during a full systematic review. In addition, the development of evidence-based clearing houses and repositories in social work have clearly helped to promote evidence-based practice, and quality ratings of some programmes considered in the review are readily accessible therein. Although these were consulted informally as part of the initial trawl of literature, a structured search strategy was not applied.

Footnotes

Note

Louise Roberts is a Research Associate, Children’s Social Care Research and Development Centre (CASCADE), Cardiff University, Wales, UK.

Nina Maxwell is a Research Associate, Children’s Social Care Research and Development Centre (CASCADE), Cardiff University, Wales, UK.

Paul Rees is Associate Professor and Director of the Centre for Children and Young People’s Health and Well-being, Swansea University, Wales, UK.

Sally Holland is the Children’s Commissioner for Wales.

Nicholas Forbes is a Research Assistant, University of Bath, UK.

Appendix A. Quality appraisal checklist and rating scale

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