Innovations in Practice
Innovations in Practice: group work with children who are in care or who are adopted: lessons learnt
There is limited evidence on effective group interventions for looked-after and adopted children. A specialist Children and Adolescent Mental Health Service (CAMHS) developed and evaluated a group intervention based on Mentalisation-based therapy (MBT).
Data was collected through semi-structured interviews with all young people before and after the programme. Additional information was collected from the facilitators' reflective diaries. The study aimed to evaluate the impact and applicability of a Mentalisation-based group programme on looked-after and adopted children.
Feedback from the young people indicated that the intervention had a positive impact on the young people.
Having a chance to meet other young people in similar circumstances, sharing experiences and making connections were the greatest benefits gained from the group.
Key Practitioner Message
- A number of interventions have been developed to improve physical and emotional health and wellbeing for children looked after, but there is a lack of evidence on their effectiveness
- Evidence suggests that children prefer peers to be involved in their treatment. Therefore, a group intervention was developed using a Mentalisation framework
- Mentalisation-based therapy, originally created for treating personality disorders, focuses upon difficulties commonly seen in looked-after and adopted children. Mentalisation therapy focuses on helping individuals to understand errors in understanding self and others
- Having a chance to meet other young people in similar circumstances, sharing experiences and making connections were the greatest benefits gained from the intervention
- Practical issues that need to be considered when running a group intervention for looked-after and adopted children are outlined
Research literature indicates that children who are in care or who are adopted experience many difficulties, resulting from their pre-care and care experiences. Children in care are five times more likely to have a mental health difficulty (Meltzer, Lader, Corbin, Goodman & Ford, 2004), and adopted children are twice as likely to need a mental health service (Keyes, Sharma, Elkins, Iacono & McGue, 2008).
With the increased awareness of the specific needs related to the mental health of children in care, there is also a growing pressure to develop and evaluate appropriate and efficient clinical interventions. NICE [draft] guidance (2010) acknowledges that ‘there is a lack of evidence on the effectiveness of interventions that improve the physical and emotional health and well-being of looked-after children and young people’ (page 24). Activity-based interventions have been widely used with children who are in care or who are adopted (Jernberg & Booth, 1999; Daniel Hughes, 2006); Perry (2008) suggests a staged approach to treatment where regulation techniques are introduced and mastered before more complex ideas are introduced. Although these interventions are commonly offered, evidence is lacking with regard to their effectiveness.
Mentalisation-based therapy (MBT) has been mostly used for treating borderline personality disorder (Fonagy & Bateman, 2007), but in recent years, Mentalisation for CAMHS populations, primarily Mentalisation-based family therapy (MBFT), has also been developed. Mentalising is the process in which individuals interpret their own actions and those of others in relation to their respective underlying intentional states, such as personal desires, needs, feelings, beliefs and reasons (Bateman & Fonagy, 2008). Mentalisation comprises of affect regulation, attention control and a person's relationship with others (Fonagy & Target, 1997), which are common difficulties seen in looked-after and adopted children. This underpins the idea of developing a specific intervention for this population based on Mentalisation theory. MBT seeks to increase Mentalisation capacity and provide strategies to manage difficulties. MBT focuses on the mind and aims to help individuals understand their difficulties in relation to the way they think and feel about themselves and others, as well as recognising how this can influence their own actions and that of others.
Recent evidence suggests that children prefer peers to be involved in their treatment (Davies, Wright & Bunting, 2009) and with potential budget cuts and increased demands on services, the specialist CAHMS team developed a Mentalisation-based group programme. A group programme seemed particularly suited to address relational difficulties and help children develop appropriate strategies.
The package was developed by a specialist CAMHS service for looked-after and adopted children, and focused on affect regulation, attention control and relational skills. Eight group sessions were delivered.
Eleven children completed the programme. Due to the wide age range (9–16 years) and number of participants, the young people were assigned to one of two groups. One group consisted of two girls and three boys aged between eleven and fifteen; two were adopted and three were in foster care. The second group consisted of six girls aged between nine and eleven; three were adopted and three were in foster care.
The evaluation of the project was registered with the local Clinical Audit Department. Written informed consent was gained from all young people and their social worker/parent who held parental responsibility. All young people were interviewed before and after the group which gathered information ascertaining the children's worries, goals and expectations about attending the group, the children's views on the programme with specific emphasis on their experience of being in a group with other children who were in care or adopted. Interviews were conducted by two clinicians who had not been involved with the programme and who had not met the children before. All interviews were transcribed verbatim and entered into NVivo8 (QSR International, Doncaster, Australia), a software package designed to support qualitative data analysis. The facilitators' reflective diaries provided an additional record of observations. All data was analysed using thematic content analysis (Miles & Huberman, 1994). Themes were identified by the first author and discussed with the second author who also checked for coding consistency.
Table 1 outlines the main findings from the study.
Table 1. Main findings
|1||9||Female||Adopted||‘To not shout as much as I usually do’||3½||‘How to control angry feelings’||‘It was good, because at my school you don't have a lot of people who are adopted’|
|2||11||Female||Adopted||‘How to get on with other people and how to stop arguments’||3||‘Finding out about different feelings’||‘They were friendly and kind’|
|3||11||Female||Foster care||‘How to stop arguments quickly’||4||‘What I do when I'm angry and how I behave’||‘It made me feel the same as some of them because I'm not the only one… they told us about their families’|
|4||10||Female||Foster care||‘Learn how to get on with others’||5||‘Spotting feelings in others’||‘Sometimes they helped me and were nice’|
|5||9||Female||Foster care||‘Help with feelings’||4||‘Different feelings’||‘It was nice to meet up with other foster children’|
|6||10||Female||Adopted||‘How to sort out arguments’||3||‘How to relax’||‘It was good to meet others… They were kind to me and helped me with everything’|
|7||13||Female||Adopted||‘Learn ways to control myself when I start getting angry and how to stop an argument cause I usually let my arguments drag on a long time’||3||‘How to control my temper a bit more. I'm not stamping and shouting as much. I can control it a bit better’||‘I liked getting to know everyone, and getting to know people in my situation, because I do feel a bit different at school’|
|8||11||Female||Adopted||‘Help with friendships. I'm not good at making friends’||–||‘Fight and Flight’||‘It was nice and I met new people’|
|9||14||Male||Foster care||‘To understand how other people are feeling and to understand how I'm feeling at certain times’||4.7||‘Understanding misunderstandings’||‘It was good to have other fostered and adopted children there… I was talking to them about some stuff and they were really interested’|
|10||12||Male||Foster care||‘To be more observant and have a better attitude’||4.7||‘The flight or flight thing. When I argue with my brother to stop and walk off’||‘It was good to meet up with other foster children’|
|11||13||Male||Foster care||Did not have a goal||–||‘Different ways to help me with my feelings’||‘I found it helpful like, cause I know that there's other people fostered in the area’|
Talking versus doing – engaging children in therapy
Participant interviews and direct observations indicated that the young people found it difficult to engage with the psycho-education elements of the programme. To maintain engagement with the children, facilitators adapted the programme and increased the amount of activity-based learning. Children were asked which activities they enjoyed most and could pick more than one activity. Interviews with the young people indicated that the elements most enjoyed in the group were practical-based activities.
Initial interviews revealed that nine of the eleven young people had specific goals at the beginning of the programme. At follow-up, all nine of the children reported achieving part or all of their goals (giving a rating of at least 3/5). Five reported achieving their goal fully. When questioned about the key factors to their perceived success, five of the young people put the changes down to the help received from other young people in the group.
‘They helped me with everything’.
All children were asked to identify the most important thing they learnt from the group sessions. The majority of the young people reported that understanding and managing feelings were the most important things learnt from the programme.
Most young people had regulation difficulties. Post interviews and direct observations highlighted difficulties with sitting, listening to others and managing their own behaviour; this resulted in difficulties between young people.
‘I was saying can you shut up I'm trying to learn here, I'm not here to go on the Jeremy Kyle show, I'm here to learn.’
As the programme developed, a more structured approach was adopted and the younger group was split into two groups of three. With added structure, the young people were more able to focus and four children reported added benefits.
‘It helps me, made me focus’
Despite the difficulties in managing relationships, positive experiences with the other young people were reported. Ten of eleven young people reported positive experiences with others in the group.
‘It made me feel the same as some of them because I'm not the only one’.
Over a third of the young people did not know any other children who were in care or who were adopted before the group. All 11 young people said that meeting up with peers had been useful; this promoted conversations around not living with biological parents and the resulting difficulties at school.
Reducing stigma and meeting others in similar circumstances was the chief success of the programme. Feedback from the young people revealed that by having peers involved in treatment, their own situation and difficulties were normalised. Children indicated that they shared similar experiences because they were not living with their biological parents. In the group sessions, conversations took place around placements and difficulties at school caused by not living with their biological families. By having peers involved in their treatment, young people could discuss, normalise and implement strategies to help with their difficulties; this would have been more difficult to achieve through individual sessions.
Behaviour difficulties were prominent in both groups, resulting in reduced concentration levels. All children in the younger group had difficulties with regulation; consequently, the focus of the intervention shifted to managing and containing behaviour. The older group included children with mixed abilities: some of them had basic emotional understanding and management of their affect, leading to more immediate collaboration between the young people. The development of regulation has been found to follow biological maturation (Gross, 2007) and it is therefore not surprising that the older group seemed better able to manage and contain their behaviour than the younger group.
To reduce disruptions, the younger children were separated into two groups of three; behavioural issues were drastically reduced, and the level of concentration and work improved conversely. The younger children may have found it difficult to regulate their behaviour and relied on the facilitators to manage this; this was not possible in the larger group. Arnsten (1998) suggests that when the arousal system is triggered, parts of the brain that are associated with mentalising and thinking become ‘offline’. By inheriting a more structured approach, such as clear boundaries, defined spaces to work and time limited tasks, focus and behaviour improved. By adding structure, it could be hypothesised that the young people felt safer in their environment resulting in a reduction in their arousal levels. Although children seemed to appreciate and benefit from the opportunity to interact with their peers, potential benefits may also be outstripped by the difficulties some children have when dealing with complex social interaction. However, by reducing the group size, the positive impact generated by peer interaction was still achieved.
Despite the young people's difficulties in regulating their behaviour, only two sessions focused on this. Feedback from the young people and the facilitators' observations indicated that initial expectations were too high. This highlights the difficulties inherent to teaching thoughts and getting on with others, before children have the basis to maintain attention and regulate their own emotions. Perry (2008) suggests that a child needs to master one stage at a time, starting with attention control, because these developmental stages have often been missed. Therefore, an entire programme, focusing on practical techniques to build regulation capacity, such as biofeedback and modelling, could be more effective for this population.
Feedback from the young people indicated a preference for activity-based interventions. The young people suggest that activity-based techniques are more adapted to their needs. This could indicate the need to move away from traditional language-based therapies towards activity-based techniques for those children who have missed out on early social development. This is in line with Fonagy and Target (1997) who suggest that children learn from early interactions with their caregivers, which many children who are in care or who are adopted have not experienced.
Differences between what the younger and older children enjoyed were apparent. Davies et al. (2009) highlight that children of different ages can often have different experiences of the same service. The needs of children in care are also particularly challenging and can reflect sudden alterations in crucial areas such as contact arrangements with parents or placements. Consequently, it appears imperative to fully develop the content of group interventions only once participants, and their specific needs, have been identified. It is also essential to allow the facilitators to make full use of their therapeutic skills and creativity to adapt the programme to the participants' changing needs, thus developing a truly needs-led approach to the intervention.
The young people enjoyed the group programme. Having a chance to meet other young people in similar circumstances, sharing experiences and making connections were the greatest benefits gained from the group and of high importance to the young people themselves. However, practical issues need to be considered and addressed in a timely fashion. The size of group needs to be adapted to the needs of the children, with younger children potentially benefiting more from a smaller group. Group work with this population also needs to be flexible and adaptable to the children's needs, which may change throughout the course of the intervention. Further work needs to take place to develop and evaluate group interventions that will aid the development of skills that many fostered and adopted children lack. Such interventions will need to be carefully adapted to the individual needs of the participants and take into account their developmental stage. However, MBT provides an appropriate model for developing group interventions with this population.
There was no external funding for this study. The authors have declared that they have no competing or potential conflicts of interest.