What is ‘care’?

Children enter care for many different reasons. Around two-thirds are taken into care under legal orders, while a third enter under a voluntary arrangement with parents. Taken as a whole, children in care come from poor and deprived backgrounds, they have usually experienced abuse and neglect, and they are more likely to have serious problems (such as behavioural or emotional difficulties, physical or mental health problems and educational under-performance) than most children (see for instance Bebbington and Miles, Reference Bebbington and Miles1989; Meltzer et al., Reference Meltzer, Gohuard, Corbin, Goodman and Ford2003; Berridge, Reference Berridge2007).

Most children ‘in care’ are in foster placements (around 70 per cent); however, 9 per cent are placed at home with parents (under a court order), a further 16 per cent are in various forms of residential provision, while 5 per cent are placed for adoption (prior to legal confirmation of the adoption). Placements are used differently depending on the age and needs of the child, and the availability of different placements. There is a great deal of movement within the care population over time, and those children who spend more than two years in care are a minority of children in care. Some key points to highlight based on government figures (DfES, 2006; Schofield et al., Reference Schofield, Thoburn, Howell and Dickens2007) are that:

• • 40 per cent of the children who come into care will do so for less than six months – with many in care for very short periods;

• • half of all children in care will have two or more separate periods in care;

• • only around 8 per cent of children looked after at any one time will be adopted;

• • around 13 per cent of children leave care for independence each year;

• • 30 per cent of children remain in care for four years or more.

This highlights the fact that the ‘care’ system performs a number of functions. For many children it is a shelter while longer-term plans are made. For most children it is a temporary experience followed by return home. For some it becomes the setting in which they experience most of their childhood.

What do we know about the impact of care on the welfare of children and young people?

Given that children in care do very poorly on a wide range of measures, outcomes for these children are an appropriate focus for public concern and policy attention. Yet the difficulties these children have compared to the general population of children do not show that the care system is the cause of their problems (Stein, Reference Stein2006). Children enter care for a reason. They tend to be the most individually and socially disadvantaged in society. They may have suffered harm as a result of abuse and some of them are likely to be at increased genetic risk of particular difficulties, such as mental illness or learning difficulties. It is therefore possible that their problems existed prior to care entry. Differentiating the impact of care from the problems that led to the child entering care is important if effective policies are to be developed to reduce or prevent the extent of children's difficulties. So, what is the empirical evidence for the impact of public care on children's welfare?

Three key challenges arise in any attempt to review research in order to discover the impact of the care system on children. The first is that the system has changed over time. In the 1950s and 1960s many children were given up for adoption because of issues of illegitimacy, with few being removed because of concerns about abuse; more children lived in residential homes than foster care; most children entered care voluntarily as teenagers; there was far less government and research attention on outcomes for children looked after. Great care therefore needs to be taken in drawing conclusions about care from historical studies. Similarly, while there is an extensive international literature, the social care systems are different in such important ways that it is difficult to draw conclusions from international studies about the impact of the British care system on children.

The second challenge is that, as discussed above, ‘care’ is not a homogenous intervention. As a result, studies tend to focus on particular groups. Generalisations about the impact of ‘care’ in general are therefore impossible in both theory and practice. Third, few studies gather information on children before they enter care or at the time of care entry, comparatively few follow children's progress over time and it is very rare for children who enter care to be compared to children who nearly entered care.

To address these issues, this article focuses on a review of British research studies published since 1991 (when the 1989 Children Act came into force) that provide data on any aspect of the welfare of children in care over time. Child welfare is understood broadly to encompass any element of welfare: that is, including education, behaviour and later-life outcomes (such as unemployment). However, before turning to consider this literature, it is worth considering key messages from the international literature on care entry.

International studies

In general, studies in other countries have tended to find that care has a positive impact on children's welfare. In common with the British literature, outcomes for adopted children have usually been found to be good. In a Swedish study, Bohman and Sigvardsson (Reference Bohman and Sigvardsson1980) followed up 624 children registered for adoption as infants and found that 15 years later the adopted children were comparable to classmates, but that children who had returned home or who remained in foster care did less well. Fergusson and Horwood (Reference Fergusson and Horwood1998) looked at a large birth cohort study in New Zealand. They compared the progress of 42 adopted children with a group of 98 matched for family structure (that is, from single-parent families) and socio-economic background. In general, adopted children did better than the comparison group, though less well than might have been expected for biological children in the families that they were placed in, on a range of measures of health and social development.

Comparatively positive outcomes are by no means confined to adopted children. Dumaret and Coppel-Batsch (Reference Dumaret and Coppel-Batsch1998) considered 59 children who had spent five or more years with a foster family in a French agency. The follow-up of the children when in their 20s found that most had jobs and reported good health and that 56 per cent had ‘good’ social integration. Social integration was negatively influenced by cumulative parent and child problems at the time of foster care. This highlights the importance of pre-care situations and experiences in shaping post-care outcomes.

In an important recent study, Barber and Delfrabbro (Reference Barber and Delfabbro2005; Barber et al., Reference Barber, Delfabbro and Cooper2001) studied 235 children aged between four and nine who entered foster care in South Australia between 1999 and 2000. Children were tested on a variety of measures of well-being at intake, four, eight, 12 and 24 months after entering care. Conduct scores improved considerably from entry to four months, with marked improvements in behaviour at school. The improvement was maintained at the follow-up points. Rates of hyperactivity were not affected by care entry. The children reported very positively on their experience of foster care.

Positive findings about the impact of foster care were also found by Horwitz et al. (Reference Horwitz, Balestracci and Simms2001), who followed up 120 children 12 months after they entered foster care in Connecticut, USA and evaluated changes in their ‘adaptive behaviour’. They found very significant positive changes, with children's behaviour moving from below-average functioning into the normal range. The positive changes were greatest for older children, girls, African American children, those who had spent longer in foster care, those who had been abused and those with fewer recommended services in care.

A similar positive impact of care was also found in a study by Taussig et al. (Reference Taussig, Clyman and Landsverk2001) who compared children remaining in foster care with similar children returned to their birth parents. This study looked at 149 children aged between seven and 12 years who were returned home from foster care in San Diego, USA. Compared to children who remained in foster care, children returned home had more significant social and behavioural problems. They had higher self-destructive behaviour, substance use, risky behaviours and were more likely to have been in trouble with the criminal justice system. They also did less well in school.

The general picture, therefore, appears to be of public care generally having a positive impact on child welfare although, as noted above, the social and policy context varies enormously between countries. Such findings cannot therefore be extrapolated to the British context, and this article therefore focuses on studies carried out within the United Kingdom. However, while the searches included any United Kingdom study, those found all appeared to relate to England and Wales. This suggests a significant lack of follow-up research on the impact of care over time in Scotland and Northern Ireland. In the following text ‘United Kingdom’ is sometimes referred to (as this was the scope of the search), but findings are related to England and Wales.

Approach to the review of the literature

The method for the literature search was that electronic searches were carried out on the following databases: PubMed, Science Direct, Ingenta Connect, Blackwell Synergy, Google Scholar. The following key words were entered: Care, child services, child welfare, institution, looked after children, residential care, substitute care, foster care, fostering, welfare systems. In addition, the following outcomes were searched for: academic, achievement, assessment, attachment, behaviour, development, education, health, underachievement. Searches were extended by following links identified in articles, from relevant studies to ‘related’ articles. Fingertip searches were also carried out looking for all relevant studies published between 1991 and 2006 in the following journals: The British Journal of Social Work, Adoption and Fostering, and Child and Family Social Work. In addition, a review was undertaken of all government-funded research identified in published summary reports. Where these appeared appropriate they were read in full. The searches were supplemented by reading and following up references in key texts produced by the Social Care Institute for Excellence. Finally, experts in the field were contacted and some read drafts of the report to identify missing studies.

Despite the thorough approach to the literature searches, it is unlikely that every relevant study was included. Some studies on other issues (such as the child protection system) had important information on children who entered care, but this was not always immediately apparent; the same may be true for some research we did not identify. Furthermore, research on this topic is often published in other forms that are difficult to identify through electronic searches. Therefore, while the review appears to be comparatively thorough, it cannot claim to be comprehensive.

Relevant studies were summarised in a pro forma. It was considered most appropriate to present information on them in a narrative discussion because only 12 studies met the above criteria and they varied enormously in focus, scope and method.

Studies 1991 to 2006 that included outcomes for children in care over time in the United Kingdom

Studies can be divided into two broad types. First, those that were able to compare children in care with children in broadly similar situations who had not entered care (three studies). Second, studies that looked at the welfare of children in care over time (a total of nine studies). This group is further subdivided into general studies and those relating to adoption, foster care or residential care. (No research on outcomes over time for children in kinship placements was identified.)

Studies that compared children in care with children who did not enter care

Only one study was identified that considered the progress of children in care over time and also that of a comparison group of children not in care. This study was undertaken by Heath, Colton and colleagues and the results were published in a variety of papers in the late 1980s and early 1990s. Heath et al. (Reference Heath, Colton and Oldgate1989) compared the educational progress and behaviour of 49 children in medium or long-term foster care compared to 58 children living at home but receiving social work services. Both groups were doing comparatively poorly on a range of measures, with those at home having slightly higher levels of behavioural problems. In follow-up studies (Colton and Heath, Reference Colton and Heath1994) over the next two years there was little change in the comparative situation of either group. Heath et al. (Reference Heath, Colton and Oldgate1994) further analysed this. It proved difficult to disentangle the impact of foster care as children often moved type of placement, including returning home.

A significant limitation in this study is that children's educational achievements were not measured when they entered care. As a result, it is possible that there were differences between the groups prior to the point of measurement. However, the Heath et al. research appears to be the only British study using a comparative method to explore the impact of care. Its findings are not particularly positive about the impact of care; however, neither are they negative. Foster care did not enable children to overcome initial educational disadvantage; on the other hand, given that the children in care had very similar scores to those in families that social workers were working with, it seems fair to suggest that care was also not causing the low performance of the children.

While the Heath et al. study was the only one that included a comparison group, two other studies looked at a broader group of children at risk and commented on outcomes for those who entered care compared to those who did not. Gibbons et al. (Reference Gibbons, Gallagher, Bell and Gordon1995) carried out a follow-up study of 170 children placed on the child protection register for physical abuse nine to ten years after registration. The children were matched with a similar child who attended the same school but had no previous connection with child protection. For our purposes, the most important aspect of this study was that over 30 per cent of the study group entered the care system. For the majority the experience of substitute care was positive and there were measurable gains in their physical growth. In terms of their behaviour and mental well-being there was no evidence of general advantage. Children in long-term foster care tended to show fewer behaviour and friendship problems and were less depressed than adopted children. Adopted children had as many behaviour problems as those who had remained with their natural parents.

The finding that the children in foster care did better than those adopted is somewhat at odds with the general literature (Rushton, Reference Rushton2003). Given the comparatively small numbers involved and the fact that the choice of foster care rather than adoption might have been related to child welfare considerations (for instance, with more serious abuse leading to adoption), caution is needed in interpreting this finding. Nonetheless, the findings point to the potentially positive impact of foster care for children in relation to behaviour, emotional development, physical growth and patterns of friendship.

A recent study by Forrester and Harwin (Reference Forrester and Harwin2006, Reference Forrester and Harwin2007) followed up 186 children for whom parental misuse of drugs or alcohol was of concern who had been allocated a social worker two years after the family was referred to social services. Two of the findings of the study are of particular significance. First, most of the children came into care at some point, and at the follow-up point 54 per cent were no longer living with their mother. Second, based on information from social work files, the researchers made a judgement of child welfare. They found the biggest predictor of positive welfare outcome was children no longer living with their birth parent. Furthermore, many of the children living at home continued to be at risk of significant harm as a result of their parent's difficulties.

A limitation in this study is the reliance on social work records. Social workers may record child welfare problems more thoroughly for children at home than for those in care. Furthermore, the study compares remaining at home with a wide range of alternatives: including informal family alternatives. Nonetheless, the strength of the relationship suggests that entering care may have been a positive intervention for many of these children

Studies that looked at the progress of children in care over time without comparison groups

Key findings

Five findings appear important from this review. The first is that there is a lack of research in a number of areas. Given this lack of evidence, it is important to be circumspect about findings. This is in itself an important policy issue. The government and major charities spend £25 per year on research for each person working in social care, compared to £1,613 for each person in the National Health Service (Marsh and Fisher, Reference Marsh and Fisher2005). This extraordinary lack of investment in social work and social care research severely limits our ability to develop evidence-informed policies.

The second key finding was that there was little evidence of the care system having a negative impact on children's welfare. Indeed, in almost all of the studies children's welfare improved, while there was none in which it deteriorated. As Stein said: ‘The simplistic view of care as failing 60,000 young people should be confined to the dustbin’ (2006).

This is not to say that public care was resolving all of the problems that the children exhibit. The third finding was that, considered as a group, even after positive care experiences, the children in most of the studies had significantly more difficulties than might be expected in the general population. Indeed, resolving all of the problems children in care as a group have does not appear a realistic goal for the care system (although it is an important and achievable aim for many individual children). Even successful permanent placements in which parents adopted children and treated them as their own could not always undo the consequences of abuse and neglect when younger – particularly for children who were older when placed. Only adoption in early childhood offers a realistic prospect for most children of achieving welfare outcomes at a similar level to the general population. For other children, care needs to maximise the potential that children have and offer them the opportunity to be all that they can be. Yet it is not realistic to think that – taken as a group rather than for any individual child – this can result in equivalence between children in care and all other children.

The fourth important finding was that this broadly positive picture of care did not extend to leaving care provision. The leaving care system tended not to work well for most children. In effect, it often undid the positive impact of care for many children.

Finally, the studies provide considerable insight into why the welfare of children in care tended to improve. There were many descriptions of concerning issues in the studies. High rates of turnover of social workers, multiple placement moves, descriptions of inadequate or even abusive carers can be found. However, children did comparatively well for two reasons. The first is that often the home circumstances that they left (whether temporarily or permanently) were extremely inadequate. Care therefore appears good in part because it stands in contrast to families which include the most abusive and neglectful in our society, and those in which parents are struggling with the most profound problems; its comparative success is likely to be in large part because of this. However, in addition the studies described many positive things about care. Most strikingly, in many studies there were descriptions of foster carers and social workers, residential carers and managers, who form relationships and work tirelessly to ensure that the children they are responsible for thrive. It is easy to miss these success stories in the general perception that care fails. Often the institutional arrangements that surround care are inadequate. The caring individuals who frequently make enormous sacrifices for the children in their care are in large part responsible for the broadly positive pattern of welfare outcomes identified in the research.