Title: 'Herts and Minds': supporting the emotional wellbeing of looked after children in Hertfordshire.
Funder: Department of Health and Social Care

Abstract: Background and Aims: Looked After children (LAC) are a vulnerable group, at high risk of experiencing mental health problems (Ford et al., 2007; Tarren-Sweeney & Hazell, 2006). These children are exposed to a variety of risk factors, including maltreatment, multiple placement changes, school underachievement, and peer difficulties. The mental health problems that may arise in these circumstances are significant predictors of future, long-term maladjustment (e.g., Kasen et al., 1999; Moffitt et al., 2011; Harrington et al., 1990). Tackling the emotional and behavioural difficulties of LAC promptly and effectively is therefore a priority for health and social care professionals. These children often present with a complex mix of difficulties including problems with emotional regulation, anger and oppositionality, as well as problems in close social relationships (especially with carers; Schofield & Beek, 2005). Currently these children &ndash; when referred to mental health services - are likely to be offered a range of un-manualized, eclectic interventions, and evidence is lacking regarding the efficacy of these interventions for looked after children (Cocker & Scott, 2006; Luke et al., 2014). Over the last 10 years the Anna Freud Centre (AFC) has developed an adaptation of Mentalization Based Treatment (MBT; Keaveney et al., 2012), for use with children and their carers, based on principles from attachment theory. This approach aims to promote the quality of primary relationships, support effective and sensitive parenting and help the child and family understand and manage their emotions. It has been used with a wide range of children including foster children, with promising results from uncontrolled studies (Keaveney et al. 2012; Midgley, 2010). The current proposal is for a feasibility trial to systematically study the feasibility and acceptability of this approach for children in foster care, prior to a future full-scale efficacy trial. Plan of investigation: This study, managed by a highly experienced team, will recruit 42 children currently in foster care, referred from social care to a specialist LAC mental health service in Hertfordshire, due to mild-to-moderate emotional and behavioural problems (>15 on the Strengths and Difficulties Questionnaire; Goodman and Goodman, 2012). Half will be randomized to receive MBT; half will receive standard care provided by the LAC specialist service. Expert training and supervision will be provided by the AFC to therapists delivering MBT. Research assessments measuring child emotional and behavioural functioning (the primary outcome), as well as a range of other key secondary outcomes, will be conducted at baseline, at post-treatment (12 weeks) and follow-up (24 weeks). The key objectives of the study will be to test 1) the training model for MBT, 2) the robustness of recruitment into the trial, 3) credibility and acceptability of MBT as a treatment for LAC, 4) the feasibility and acceptability of the research trial procedures (consent, randomization, assessments), 5) the logistics of collecting resource-use data for future health-economic evaluation, and 6) to constrain estimates of treatment effect sizes. The proposal has benefited from extensive partnership from foster carers in providing feedback on the design of the study, and such engagement will be a feature of the study throughout its set-up, execution and dissemination. The study also has strong support from the LAC team, clinical commissioners and the local authority. Potential benefits to patients and the NHS: If the feasibility study is successful and provides the platform to continue to a full clinical trial, with positive outcomes, this would be a major step towards identifying an evidence-based intervention that could help address the needs of LAC - among the most vulnerable children in the UK, with very poor long-term outcomes, who currently make extensive use of mental health services in England and Wales.

Lay abstract: Background: About 60,000 children are in foster care in England, over fifty percent due to abuse and neglect. Forty-five percent of looked after children have mental health problems, but there is evidence to suggest that these children (and their carers) do not always get the support they need. Aims: We plan to test a new approach to supporting foster children with mental health problems, and their carers. Our new approach has been developed to promote good communication between professionals, carers and children in care. It aims to support caring relationships, and to improve emotional well-being. Design: Our longer-term aim is to do a large study which would find out whether this new way of working improves the well-being of children in care. To prepare for this large study, we will firstly run a smaller study, based in Hertfordshire's Targeted Looked After Children team. This should give us the information we need to design the full scale study. 42 children, referred to the Looked After Children service in Hertfordshire, will take part in this study - half of them will be offered our new way of working, and half will be offered normal care. Outcomes: The purpose of this study is to find out whether it is possible to conduct a large-scale study, and to identify any obstacles to doing so. We will share our findings with the families taking part in the study, and with managers who run NHS services, with the ultimate aim of improving the quality of life of children in care.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH