Condition category
Mental and Behavioural Disorders
Date applied
Date assigned
Last edited
Prospectively registered
Overall trial status
Recruitment status
Not yet recruiting

Plain English Summary

Background and study aims
A secure and supportive foster placement gives children the best chance in life. However, many children in care have emotional and behavioural difficulties that can make it a challenge to meet their needs. Carers report that they don't receive the support they need, and this can affect the quality of care they provide and can lead to placement breakdown, creating yet more disruption for the child. The aim of this study is to look at a new program called the Reflective Fostering Programme which was developed to support foster carers (including kinship/connected carers). The researchers want to find out whether offering foster carers/kinship carers the chance to attend Reflective Fostering groups improves the carer-child relationship and promotes the child’s emotional and behavioural well-being.

Who can participate?
Local Authority foster carers or kinship carers (also known as 'connected carers') who are currently looking after a fostered child, aged 4 to 13. The child needs to have been in their care for at least 4 weeks and the plan is for them to stay in the home for at least 4 months.

What does the study involve?
Foster carers will be provided with written information about the study and invited to attend an information meeting where they will find out more and have the opportunity to ask questions of the research team. If they wish to take part they will be invited to provide consent online. After providing consent they will be randomly allocated to one of the groups in the study: Reflective Fostering Programme in addition to usual support, or usual support only. They will complete some questionnaires online about themself and one child in their care. The same online questionnaires will be repeated two more times: after 4 months (which is when the programme is over) and again 8 months later (12 months after they join the study). Shortly after completing the questionnaires for the first time, those carers who are allocated to the Reflective Fostering group will begin attending the Programme. The Programme will consist of 10 two to three-hour sessions over a period of up to 12 weeks delivered by a social worker and an experienced foster carer who have been trained to deliver the Programme. Groups will be of between 6-10 carers.
Some participants will be invited to take part in interviews when they have finished their involvement in the study so that the researchers can find out how it was to take part in the study and examine how the Programme impacts the relationship between the foster carer and the children they care for.

What are the possible benefits and risks of participating?
For those attending the Reflective Fostering Programme, it is hoped that participants will find it helpful and that will develop a better understanding of their own and their child’s emotions and behaviours, leading to positive changes for both. Even for those not allocated to the group which attends the Programme, there are possible benefits. The information collected in this study will help improve services to other families with foster children in the future. By taking part and providing feedback foster carers will be helping to shape how support services are offered in the future, which may positively impact a large number of foster carers and their children. Some carers have also said that they find filling in the research questionnaires interesting and helpful, as it is an opportunity to reflect on how things are going for them and the child(ren) they are caring for. The researchers do not anticipate that there will be any risks in taking part. However, attending the groups and completing questionnaires could involve moments when reflecting on their experience as a carer may feel challenging or bring up difficult emotions.

Where is the study run from?
The study is being run by a team of researchers working at UCL (lead organisation), the University of Hertfordshire (study sponsor), Anna Freud National Centre for Children and Families, University of East Anglia, Kings College, London and Kent County Council (UK)

When is the study starting and how long is it expected to run for?
April 2020 to August 2023

Who is funding the study?
National Institute for Health Research (NIHR) (UK)

Who is the main contact?
Prof. Nick Midgley

Trial website

Contact information



Primary contact

Prof Nick Midgley


Contact details

UCL Main Building
Gower Street
United Kingdom
+44 (0)7812 138637



Additional contact

Dr Karen Irvine


Contact details

University of Hertfordshire
College Lane
AL10 9AB
United Kingdom
+44 (0)1707 286182

Additional identifiers

EudraCT number

Nil known number

Nil known

Protocol/serial number

CPMS 46949

Study information

Scientific title

The Reflective Fostering Programme – improving the wellbeing of children in care through a group intervention for foster carers: a randomised controlled trial


Study hypothesis

Adding the Reflective Fostering Programme to usual support is more effective than usual support alone at:
1. Promoting the emotional and behavioural well-being of children in care
2. Reducing levels of foster carer stress and burnout
3. Increasing foster carer parental reflective capacity
4. Increasing foster carer quality of life and meeting their personalised goals
5. Improving the carer-child relationship
6. Reducing placement instability

Ethics approval

Approved 27/08/2020, Health, Science, Engineering and Technology ECDA (University of Hertfordshire, College Lane, Hatfield, Herts, AL10 9AB, UK; +44 (0)1707 285568;, ref: cLMS/SF/Uh04242

Study design

Randomized; Interventional; Design type: Treatment, Education or Self-Management, Psychological & Behavioural

Primary study design


Secondary study design

Randomised controlled trial

Trial setting


Trial type

Quality of life

Patient information sheet

Not available in web format, please use the contact details to request a participant information sheet


Mental health


There are two study arms. One group (intervention arm) will attend the Reflective Fostering Programme alongside Usual Support and the other (control arm) will receive Usual Support only. Usual support is defined as the support, advice and guidance that all foster carers receive from their allocated social worker, plus any additional support services that they may receive as part of their role as a foster carer

Foster carers will be randomised individually to the Reflective Fostering Programme arm or the control arm. Randomisation will be managed online (using a tool built by NCTU Data Management) and overseen by the TM. Randomisation will be 1:1, stratified by age of child (4-9 vs 10-13), number of previous placements (1 or less, vs 2 or more) and recruiting region. The randomisation sequence will be blocked in random block lengths of two or four. Participants will be informed of group allocation by the local Site Coordinator, who will also contact the relevant social worker(s), so that they are aware that the foster carer is taking part in the study. If they are in the intervention group, the Reflective Fostering Programme Facilitators at each site will be informed.
The Reflective Fostering Programme is a group-based, psychoeducational intervention for foster carers. Reflective Fostering focuses on the practical application of a set of tools that represent the principles of reflective caregiving in a shortened, highly applicable form, for foster carers of children aged 4 to 13.

The Reflective Fostering Programme
The focus of the intervention is on improving the capability of the foster carer in relation to a nominated child currently in their care. Unlike parenting programmes that focus more on behaviour management, it focuses on improving the carer-child relationship, by helping carers to attend to their own state of mind and experiences, so they can better manage their own feelings, and respond better to the needs of the child in their care. Reflective Fostering aims to provide carers with practical ways to help build and maintain supportive relationships with the children in their care, drawing on the model of 'reflective parenting'. The Programme uses both psychoeducation and practical activities that link directly to the foster carers' own experiences. The aim is to enhance the capacity of foster carers to be mindful of the impact that caring for the child has on their own thoughts and feelings, and the influences on their current state of mind on their reaction to their foster child, which in turn helps them to become more open and curious about the thoughts, feelings and experiences of the child.

The Reflective Fostering Programme involves 10, 2-3-hour sessions offered to a group of 6-10 foster carers over a 12-14 week period. After the Programme ends, participants will be able to access materials about Reflective Fostering online and will be encouraged to form an online support group. If and when COVID-19 related social distancing regulations are sufficiently relaxed, the groups will be held at a LA site easily accessible to the participants. However, if restrictions are in place that mean it is not possible to hold face to face meetings, the sessions will take place online. The groups will be delivered by two trained Facilitators, one member of the children’s social care team (e.g. a social worker) and one foster carer, who will be provided with weekly consultation from specialists at the AFNCCF.

Intervention type



Drug names

Primary outcome measure

Emotional and behavioural difficulties measured using Strengths and Difficulties Questionnaire (SDQ) at baseline, 4 and 12 months

Secondary outcome measures

All measures will be collected at baseline, 4 and 12 months:
1. Caregiver functioning, the functioning of the child, and the level of stress in the caregiver-child relationship, measured using the Parenting Stress Index – Short Form (PSI 4-SF)
2. Carers’ capacity for reflective functioning in their caregiving role, measured using the Parental Reflective Functioning Questionnaire (PRFQ)
3. Compassion fatigue and burnout measured using the Professional Quality of Life Questionnaire
4. Carer’s view of a child’s emotional self-regulation and dysregulation, measured using Emotion Regulation Checklist (ERC) – Questionnaire
5. Achievement of carer's personalized goals in relation to the child, measured using the Carer Defined Problem Scale
6. Health-related quality of life measured using the Child Health Utility instrument (CHU9D), completed by the carer for use in cost-utility analysis
7. Service use in children in care, measured using Child and Adolescent Service Use Schedule, adapted (CA-SUS)
8. Changes of social worker, change of school or placement change and reasons for any change, recorded in Placement Stability Log

Overall trial start date


Overall trial end date


Reason abandoned (if study stopped)


Participant inclusion criteria

1. The carer is currently fostering a child aged between 4 and 13 years
2. The child has been in this placement for at least 4 weeks
3. The care plan is for the child to remain in this placement for more than 4 months
4. The inclusion criteria are in place to ensure that the intervention targets carers of children in medium to long-term placements, rather than respite care or emergency placements

Participant type


Age group




Target number of participants

Planned Sample Size: 720; UK Sample Size: 720

Participant exclusion criteria

1. Recruitment of foster carers in England and Wales specifies that they must have sufficient English language ability to engage with the child’s school and other services. For this reason, participating LAs have confirmed that they would expect no foster carers to be excluded on this basis. However, the process evaluation (see below) will include the number of potential participants excluded due to not meeting the language criteria, to check if this assumption is correct. The recruitment screening logs will also include this. Those with poor literacy will be supported through having a research assistant read questionnaires to them.
2. To ensure health inequalities are addressed, foster carers of any child with a disability (e.g. autism, developmental delay), and those currently caring for more than one child will be eligible to take part. If carers or the child in their care are currently receiving any other form of counselling or mental health support, this will not be a reason to exclude them from participating in the study. Attendance at the Reflective Fostering Programme is not designed to replace such usual support.

Recruitment start date


Recruitment end date



Countries of recruitment

United Kingdom

Trial participating centre

Kent County Council
Sessions House
ME14 1XQ
United Kingdom

Trial participating centre

Hertfordshire County Council
County Hall Pegs Lane
SG13 8DE
United Kingdom

Trial participating centre

Lancashire County Council
PO Box 78 County Hall Fishergate
United Kingdom

Trial participating centre

London Borough of Hackney
1 Hillman Street Hackney
E8 1DY
United Kingdom

Trial participating centre

London Borough of Barnet
1255 High Road
N20 0EJ
United Kingdom

Trial participating centre

Camden Council
5 Pancras Square
United Kingdom

Trial participating centre

Haringey Council
187-197A High Road
Wood Green
N22 6XD
United Kingdom

Trial participating centre

London Borough of Enfield
Silver Street
United Kingdom

Trial participating centre

Islington Council
222 Upper Street
N1 1XR
United Kingdom

Trial participating centre

Bristol City Council
The Council House College Green
United Kingdom

Trial participating centre

Devon County Council
County Hall Topsham Road
United Kingdom

Trial participating centre

North Tyneside Council
Cobalt Business Park The Quadrant 16 The Silverlink N
Newcastle upon Tyne
NE27 0BY
United Kingdom

Trial participating centre

Wandsworth Borough Council
The Town Hall Wandsworth High St
SW18 2PU
United Kingdom

Sponsor information


University of Hertfordshire

Sponsor details

c/o John Senior
College Lane
AL10 9AB
United Kingdom
+44 (0)1707 284300

Sponsor type




Funder type


Funder name

NIHR Evaluation, Trials and Studies Co-ordinating Centre (NETSCC); Grant Codes: NIHR127422

Alternative name(s)

Funding Body Type

Funding Body Subtype


Results and Publications

Publication and dissemination plan

The statistical analysis plan will not be available until towards the end of the study. The researchers are preparing the study protocol for publication in an academic journal. They also plan the publication of the trial results in a high-impact peer-reviewed journal within 12 months of the end of the trial.

2020 protocol in (added 19/11/2020)

IPD sharing statement
During the trial, requests for data should be directed to the CI (Prof. Nick Midgley []) and Trial Management Group, who will review the data request in line with the trial objectives to ensure that the trial objectives would not be impacted by the proposed data request and analysis; post-trial, requests for data should be directed to the CI (Prof. Nick Midgley) and Sponsor (University of Herts).

Intention to publish date


Participant level data

Available on request

Basic results (scientific)

Publication list

Publication citations

Additional files

Editorial Notes

09/12/2020: Contact details updated. 19/11/2020: Protocol link added to publication and dissemination plan. 27/10/2020: Trial's existence confirmed by the NIHR.