A longitudinal study examining the effect of carer-child relationship quality on child’s emotional and behavioural difficulties while in foster care

A longitudinal study examining the effect of carer-child relationship quality on child’s emotional and behavioural difficulties while in foster care | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A longitudinal study examining the effect of carer-child relationship quality on child’s emotional and behavioural difficulties while in foster care Rosa Sparks, Jala Rizeq, Karen Crawford, Helen Minnis This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6828302/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Nov, 2025 Read the published version in European Child & Adolescent Psychiatry → Version 1 posted 11 You are reading this latest preprint version Abstract Background Early relationships between a caregiver and their child set the foundations for many aspects of the child’s development [ 1 ]. Exposure to abuse or neglect can negatively impact the security and stability within these early relationships [ 2 ]. The aim of this project was to characterise the association between carer-child relationship quality and child’s mental health over time. Methods Data for 220 children, collected between 2011–2022 as part of the Best Services Trial (BeST ? ) were used. Relationship quality was assessed using Parent-Infant Relationship Global Assessment Scale (PIR-GAS), and child emotional and behavioural difficulties was assessed using the Strengths and Difficulties Questionnaire (SDQ) and The Infant Toddler Social Emotional Assessment (ITSEA). Data was examined from two time points, a few weeks after entering care and after 2.5 years. Results The quality of the carer-child relationship did not predict emotional and behavioural outcomes for the child at a later time point. Nonetheless, we found that overall children had significantly better relationships with their carers at the 2.5 year follow up than at baseline. Conclusions This highlights a need for specific tailored interventions for care experienced children, to support their emotional and behavioural needs and improve long term outcomes. Foster care placement instability mental health carer-child relationship quality Figures Figure 1 Figure 2 Introduction In 2021/2022 there were approximately 105,400 children and in care in the United Kingdom, and this number is growing with an increase of 9% in the past five years [ 3 ] This number includes children who have been placed in foster care, kinship care, those who remain at home with their parents (Scotland) and those in residential accommodation. Due to different legal systems in Scotland, many children who are in the care system continue to live at home with their parents but are under a supervision requirement, which requires them to have regular contact with social services [ 4 ]. Reasons for entry to care vary, with the most common reason being abuse or neglect, and all looked-after children and young people will have experienced some level of adversity [ 5 ]. These experiences are often referred to as adverse childhood experiences (ACE’s) which is a term used to categorise stressful events that occur in childhood, such as exposure to domestic abuse, having a parent with a mental health condition, a household member being in prison and exposure to abuse and neglect [ 6 ]. A large cohort study conducted in the USA found that 40.8% of children and young people in care reported between six and nine ACE’s and 37.4% reported more than ten ACE’s [ 7 ]. Therefore, this early exposure to adversity can have an impact on how children go on to form relationships with their caregivers, considering children’s feelings of safety and security being disrupted by the maltreatment [ 8 ]. The caregiver-child relationship is the first crucial relationship that a child forms, and the quality of this relationship impacts many aspects of the child’s development [ 1 ]. Based on attachment theory, the security of the early parent child relationship impacts how the child forms interpersonal relationships throughout the course of their life [ 9 ]. A secure attachment forms when a child perceives their caregiver to be responsive and sensitive to their needs and offers a safe base for them to explore the world from [ 10 ]. A lack of an early secure attachment can impact on a child’s mental health, with reviews of the literature finding that insecure attachment is associated with higher levels of anxiety and internalising difficulties compared to secure attachments [ 11 , 12 ]. Early exposure to adversity and caregiver disruption hinders the development of secure attachments [ 2 ]. A meta-analysis examining the attachment of pre-school aged children in foster care, found that approximately 40% of children in care had insecure attachments and approximately 22% of children had disorganised attachment [ 13 ]. Children in care are also at risk of developing attachment disorders, such as reactive attachment disorder (RAD) [ 8 , 14 ]. Children with RAD show disturbances in how they interact with others, and this is characterised by lack of attachment behaviours (e.g., reaching out to be picked up), focused towards their caregiver(s). Children with RAD display these disturbances across individuals and contexts rather than just with the primary caregiver [ 15 ]. Risk factors for RAD include; neglect, physical abuse, sexual abuse, parental alcoholism, parental mental illness, parental drug use, and the absence of a consistent primary caregiver [ 16 ], commonly present in children who have entered into care. These difficulties may therefore impact how they interact with their carer and in turn pose challenges on the quality of the child-carer relationship. Due to these early attachment disruptions as well as high levels of adversity often experienced by children in care, this population group are especially at risk for developing mental health difficulties. Compared to the general population, it has been estimated that children in care are three times more likely to have a mental health disorder than in children who have not been in care [ 17 ]. These numbers are high, with one study finding that 60.5% of pre-school aged children who are in care have a diagnosis of at least one mental health disorder [ 18 ]. The most common diagnoses of children in care were found to be major depressive disorder, oppositional defiant disorder, conduct disorder, reactive attachment disorder and post-traumatic stress disorder [ 19 ]. Levels of externalising difficulties (such as hyperactivity or behavioural difficulties) are also common, with one study finding 40.6% of a sample of children in care having externalising difficulties [ 20 ]. Another factor which has been found to impact the mental health of children in care is the number of care placements they experience. Throughout their time in care, children may experience multiple placement changes, with 10% of children in care in England and 4% of children in care in Scotland experiencing three or more placement moves within a 12-month period [ 3 , 4 ]. This instability in residence, also represents an instability in caregiving which could lead to children struggling to develop meaningful relationships with caregivers. There is a significant body of literature exploring the impact of placement instability on emotional and behavioural difficulties of children in care, which shows that placement instability is associated with poorer outcomes [ 21 – 23 ]. Importantly, stable care placements are associated with positive emotional and behavioural outcomes for children [ 24 – 27 ]. Therefore, placement instability is an important factor to consider when exploring the impact of the carer-child relationship on mental health outcomes for care experienced children and young people. This study aimed to explore whether the carer-child relationship predicts emotional and behavioural difficulties, while controlling for placement stability/instability. The current study and aims The current evidence base highlights the importance of a good quality relationship between carer and child, however this relationship has not been examined longitudinally for children who are in care, especially in early childhood. There is also a lack of research which explores the association between carer-child relationship and child mental health outcomes, and it is unclear how these two domains impact on one another, above and beyond the impact of number of placements a child has experienced. Therefore, the primary aim of this project was to characterise the strength and direction of the association between carer-child relationship quality and child’s emotional and behavioural difficulties, over a period of time a child is in foster care. A secondary aim was to understand the unique effects of carer-child relationship quality on child’s emotional and behavioural difficulties, above and beyond the effects of relevant factors including child sex, age at entry to care, and number of placement moves. Research Questions What is the direction of the association between carer-child relationship and child emotional and behavioural difficulties over time? Does the quality of the carer-child relationship predict the child’s emotional and behavioural difficulties at a later time point, above and beyond the effect of number of placement moves? Methods Design and Procedure This study used a longitudinal repeated measures design, using existing data collected between 2011–2022 as part of the Best Services Trial (BeST ? ) [ 28 ]. BeST ? is a randomised control trial comparing an infant mental health service (the New Orleans Intervention Model (NMI) with the Social Work Services (as usual). The aim of this trial was to explore what the best service is for abused and neglected pre-school aged children coming into foster care. Families were invited to take part in the trial if they had a child aged between 0–5 years when entering an episode of foster care, in either Glasgow or South London. Participants completed quantitative measures over a period of 2.5 years. Measures of child mental health and carer-child relationship functioning were collected at three time points throughout the trial; 1) a few weeks after entering foster care (T1), 2) 15 months after entering care (T2) and 3) 2.5 years after entering care (T3). To be eligible for inclusion in this current study, participants had to have completed a baseline rating of the quality carer-child relationship at T1 and data were used from baseline collection (T1) and follow up (T3). The decision was made not to use data from T2, due to ratings of carer-child relationship quality being missing or deemed not ratable at that timepoint due to disruptions to how the data was collected at that time, which overlapped with COVID-19 restrictions. To complete the assessments, carers were invited to health care settings where they completed a number of questionnaires and a video recording was taken to observe interactions which was used to score the quality of the relationship. Due to the COVID-19 pandemic and lockdown restrictions, some carers were asked to complete these measures and video recordings at home. The BeST ? Trial was approved by the West of Scotland Research Ethics Service, Committee 3 (approval number 15/WS/0280) and this current study was covered within the project’s ethical approval [ 28 ]. Informed written consent was obtained from all carers and each child (participant) in the study was assigned a unique ID number to link their data throughout the trial in order to maintain confidentiality. Participants The total number of participants recruited to the BeST ? was 488 children, from 382 families, 378 of whom were in Glasgow and 110 in London. Of this sample, data from 220 participants who had a rating of the quality carer-child relationship at T1 were included in this study. Of those, 101 participants had complete data across T1 and T3. The age range of the participants was between less than a year and five and a half years. The sample characteristics of the 220 participants included are summarised in Table 1 . Table 1 Sample Characteristics Demographics % Sex Male 53.64% Female 46.36% Ethnicity White 88.43% Mixed 5.09% Asian/ Asian British 4.16% Black/Black British 2.31% Supervision order Compulsory 52.73% Voluntary 47.27% Index of Multiple Deprivation (IMD) 1 (most deprived) 63.47% 2 18.72% 3 9.13% 4 5.48% 5 2.28% 6 (least deprived) 0.92% Materials and measures Child emotional and behavioural difficulties Depending on child age, emotional and behavioural difficulties were measured using one of two or both measures: the Strengths and Difficulties Questionnaire (SDQ) [ 29 ], and the Infant Toddler Social Emotional Assessment (ITSEA) [ 30 ] described below. SDQ is a measure which is used to assess child’s mental health in children aged 2–17 years old (Goodman, 1997). The 25-item carer-report version of the SDQ was used in this study. The version used with two to four year olds has three items modified from the original four to 17 year old version, to ensure developmental appropriateness [ 31 ] both versions of the SDQ were used in this trial (2–4 years and 4–17 years). The SDQ has 5 subscales; emotional symptoms subscale, conduct problems, hyperactivity/inattention, peer relationship problems and prosocial behaviour. These are scored on a three-point scale; not true, somewhat true and certainly true. Somewhat true is always scored as a 1, but the score for not true and certainly true varies between the item (either scored as 0 or 2). The scores from all the subscales, excluding prosocial behaviour, add together to generate a total difficulties score, which was the score used in this study, with higher scores indicative of more difficulties. The SDQ has been shown to have good reliability and validity [ 32 ]. For children under the age of 2, the ISTEA was used [ 30 ]. This is a carer-report measure used to assess social-emotional and behavioural problems. It consists of 166 items across 4 domains; externalising (activity/impulsivity, aggression/defiance and peer aggression), internalising (depression/withdrawal, general anxiety, separation distress and inhibition to novelty), dysregulation (negative emotionality, sleep and eating problems, sensory sensitivity) and competence (attention, mastery, motivation, play, empathy and prosocial peer relations). Items are rated as 0 = not true/rarely true, 1 = somewhat true/sometimes and 2 = very true/always. For some items there is an option to respond ‘N’, which would be used where the parent or carer has not had the opportunity to observe that behaviour. In these instances, items marked ‘N’ are scored as missing or ‘M’ and if there are two or more ‘M’ answers in each subscale the subscale cannot be used. For this study the ITSEA was scored in alignment with the manual. The ISTEA has been found to be a valid measure to assess emotional and behaviour problems in children under 2 years [ 33 ]. Total emotional and behavioural difficulties score was computed using either the SDQ or ITSEA, depending on availability, and converted into a standardised z score to allow comparability. For the ITSEA an average of both the internalising and externalising z-scores represented total emotional and behavioural difficulties score. For the SDQ the total difficulties score was converted into a z score. Where there was both an SDQ score and an ITSEA score available for one child, the SDQ score was prioritised and used. Carer-child relationship functioning The Parent Infant Relationship Global Assessment Scale (PIR-GAS) [ 34 ] was used to assess carer-child relationship quality as indicated by Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0–3). The PIR-GAS is commonly used as a rating instrument and is used in clinical settings to observe parent-infant relationships, to describe the strengths of a relationship as well as the severity of a disorder. PIR-GAS can also be used as a research tool [ 35 ]. Three aspects of the relationship are evaluated: behavioural quality of interactions, affective tone , and psychological involvement. The relationship is initially placed into one of ten categories ranging from well adapted (100 − 91) to grossly impaired (10 and under), therefore a higher score would indicate a better quality relationship. A continuous measure of carer and child relationship quality was created by choosing a final score within the chosen decile. PIR-GAS scores were derived from video recording of the carer child interaction. Carers were asked to play with their child for a period of time and eat lunch with their child and both elements were recorded. The videos were rated by a team of trained raters, including the primary author, and scored using the PIR-GAS rating scale. Twenty percent of the videos were watched by a second rater to establish inter-rater reliability. Where there was a discrepancy of more than 10 points, scores were discussed at conference with experienced PIR-GAS raters, including the research supervisor, and a final score was agreed. Placement instability To explore placement instability each child experienced prior to the trial, a binary variable was created. This was coded as 0 or 1, where 0 was no prior placement moves and 1 was one or more placement moves. In total 174 children had experienced 0 prior placement moves, 22 had experienced 1 placement move and 2 had experienced 2 or more placement moves. Analytic strategy Analyses were conducted using R Studio (R version 4.3.3). Preliminary screening of the data was conducted using descriptive statistics and visualised using histograms and scatterplots to assess normality (univariate distributions) and linearity (bivariate distributions), respectively. To examine the associations between carer-child relationship quality and child emotional and behavioural difficulties at the two time points, bivariate Pearson correlations were estimated. To examine if the quality of the carer-child relationship at T1 predicted child emotional and behavioural difficulties at T3, above and beyond the number of previous placements and whilst controlling for child initial emotional and behavioural difficulties, multiple regression analysis was used. Two regression models were estimated, firstly using PIR-GAS score at T1 as the predictor and next using a PIR-GAS change score as the predictor (the difference between T1 PIR-GAS score and T3 PIR-GAS score). To explore the longitudinal association between carer and child relationship quality and child emotional and behavioural difficulties and the direction of this relationship, a cross-lagged path analysis model was estimated. This model was estimated using the lavaan package (version 0.6–7; [ 36 ] and adjusted for multivariate non-normality using maximum likelihood estimation with robust standard errors and fit statistics [ 37 ]. Missing ratings were handled using full-information maximum likelihood. The model estimated was fully saturated and therefore model fit was not assessed. A sensitivity analysis was conducted, estimating the same cross-lagged panel model, using data from the subset of participants who have complete data across T1 and T3. Sample size To make sure the current study would be well powered, a sample size analysis was calculated prior to data analysis. This was completed based on previous effect taken from research with the same sample using the SDQ scores at time 3 and carer commitment scores at time 1. With an effect size of .201, in a multiple regression with 4 predictors using a power of 0.8 and an alpha level of .05, it was estimated we would need a sample of 66 participants. For the path analysis model, our sample being between 100 and 200 is considered acceptable [ 38 ]. Our path analysis includes 8 free parameters, and as such a sample of 220 (and a sample of 101 with only complete data) is well powered to conduct the analysis. Results Descriptives and Correlations Table 2 presents the descriptive statistics for the variables included in this study (n = 220) and shows the degree of missingness across variables and timepoints. Table 3 shows the bivariate correlations. Overall, there was no meaningful correlation between the quality of the carer-child relationship (PIR-GAS score) and the child’s emotional and behavioural difficulty score at T1 and T3; all associations were non-significant and small. Emotional and behavioural difficulties at T1 showed a small-moderate and significant correlation with emotional and behavioural difficulties at T3 ( r = .30, p < .001). There was a small-moderate negative correlation between placement instability and PIR-GAS T3 ( r = -0.34, p < .01), indicating instability was associated with poorer relationship quality at T3. Placement instability also had a small significant association with emotional and behavioural difficulties at T3 ( r = 0.19, p < 0.01). Sex and PIR-GAS at T1 showed a weak but significant correlation ( r = 0.20, p < 0.01), indicating that higher quality relationship is reported with females as compared to males. Age at T1 showed a weak but significant correlation with PIR-GAS T1 ( r = 0.23, p < 0.01) and emotional and behavioural difficulties at T3 ( r = 0.18, p < 0.01), indicating that older age at entry to care is associated with better relationship quality ratings at T1 and higher emotional and behavioural difficulties at T3. Table 2 Descriptives of Variables Variable N Mean SD Min Max Age (T1) 220 2.44 1.58 0.08 5.58 PIR-GAS T1 220 80.07 13.58 25 100 PIR-GAS T3 101 85 10.58 35 98 Emotional & behavioural difficulty T1 146 -0.02 0.91 − 1.52 2.60 Emotional & behavioural difficulty T3 188 0.00 1.00 -1.55 2.67 SDQ raw score T1 102 12.20 8.01 0.00 33 SDQ raw score T3 188 11.36 7.35 0.00 31 ITSEA internalising raw score T1 69 0.47 0.25 0.00 1.06 ITSEA externalising raw score T1 69 0.61 0.41 0.00 1.58 ITSEA internalising raw score T3 5 0.45 0.30 0.10 0.76 ITSEA externalising raw score T3 5 0.30 0.22 0.00 0.53 Table 3 Correlations Among Variables Variable 1 2 3 4 5 6 7 1.PIR-GAS T1 1 2. PIR-GAS T3 0.10 1 3. Emotional & behavioural difficulties T1 -0.09 0.04 1 4. Emotional & behavioural difficulties T3 -0.06 -0.10 0.30* 1 5.Placement instability 0.05 -0.34* 0.04 0.19* 1 6. Sex 0.20* 0.00 -0.04 -0.06 0.05 1 7. Age T1 0.23* 0.05 -0.03 0.18* 0.05 -0.06 1 Note *significant at p ≤ 0.05. Multiple Regression Table 4 summarises the results from the multiple regression analysis with emotional and behavioural difficulties at T3 as the outcome. The first model uses PIR-GAS score at T1 as the predictor and the second model uses PIR-GAS change score as the predictor (calculated by subtracting PIR-GAS score at T3 from PIR-GAS score at T1). Model 1 (F(5,108) = 2.40, p = 0.04) explained 10% of the variance in child emotional and behavioural difficulties at T3, with an adjusted R² of 0.06. Model 2 (F(5,68) = 1.91, p = 0.10) explained 12.3% of the variance in child emotional and behavioural difficulties at T3, with an adjusted R² of 0.06. In both models, only child emotional and behavioural difficulties at T1 was a significant predictor of the outcome at T3. None of the other predictors had a significant effect, meaning that the quality of carer-child relationship at T1, or the change in this relationship, did not predict child emotional and behavioural difficulties at T3 above and beyond other variables considered, which also did not present with any significant effects on the outcome. Table 4 Multiple Regression Models Examining Unique Effects on Child Emotional & Behavioural Difficulties at T3 Model 1 b β t p PIR-GAS score T1 -0.00 -0.06 -0.63 0.53 Placement instability 0.21 0.08 0.84 0.40 Sex -0.07 -0.03 -0.35 0.73 Age at T1 0.10 0.12 1.33 0.19 Child emotional & behavioural difficulties T1 0.28* 0.28 3:03 < .001 Model 2 PIR-GAS change score -0.00 -0.02 -0.18 0.86 Placement instability 0.18 0.06 0.46 0.65 Sex -0.02 -0.01 -0.10 0.92 Age at T1 0.07 0.10 0.83 0.41 Child emotional & behavioural difficulties T1 0.32* 0.35 3.05 0 < .001 Note * significant at p < 0.01 Cross Lagged Panel Model Figure 1 below shows the cross lagged panel model, depicting the direction of the paths between PIR-GAS score and child emotional and behavioural difficulties score over time. The figure includes the standardised regression coefficients. This model was estimated using a proportion of the total sample (n = 146) due to missing child emotional and behavioural difficulties scores at T1. As shown in Fig. 1 , there is no stability in PIR-GAS scores from T1 to T3 ( β = 0.11, p = 0.200). There was some stability in emotional and behavioural difficulties scores from T1 to T3 ( β = 0.31, p = 0.002). None of the cross lagged effects were significant, and both very small. The model explained 10% of the variance in emotional and behavioural difficulties at T3 and 1.5% of the variance in PIR-GAS scores at T3. The sensitivity analysis (Fig. 2 ), using only complete data across T1 and T3 (n = 101), yielded similar results. Based on these findings, further exploratory analysis was completed to examine the differences in PIR-GAS and emotional and behavioural difficulty scores between T1 and T3. The distribution of change scores were assessed by visually examining the histogram, with no issues noted with normality. Two paired samples t-tests were performed to compare the difference in PIR-GAS scores and in emotional and behavioural difficulties between T1 and T3. There was a significant difference, with higher PIR-GAS scores at T3 ( M = 85.00 SD = 10.58) than at T1 ( M = 80.07 SD = 13.58), t(100) = 1.99, p = 0.0495 with a 95% mean difference confidence interval = 0.006, 6.092. The effect size as measured by Cohen’s d was d = 0.31, indicating a small effect. The findings indicate that the overall relationship quality between carer and child is rated as significantly better at T3 compared to T1. In terms of emotional and behavioural difficulties, the t-test showed no significant difference between the emotional and behavioural difficulty scores at T1 (M = 0.02, SD = 0.91) and T3 (M = 0.00, SD = 1.00), t(125) = 0.86, p = 0.39, with a 95% mean difference confidence interval = 0.11, 0.28. The effect size as measured by Cohen’s d was d = 0.02, indicating a very small effect; this is consistent with the stability noted in earlier analysis. Discussion The results of this study provide insight into how relationship quality between carer and child change over time spent in care, and the degree to which these relationships are implicated in the emotional and behavioural outcomes for the child. This study shows that the quality of the relationship between carer and child over time does not predict emotional and behavioural outcomes for the child, but the overall quality of this relationship is significantly better later in the child’s journey in care than early on. Placement instability Consistent with literature highlighting the negative impact of placement instability on children’s mental health outcomes [ 21 , 39 ], placement instability at time in this study was significantly associated with poorer relationship quality and higher emotional and behavioural difficulties 2.5 years later. This is further evidence that the history of placement instability is a risk factor for negative outcomes. It is important to note that in this sample, the first entry to care for the majority of the children (88%) was at the time of entering this study. This could be due to the young age of the children at Time 1, with the average age of the child being under one years of age. Nonetheless, even at this young age, the presence of early instability had an effect on relationship quality and emotional and behavioural outcomes. The foster care system in the UK is unstable relative to that of other countries. In Scotland, many children experience repeated short-term episodes of foster care, specifically in Glasgow where two thirds of children who returned home re-entered the care system, often being referred to the ‘revolving door effect’ [ 40 ]. It is important to invest in supportive and stable placements for children to ensure we promote healthy development and functioning [ 41 ]. Relationship quality is a crucial factor in maintaining supportive and safe placements [ 42 ]. Effect of relationship quality on emotional and behavioural outcomes Based on the importance of the relationship quality between child and carer, it was expected that better quality of the relationship would be associated and predictive of lower emotional and behavioural difficulties for the child. However, the results from this study found that the quality of the child’s relationship with their foster carer did not predict later emotional and behavioural difficulties. Similarly, sex, age at entry to care and placement instability also did not predict later emotional and behavioural difficulties. The only predictor of later emotional and behavioural difficulties was baseline emotional and behavioural difficulties, with no differences in average difficulties between baseline and two and a half years in care into their time in care during the study. This is an important finding to consider, as to why when a child is placed in nurturing foster care do we not see improvement in their emotional and behavioural functioning over time. Research has shown that stable mental health profiles are the most common in care experienced children and young people and much less likely for children’s mental health trajectory to change over time in care [ 43 ]. Our findings show similar results. Another important consideration with children who have been abused and neglected is that as a group they are much more likely to have heritable neurodevelopmental conditions than their peers (not caused by abuse and neglect) [ 44 ]. Minnis [ 45 ] suggests that if the high rates of neurodevelopmental problems within this population are not due to the environment they are placed in, but more due to inherited difficulties, then it would not be expected that being placed in foster care would be able to ‘treat’ the difficulties, which again may speak to the stability of some of the emotional and behavioural difficulties measured in our study. This means that this group of children would require comprehensive mental health assessment and individualized treatment, and care placement alone, even when the quality of child-carer relationship is good or improves, is not sufficient to address emotional and behavioural difficulties. Stability in carer-child relationships The lack of stability in the quality of the relationship between carer and child over time spent in care highlights the dynamic and evolving nature of relationships between foster carer and child. Nonetheless the relationship between carer and child improves over time spent in care, in part explaining the lack of stability. This is a hopeful finding for care experienced children, as it shows the ability to improve a relationship with a caregiver over time spent in care, irrespective of their mental health and initial relationship quality. This suggests that, whilst living in foster care, an environment which is hopefully stable and nurturing, and given the time, children are able to build connections with their caregiver and develop positive relationships. This is the first study we are aware of that has looked at this relationship over time using validated tools. It will be important to see how this relationship continues to change over a longer period of time in care, and for children at different developmental stages. Limitations and future directions This is a novel study that examined how the quality of carer-child relationship changes over a period of time a child is in foster care and how this relates to child mental health, in a representative sample of young children in care. Although the sample size in this study was smaller than initially anticipated, due to missing data on the variables of interest, there was still sufficient information to answer the questions of interest. Further, attrition commonly occurs in longitudinal research, and in this study, it may also have been influenced by the COVID-19 pandemic, which occurred during the data collection period. The sensitivity analysis conducted using the subsample with complete data at Time 1 and 2 suggests that there is no bias resulting from attrition or missingness. Further, as reported in the main trial paper, there were no differences in between those who completed follow ups from those who dropped out [ 46 ]. Conclusions and implications Overall, the findings from this study highlight the variable nature of relationships between carer and child and how they evolve over time, finding no stability in individual relationships but an improvement in the group as a whole over 2.5 years. As the quality of the relationship does not predict emotional and behavioural outcomes, there must be other factors which are influencing the emotional and behavioural difficulties of children in foster care, with a small effect observed due to initial placement instability. This highlights a need for further longitudinal research to better understand these relationships, and how they might support improvements in emotional and behavioural wellbeing of children in foster care. The results from this study show that simply placing a child in foster care and removing them from a neglectful and/or abusive home environment, does not, by itself, improve their emotional and behavioural outcomes. This highlights the need for other measures to be put in place, including follow up assessments and the use of evidence-based treatment and management strategies which are tailored to care experienced children, in order to improve the long-term outcomes for this population. Declarations The BeST ? trial was sponsored by NHS GG&C, coordinated on behalf of the National Institute of Health Research by Glasgow University Institute of Health and Wellbeing. The author has no competing interests to declare. Ethical Information The BeST ? Trial was approved by the West of Scotland Research Ethics Service, Committee 3 (approval number 15/WS/0280) and this current study was covered within the project’s ethical approval [ 28 ]. Informed written consent was obtained from all carers and each child (participant) in the study was assigned a unique ID number to link their data throughout the trial in order to maintain confidentiality. Author Contribution R.S and J.R wrote the main manuscript text. H.M reviewed the manuscript of the text.K.C supported the preparation of the data and supported PIR-GAS training to rate the video recordings. Data Availability As the findings of this paper are based on data from a larger trial, all data requests will have to be submitted to the chief investigator (H.M.) and then will be reviewed and considered by the Trial Management Group (TMG). References Hornor G (2019) Attachment disorders. J Pediatr health care 33(5):612–622 Prather W, Golden JA (2009) A behavioral perspective of childhood trauma and attachment issues: Toward alternative treatment approaches for children with a history of abuse. Int J Behav Consultation Therapy 5(1):56 Department for Education (DfE) (2022a) Children looked after in England including adoption. London: Department for Education (DfE). Accessed 2024: https://explore-education-statistics.service.gov.uk/find-statistics/children-looked-after-in-england-including-adoptions Scottish Government (2023a) Children's social work statistics Scotland: 2021 to 2022. Edinburgh: Scottish Government. Accessed 2024 from: https://www.gov.scot/publications/childrens-social-work-statistics-scotland-2021-22/ NICE guideline, Looked- after children and young people (2021) Accessed 2022 from: https://www.nice.org.uk/guidance/ng205 Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Marks JS (1998) Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 14(4):245–258 Liming KW, Akin B, Brook J (2021) Adverse childhood experiences and foster care placement stability. Pediatrics, 148(6), e2021052700 Turner, M., Beckwith, H., Duschinsky, R., Forslund, T., Foster, S. L., Coughlan, B.,… Carloe Schuengel, P. (2019). Attachment difficulties and disorders. InnovAiT, 12(4), 173–179. Bowlby J (1969) Attachment and loss (No. 79). Random House Ribera LB, Longobardi C, Prino LE, Fabris MA (2023) Secure attachment to mother and children’s psychological adjustment: The mediating role of pet attachment. Anthrozoös 36(2):279–293 Colonnesi C, Draijer EM, Jan JM, Stams G, Van der Bruggen CO, Bögels SM, Noom MJ (2011) The relation between insecure attachment and child anxiety: A meta-analytic review. J Clin Child Adolesc Psychol 40(4):630–645 Brumariu LE, Kerns KA (2010) Parent–child attachment and internalizing symptoms in childhood and adolescence: A review of empirical findings and future directions. Dev Psychopathol 22(1):177–203 Vasileva M, Petermann F (2018) Attachment, development, and mental health in abused and neglected preschool children in foster care: A meta-analysis. Trauma Violence Abuse 19(4):443–458 Oliveira, P., Barge, L., Stevens, E., Byford, S., Shearer, J., Spies, R., … Fearon,P. (2022). Children in foster care with symptoms of reactive attachment disorder:feasibility randomised controlled trial of a modified video-feedback parenting intervention.BJPsych Open, 8(4), e134. Román M, Palacios J, Minnis H (2022) Changes in Attachment Disorder symptoms in children internationally adopted and in residential care. Child Abuse Negl 130:105308 Guttmann-Steinmetz S, Crowell JA (2006) Attachment and externalizing disorders: A developmental psychopathology perspective. J Am Acad Child Adolesc Psychiatry 45(4):440–451 Lohr WD, Jones VF (2016) Mental health issues in foster care. Pediatr Ann 45(10):e342–e348 Hillen T, Gafson L (2015) Why good placements matter: Pre-placement and placement risk factors associated with mental health disorders in pre-school children in foster care. Clin Child Psychol Psychiatry 20(3):486–499 Engler AD, Sarpong KO, Van Horne BS, Greeley CS, Keefe RJ (2022) A systematic review of mental health disorders of children in foster care. Trauma Violence Abuse 23(1):255–264 Vanschoonlandt F, Vanderfaeillie J, Van Holen F, De Maeyer S, Robberechts M (2013) Externalizing problems in young foster children: Prevalence rates, predictors and service use. Child Youth Serv Rev 35(4):716–724 Cullen GJ, Yule C, Walters D, O’Grady W (2022) Mental health outcomes of youth in-care: Investigating the effect of general strain and self-control theories. Child Adolesc Soc Work J 39(4):409–423 Mishra AA, Schwab-Reese LM, Murfree LV (2020) Adverse childhood experiences associated with children’s patterns of out of home placement over time and subsequent negative outcomes during adolescence. Child & youth care forum, vol 49. Springer US, pp 247–263 Delaville E, Pennequin V (2020) Foster placement disruptions in France: Effects on children and adolescents’ emotional regulation. Child Adolesc Soc Work J 37(5):527–536 Bederian-Gardner, D., Hobbs, S. D., Ogle, C. M., Goodman, G. S., Cordón, I. M., Bakanosky,S., … NYTD/CYTD Research Group. (2018). Instability in the lives of foster and nonfoster youth: Mental health impediments and attachment insecurities. Children and Youth Services Review, 84, 159–167. McGuire A, Cho B, Huffhines L, Gusler S, Brown S, Jackson Y (2018) The relation between dimensions of maltreatment, placement instability, and mental health among youth in foster care. Child Abuse Negl 86:10–21 Fernandez E (2008) Psychosocial wellbeing of children in care: A longitudinal study of outcomes. Child Indic Res 1(3):303–320 Proctor LJ, Skriner LC, Roesch S, Litrownik AJ (2010) Trajectories of behavioral adjustment following early placement in foster care: Predicting stability and change over 8 years. J Am Acad Child Adolesc Psychiatry 49(5):464–473 Crawford K, Fitzpatick B, McMahon L, Forde M, Miller S, McConnachie A, Minnis H (2022) The Best Services Trial (BeST?): a cluster randomised controlled trial comparing the clinical and cost-effectiveness of New Orleans Intervention Model with services as usual (SAU) for infants and young children entering care. Trials 23(1):1–16 Goodman R (1997) The Strengths and Difficulties Questionnaire: a research note. J Child Psychol Psychiatry 38(5):581–586 Briggs-Gowan MJ, Carter AS (2006) Brief Infant Toddler Social Emotional Assessment (BITSEA) [Database record]. APA PsycTests. https://doi.org/10.1037/t14990-000 Croft S, Stride C, Maughan B, Rowe R (2015) Validity of the strengths and difficulties questionnaire in preschool-aged children. Pediatrics 135(5):e1210–e1219 Goodman R (2001) Psychometric properties of the strengths and difficulties questionnaire. J Am Acad Child Adolesc Psychiatry 40(11):1337–1345 Carter AS, Briggs-Gowan MJ, Jones SM, Little TD (2003) The infant–toddler social and emotional assessment (ITSEA): Factor structure, reliability, and validity. J Abnorm Child Psychol 31:495–514 Zero to Three/National Center for Clinical Infant Programs, Arlington VA (1994) Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. ERIC Clearinghouse, Diagnostic Classification, pp 0–3 Müller, J. M., Achtergarde, S., Frantzmann, H., Steinberg, K., Skorozhenina, O., Beyer,T., … Postert, C. (2013). Inter-rater reliability and aspects of validity of the parent-infant relationship global assessment scale (PIR-GAS). Child and Adolescent Psychiatry and Mental Health, 7, 1–10. Rosseel Y (2012) Lavaan: An R package for structural equation modeling and more. Version 0.5–12 (BETA). J Stat Softw 48(2):1–36 Yuan KH, Bentler PM (2000) 5. Three likelihood-based methods for mean and covariance structure analysis with nonnormal missing data. Sociol Methodol 30(1):165–200 Kline RB (2005) Principles and practice of structural equation modeling. Guilford Press Maguire D, May K, McCormack D, Fosker T (2024) A Systematic Review of the Impact of Placement Instability on Emotional and Behavioural Outcomes Among Children in Foster Care. J Child Adolesc Trauma, 1–15 Minnis H, Bryce G, Phin L, Wilson P (2010) The Spirit of New Orleans: translating a model of intervention with maltreated children and their families for the Glasgow context. Clin Child Psychol Psychiatry 15(4):497–509 Asif N, Breen C, Wells R (2024) Influence of placement stability on developmental outcomes of children and young people in out-of-home care: Findings from the Pathways of Care Longitudinal Study. Child Abuse Negl 149:106145 Miller L, Randle M, Dolnicar S (2019) Carer factors associated with foster-placement success and breakdown. Br J social work 49(2):503–522 Hiller RM, Fraser A, Denne M, Bauer A, Halligan SL (2023) The development of young peoples’ internalising and externalising difficulties over the first three-years in the public care system. Child Maltreat 28(1):141–151 Dinkler L, Lundström S, Gajwani R, Lichtenstein P, Gillberg C, Minnis H (2017) Maltreatment-associated neurodevelopmental disorders: A co‐twin control analysis. J Child Psychol Psychiatry 58(6):691–701 Minnis H (2023) Science into policy for the benefit of children: the Bucharest early intervention project. Am J Psychiatry 180(8):528–529 Crawford, K., Young, R., Wilson, P., Deidda, M., Forde, M., Millar, S., … Minnis,H. (2025). Infant mental health services for birth and foster families of maltreated pre-school children in foster care (BeST?): a cluster-randomized phase 3 clinical effectiveness trial. Nature medicine, 1–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 10 Nov, 2025 Read the published version in European Child & Adolescent Psychiatry → Version 1 posted Editorial decision: Revision requested 15 Sep, 2025 Reviews received at journal 05 Sep, 2025 Reviewers agreed at journal 20 Aug, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviewers agreed at journal 15 Aug, 2025 Reviews received at journal 13 Jul, 2025 Reviewers agreed at journal 26 Jun, 2025 Reviewers invited by journal 23 Jun, 2025 Editor assigned by journal 07 Jun, 2025 Submission checks completed at journal 07 Jun, 2025 First submitted to journal 05 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6828302","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":475792896,"identity":"9634cdab-d7ae-41a7-9398-8b7d38271859","order_by":0,"name":"Rosa Sparks","email":"","orcid":"","institution":"University of Glasgow","correspondingAuthor":false,"prefix":"","firstName":"Rosa","middleName":"","lastName":"Sparks","suffix":""},{"id":475792897,"identity":"40b447cb-4042-4602-aa08-fcd509d18ec0","order_by":1,"name":"Jala Rizeq","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIiWNgGAWjYBAC9gbmBiAlAcTMBxgeIMkY4NLC2MAI08KWwJBAghYQ4DEgUkv7wcYPjHss7PnZcz6/SKips+uXSGD88IPhsDFOLT2JzRIMzySYJXvebrNIOHY4eeaMBCCH4bAZboclNkgwHJBgM7iRu80gge1AssHtBAZpBobDNji19D9s/gHUwmN/I+eZQcK/OpAW5t/4tAjOSGwD2SJhIJHD/CCxjdkOqIUNZAtOh0lLPGyzSDgA1HHmmRlDYt/hBMn5D9ssewzScXqfjz/58I0PB+rs+duTH3/48A3I4Dl8+MaPCmvDBlx6QCABQrKBIjSxgQEUUzhjBVUj8wcgaU+U2lEwCkbBKBhRAADF7VeafKN/qgAAAABJRU5ErkJggg==","orcid":"","institution":"University of Glasgow","correspondingAuthor":true,"prefix":"","firstName":"Jala","middleName":"","lastName":"Rizeq","suffix":""},{"id":475792898,"identity":"bb757c55-42ee-4d69-8f75-fef31bb3dc1f","order_by":2,"name":"Karen Crawford","email":"","orcid":"","institution":"University of Glasgow","correspondingAuthor":false,"prefix":"","firstName":"Karen","middleName":"","lastName":"Crawford","suffix":""},{"id":475792899,"identity":"2344be55-093d-4314-92b6-4fc5acc29f19","order_by":3,"name":"Helen Minnis","email":"","orcid":"","institution":"University of Glasgow","correspondingAuthor":false,"prefix":"","firstName":"Helen","middleName":"","lastName":"Minnis","suffix":""}],"badges":[],"createdAt":"2025-06-05 10:38:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6828302/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6828302/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00787-025-02900-9","type":"published","date":"2025-11-10T15:58:31+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85725014,"identity":"1e565fba-9c8e-476b-b040-09a5c8b2a81a","added_by":"auto","created_at":"2025-07-01 06:24:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":62926,"visible":true,"origin":"","legend":"\u003cp\u003ePath Analysis Model\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote \u003c/em\u003eFigure 1 shows the standardised regression coefficients of the stability between the variables at the same time point, and the standardised regression coefficients for the cross lagged variable. It also shows the correlation coefficients between variables at the same time point (double headed arrows). *indicates a p value of less than 0.05.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6828302/v1/b1302109ad501d0c87bd8866.png"},{"id":85725015,"identity":"2d45fbc3-04de-4328-9ccc-b765d89b7064","added_by":"auto","created_at":"2025-07-01 06:24:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":65754,"visible":true,"origin":"","legend":"\u003cp\u003ePath Analysis Model for the Sensitivity Analysis\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote \u003c/em\u003eFigure 2 shows the standardised regression coefficients of the stability between the variables at the same time point, and the standardised regression coefficients for the cross lagged variable. It also shows the correlation coefficients between variables at the same time point (double headed arrows). *indicates a p value of less than 0.05.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6828302/v1/1aafff87787de8f66b5bc6a9.png"},{"id":96106288,"identity":"6fc1c9e3-a199-44d9-b0c8-b19a2b0630c0","added_by":"auto","created_at":"2025-11-17 16:13:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":942368,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6828302/v1/86890220-b1ad-40d9-bdcb-d5f0322ab4db.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eA longitudinal study examining the effect of carer-child relationship quality on child’s emotional and behavioural difficulties while in foster care\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn 2021/2022 there were approximately 105,400 children and in care in the United Kingdom, and this number is growing with an increase of 9% in the past five years [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] This number includes children who have been placed in foster care, kinship care, those who remain at home with their parents (Scotland) and those in residential accommodation. Due to different legal systems in Scotland, many children who are in the care system continue to live at home with their parents but are under a supervision requirement, which requires them to have regular contact with social services [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Reasons for entry to care vary, with the most common reason being abuse or neglect, and all looked-after children and young people will have experienced some level of adversity [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These experiences are often referred to as adverse childhood experiences (ACE’s) which is a term used to categorise stressful events that occur in childhood, such as exposure to domestic abuse, having a parent with a mental health condition, a household member being in prison and exposure to abuse and neglect [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A large cohort study conducted in the USA found that 40.8% of children and young people in care reported between six and nine ACE’s and 37.4% reported more than ten ACE’s [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Therefore, this early exposure to adversity can have an impact on how children go on to form relationships with their caregivers, considering children’s feelings of safety and security being disrupted by the maltreatment [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe caregiver-child relationship is the first crucial relationship that a child forms, and the quality of this relationship impacts many aspects of the child’s development [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Based on attachment theory, the security of the early parent child relationship impacts how the child forms interpersonal relationships throughout the course of their life [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A secure attachment forms when a child perceives their caregiver to be responsive and sensitive to their needs and offers a safe base for them to explore the world from [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A lack of an early secure attachment can impact on a child’s mental health, with reviews of the literature finding that insecure attachment is associated with higher levels of anxiety and internalising difficulties compared to secure attachments [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Early exposure to adversity and caregiver disruption hinders the development of secure attachments [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. A meta-analysis examining the attachment of pre-school aged children in foster care, found that approximately 40% of children in care had insecure attachments and approximately 22% of children had disorganised attachment [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eChildren in care are also at risk of developing attachment disorders, such as reactive attachment disorder (RAD) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Children with RAD show disturbances in how they interact with others, and this is characterised by lack of attachment behaviours (e.g., reaching out to be picked up), focused towards their caregiver(s). Children with RAD display these disturbances across individuals and contexts rather than just with the primary caregiver [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Risk factors for RAD include; neglect, physical abuse, sexual abuse, parental alcoholism, parental mental illness, parental drug use, and the absence of a consistent primary caregiver [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], commonly present in children who have entered into care. These difficulties may therefore impact how they interact with their carer and in turn pose challenges on the quality of the child-carer relationship.\u003c/p\u003e \u003cp\u003eDue to these early attachment disruptions as well as high levels of adversity often experienced by children in care, this population group are especially at risk for developing mental health difficulties. Compared to the general population, it has been estimated that children in care are three times more likely to have a mental health disorder than in children who have not been in care [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. These numbers are high, with one study finding that 60.5% of pre-school aged children who are in care have a diagnosis of at least one mental health disorder [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The most common diagnoses of children in care were found to be major depressive disorder, oppositional defiant disorder, conduct disorder, reactive attachment disorder and post-traumatic stress disorder [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Levels of externalising difficulties (such as hyperactivity or behavioural difficulties) are also common, with one study finding 40.6% of a sample of children in care having externalising difficulties [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother factor which has been found to impact the mental health of children in care is the number of care placements they experience. Throughout their time in care, children may experience multiple placement changes, with 10% of children in care in England and 4% of children in care in Scotland experiencing three or more placement moves within a 12-month period [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This instability in residence, also represents an instability in caregiving which could lead to children struggling to develop meaningful relationships with caregivers. There is a significant body of literature exploring the impact of placement instability on emotional and behavioural difficulties of children in care, which shows that placement instability is associated with poorer outcomes [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e–\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Importantly, stable care placements are associated with positive emotional and behavioural outcomes for children [\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e–\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Therefore, placement instability is an important factor to consider when exploring the impact of the carer-child relationship on mental health outcomes for care experienced children and young people. This study aimed to explore whether the carer-child relationship predicts emotional and behavioural difficulties, while controlling for placement stability/instability.\u003c/p\u003e\n\u003ch3\u003eThe current study and aims\u003c/h3\u003e\n\u003cp\u003eThe current evidence base highlights the importance of a good quality relationship between carer and child, however this relationship has not been examined longitudinally for children who are in care, especially in early childhood. There is also a lack of research which explores the association between carer-child relationship and child mental health outcomes, and it is unclear how these two domains impact on one another, above and beyond the impact of number of placements a child has experienced. Therefore, the primary aim of this project was to characterise the strength and direction of the association between carer-child relationship quality and child’s emotional and behavioural difficulties, over a period of time a child is in foster care. A secondary aim was to understand the unique effects of carer-child relationship quality on child’s emotional and behavioural difficulties, above and beyond the effects of relevant factors including child sex, age at entry to care, and number of placement moves.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResearch Questions\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat is the direction of the association between carer-child relationship and child emotional and behavioural difficulties over time?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDoes the quality of the carer-child relationship predict the child’s emotional and behavioural difficulties at a later time point, above and beyond the effect of number of placement moves?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003cp\u003e\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e\n\n "},{"header":"Methods","content":"\u003ch2\u003eDesign and Procedure\u003c/h2\u003e\u003cp\u003eThis study used a longitudinal repeated measures design, using existing data collected between 2011–2022 as part of the Best Services Trial (BeST\u003csup\u003e?\u003c/sup\u003e) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. BeST\u003csup\u003e?\u003c/sup\u003e is a randomised control trial comparing an infant mental health service (the New Orleans Intervention Model (NMI) with the Social Work Services (as usual). The aim of this trial was to explore what the best service is for abused and neglected pre-school aged children coming into foster care. Families were invited to take part in the trial if they had a child aged between 0–5 years when entering an episode of foster care, in either Glasgow or South London. Participants completed quantitative measures over a period of 2.5 years. Measures of child mental health and carer-child relationship functioning were collected at three time points throughout the trial; 1) a few weeks after entering foster care (T1), 2) 15 months after entering care (T2) and 3) 2.5 years after entering care (T3). To be eligible for inclusion in this current study, participants had to have completed a baseline rating of the quality carer-child relationship at T1 and data were used from baseline collection (T1) and follow up (T3). The decision was made not to use data from T2, due to ratings of carer-child relationship quality being missing or deemed not ratable at that timepoint due to disruptions to how the data was collected at that time, which overlapped with COVID-19 restrictions. To complete the assessments, carers were invited to health care settings where they completed a number of questionnaires and a video recording was taken to observe interactions which was used to score the quality of the relationship. Due to the COVID-19 pandemic and lockdown restrictions, some carers were asked to complete these measures and video recordings at home.\u003c/p\u003e\u003cp\u003eThe BeST\u003csup\u003e?\u003c/sup\u003e Trial was approved by the West of Scotland Research Ethics Service, Committee 3 (approval number 15/WS/0280) and this current study was covered within the project’s ethical approval [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Informed written consent was obtained from all carers and each child (participant) in the study was assigned a unique ID number to link their data throughout the trial in order to maintain confidentiality.\u003c/p\u003e\u003ch3\u003eParticipants\u003c/h3\u003e\u003cp\u003eThe total number of participants recruited to the BeST\u003csup\u003e?\u003c/sup\u003e was 488 children, from 382 families, 378 of whom were in Glasgow and 110 in London. Of this sample, data from 220 participants who had a rating of the quality carer-child relationship at T1 were included in this study. Of those, 101 participants had complete data across T1 and T3. The age range of the participants was between less than a year and five and a half years. The sample characteristics of the 220 participants included are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eSample Characteristics\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53.64%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46.36%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88.43%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.09%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsian/ Asian British\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.16%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlack/Black British\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.31%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupervision order\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompulsory\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52.73%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVoluntary\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.27%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndex of Multiple Deprivation (IMD)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (most deprived)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.47%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.72%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.13%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.48%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.28%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (least deprived)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.92%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eMaterials and measures\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eChild emotional and behavioural difficulties\u003c/h2\u003e \u003cp\u003eDepending on child age, emotional and behavioural difficulties were measured using one of two or both measures: the Strengths and Difficulties Questionnaire (SDQ) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], and the Infant Toddler Social Emotional Assessment (ITSEA) [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] described below.\u003c/p\u003e \u003cp\u003eSDQ is a measure which is used to assess child\u0026rsquo;s mental health in children aged 2\u0026ndash;17 years old (Goodman, 1997). The 25-item carer-report version of the SDQ was used in this study. The version used with two to four year olds has three items modified from the original four to 17 year old version, to ensure developmental appropriateness [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] both versions of the SDQ were used in this trial (2\u0026ndash;4 years and 4\u0026ndash;17 years). The SDQ has 5 subscales; emotional symptoms subscale, conduct problems, hyperactivity/inattention, peer relationship problems and prosocial behaviour. These are scored on a three-point scale; not true, somewhat true and certainly true. Somewhat true is always scored as a 1, but the score for not true and certainly true varies between the item (either scored as 0 or 2). The scores from all the subscales, excluding prosocial behaviour, add together to generate a total difficulties score, which was the score used in this study, with higher scores indicative of more difficulties. The SDQ has been shown to have good reliability and validity [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor children under the age of 2, the ISTEA was used [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This is a carer-report measure used to assess social-emotional and behavioural problems. It consists of 166 items across 4 domains; externalising (activity/impulsivity, aggression/defiance and peer aggression), internalising (depression/withdrawal, general anxiety, separation distress and inhibition to novelty), dysregulation (negative emotionality, sleep and eating problems, sensory sensitivity) and competence (attention, mastery, motivation, play, empathy and prosocial peer relations). Items are rated as 0\u0026thinsp;=\u0026thinsp;not true/rarely true, 1\u0026thinsp;=\u0026thinsp;somewhat true/sometimes and 2\u0026thinsp;=\u0026thinsp;very true/always. For some items there is an option to respond \u0026lsquo;N\u0026rsquo;, which would be used where the parent or carer has not had the opportunity to observe that behaviour. In these instances, items marked \u0026lsquo;N\u0026rsquo; are scored as missing or \u0026lsquo;M\u0026rsquo; and if there are two or more \u0026lsquo;M\u0026rsquo; answers in each subscale the subscale cannot be used. For this study the ITSEA was scored in alignment with the manual. The ISTEA has been found to be a valid measure to assess emotional and behaviour problems in children under 2 years [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTotal emotional and behavioural difficulties score was computed using either the SDQ or ITSEA, depending on availability, and converted into a standardised z score to allow comparability. For the ITSEA an average of both the internalising and externalising z-scores represented total emotional and behavioural difficulties score. For the SDQ the total difficulties score was converted into a z score. Where there was both an SDQ score and an ITSEA score available for one child, the SDQ score was prioritised and used.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCarer-child relationship functioning\u003c/h2\u003e \u003cp\u003eThe Parent Infant Relationship Global Assessment Scale (PIR-GAS) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] was used to assess carer-child relationship quality as indicated by Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0\u0026ndash;3). The PIR-GAS is commonly used as a rating instrument and is used in clinical settings to observe parent-infant relationships, to describe the strengths of a relationship as well as the severity of a disorder. PIR-GAS can also be used as a research tool [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Three aspects of the relationship are evaluated: \u003cem\u003ebehavioural quality of interactions, affective tone\u003c/em\u003e, and \u003cem\u003epsychological involvement.\u003c/em\u003e The relationship is initially placed into one of ten categories ranging from well adapted (100\u0026thinsp;\u0026minus;\u0026thinsp;91) to grossly impaired (10 and under), therefore a higher score would indicate a better quality relationship. A continuous measure of carer and child relationship quality was created by choosing a final score within the chosen decile.\u003c/p\u003e \u003cp\u003ePIR-GAS scores were derived from video recording of the carer child interaction. Carers were asked to play with their child for a period of time and eat lunch with their child and both elements were recorded. The videos were rated by a team of trained raters, including the primary author, and scored using the PIR-GAS rating scale. Twenty percent of the videos were watched by a second rater to establish inter-rater reliability. Where there was a discrepancy of more than 10 points, scores were discussed at conference with experienced PIR-GAS raters, including the research supervisor, and a final score was agreed.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePlacement instability\u003c/h3\u003e\n\u003cp\u003eTo explore placement instability each child experienced prior to the trial, a binary variable was created. This was coded as 0 or 1, where 0 was no prior placement moves and 1 was one or more placement moves. In total 174 children had experienced 0 prior placement moves, 22 had experienced 1 placement move and 2 had experienced 2 or more placement moves.\u003c/p\u003e\n\u003ch3\u003eAnalytic strategy\u003c/h3\u003e\n\u003cp\u003eAnalyses were conducted using R Studio (R version 4.3.3). Preliminary screening of the data was conducted using descriptive statistics and visualised using histograms and scatterplots to assess normality (univariate distributions) and linearity (bivariate distributions), respectively. To examine the associations between carer-child relationship quality and child emotional and behavioural difficulties at the two time points, bivariate Pearson correlations were estimated.\u003c/p\u003e \u003cp\u003eTo examine if the quality of the carer-child relationship at T1 predicted child emotional and behavioural difficulties at T3, above and beyond the number of previous placements and whilst controlling for child initial emotional and behavioural difficulties, multiple regression analysis was used. Two regression models were estimated, firstly using PIR-GAS score at T1 as the predictor and next using a PIR-GAS change score as the predictor (the difference between T1 PIR-GAS score and T3 PIR-GAS score).\u003c/p\u003e \u003cp\u003eTo explore the longitudinal association between carer and child relationship quality and child emotional and behavioural difficulties and the direction of this relationship, a cross-lagged path analysis model was estimated. This model was estimated using the lavaan package (version 0.6\u0026ndash;7; [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] and adjusted for multivariate non-normality using maximum likelihood estimation with robust standard errors and fit statistics [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Missing ratings were handled using full-information maximum likelihood. The model estimated was fully saturated and therefore model fit was not assessed. A sensitivity analysis was conducted, estimating the same cross-lagged panel model, using data from the subset of participants who have complete data across T1 and T3.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSample size\u003c/h2\u003e \u003cp\u003eTo make sure the current study would be well powered, a sample size analysis was calculated prior to data analysis. This was completed based on previous effect taken from research with the same sample using the SDQ scores at time 3 and carer commitment scores at time 1. With an effect size of .201, in a multiple regression with 4 predictors using a power of 0.8 and an alpha level of .05, it was estimated we would need a sample of 66 participants. For the path analysis model, our sample being between 100 and 200 is considered acceptable [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Our path analysis includes 8 free parameters, and as such a sample of 220 (and a sample of 101 with only complete data) is well powered to conduct the analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDescriptives and Correlations\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the descriptive statistics for the variables included in this study (n\u0026thinsp;=\u0026thinsp;220) and shows the degree of missingness across variables and timepoints. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the bivariate correlations. Overall, there was no meaningful correlation between the quality of the carer-child relationship (PIR-GAS score) and the child\u0026rsquo;s emotional and behavioural difficulty score at T1 and T3; all associations were non-significant and small. Emotional and behavioural difficulties at T1 showed a small-moderate and significant correlation with emotional and behavioural difficulties at T3 (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.30, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). There was a small-moderate negative correlation between placement instability and PIR-GAS T3 (\u003cem\u003er\u003c/em\u003e = -0.34, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01), indicating instability was associated with poorer relationship quality at T3. Placement instability also had a small significant association with emotional and behavioural difficulties at T3 (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.19, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Sex and PIR-GAS at T1 showed a weak but significant correlation (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.20, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), indicating that higher quality relationship is reported with females as compared to males. Age at T1 showed a weak but significant correlation with PIR-GAS T1 (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.23, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and emotional and behavioural difficulties at T3 (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.18, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), indicating that older age at entry to care is associated with better relationship quality ratings at T1 and higher emotional and behavioural difficulties at T3.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDescriptives of Variables\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMin\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMax\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (T1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePIR-GAS T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePIR-GAS T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional \u0026amp; behavioural difficulty T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;1.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional \u0026amp; behavioural difficulty T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDQ raw score T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDQ raw score T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eITSEA internalising raw score T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eITSEA externalising raw score T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eITSEA internalising raw score T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eITSEA externalising raw score T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eCorrelations Among Variables\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.PIR-GAS T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. PIR-GAS T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Emotional \u0026amp; behavioural difficulties T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Emotional \u0026amp; behavioural difficulties T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.30*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.Placement instability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.34*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.19*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.20*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Age T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.23*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.18*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNote *significant at p\u0026thinsp;\u0026le;\u0026thinsp;0.05.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eMultiple Regression\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e summarises the results from the multiple regression analysis with emotional and behavioural difficulties at T3 as the outcome. The first model uses PIR-GAS score at T1 as the predictor and the second model uses PIR-GAS change score as the predictor (calculated by subtracting PIR-GAS score at T3 from PIR-GAS score at T1). Model 1 (F(5,108)\u0026thinsp;=\u0026thinsp;2.40, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04) explained 10% of the variance in child emotional and behavioural difficulties at T3, with an adjusted R\u0026sup2; of 0.06. Model 2 (F(5,68)\u0026thinsp;=\u0026thinsp;1.91, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.10) explained 12.3% of the variance in child emotional and behavioural difficulties at T3, with an adjusted R\u0026sup2; of 0.06. In both models, only child emotional and behavioural difficulties at T1 was a significant predictor of the outcome at T3. None of the other predictors had a significant effect, meaning that the quality of carer-child relationship at T1, or the change in this relationship, did not predict child emotional and behavioural difficulties at T3 above and beyond other variables considered, which also did not present with any significant effects on the outcome.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eMultiple Regression Models Examining Unique Effects on Child Emotional \u0026amp; Behavioural Difficulties at T3\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eModel 1\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eb\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePIR-GAS score T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlacement instability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild emotional \u0026amp; behavioural difficulties T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.28*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3:03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eModel 2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePIR-GAS change score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlacement instability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild emotional \u0026amp; behavioural difficulties T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.32*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u0026thinsp;\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNote *\u003c/em\u003esignificant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCross Lagged Panel Model\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below shows the cross lagged panel model, depicting the direction of the paths between PIR-GAS score and child emotional and behavioural difficulties score over time. The figure includes the standardised regression coefficients. This model was estimated using a proportion of the total sample (n\u0026thinsp;=\u0026thinsp;146) due to missing child emotional and behavioural difficulties scores at T1. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, there is no stability in PIR-GAS scores from T1 to T3 (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.11, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.200). There was some stability in emotional and behavioural difficulties scores from T1 to T3 (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.31, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). None of the cross lagged effects were significant, and both very small. The model explained 10% of the variance in emotional and behavioural difficulties at T3 and 1.5% of the variance in PIR-GAS scores at T3. The sensitivity analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), using only complete data across T1 and T3 (n\u0026thinsp;=\u0026thinsp;101), yielded similar results.\u003c/p\u003e \u003cp\u003eBased on these findings, further exploratory analysis was completed to examine the differences in PIR-GAS and emotional and behavioural difficulty scores between T1 and T3. The distribution of change scores were assessed by visually examining the histogram, with no issues noted with normality. Two paired samples t-tests were performed to compare the difference in PIR-GAS scores and in emotional and behavioural difficulties between T1 and T3. There was a significant difference, with higher PIR-GAS scores at T3 (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;85.00 \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10.58) than at T1 (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;80.07 \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13.58), t(100)\u0026thinsp;=\u0026thinsp;1.99, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0495 with a 95% mean difference confidence interval\u0026thinsp;=\u0026thinsp;0.006, 6.092. The effect size as measured by Cohen\u0026rsquo;s d was d\u0026thinsp;=\u0026thinsp;0.31, indicating a small effect. The findings indicate that the overall relationship quality between carer and child is rated as significantly better at T3 compared to T1. In terms of emotional and behavioural difficulties, the t-test showed no significant difference between the emotional and behavioural difficulty scores at T1 (M\u0026thinsp;=\u0026thinsp;0.02, SD\u0026thinsp;=\u0026thinsp;0.91) and T3 (M\u0026thinsp;=\u0026thinsp;0.00, SD\u0026thinsp;=\u0026thinsp;1.00), t(125)\u0026thinsp;=\u0026thinsp;0.86, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.39, with a 95% mean difference confidence interval\u0026thinsp;=\u0026thinsp;0.11, 0.28. The effect size as measured by Cohen\u0026rsquo;s d was d\u0026thinsp;=\u0026thinsp;0.02, indicating a very small effect; this is consistent with the stability noted in earlier analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this study provide insight into how relationship quality between carer and child change over time spent in care, and the degree to which these relationships are implicated in the emotional and behavioural outcomes for the child. This study shows that the quality of the relationship between carer and child over time does not predict emotional and behavioural outcomes for the child, but the overall quality of this relationship is significantly better later in the child’s journey in care than early on.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePlacement instability\u003c/h2\u003e \u003cp\u003eConsistent with literature highlighting the negative impact of placement instability on children’s mental health outcomes [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], placement instability at time in this study was significantly associated with poorer relationship quality and higher emotional and behavioural difficulties 2.5 years later. This is further evidence that the history of placement instability is a risk factor for negative outcomes. It is important to note that in this sample, the first entry to care for the majority of the children (88%) was at the time of entering this study. This could be due to the young age of the children at Time 1, with the average age of the child being under one years of age. Nonetheless, even at this young age, the presence of early instability had an effect on relationship quality and emotional and behavioural outcomes. The foster care system in the UK is unstable relative to that of other countries. In Scotland, many children experience repeated short-term episodes of foster care, specifically in Glasgow where two thirds of children who returned home re-entered the care system, often being referred to the ‘revolving door effect’ [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. It is important to invest in supportive and stable placements for children to ensure we promote healthy development and functioning [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Relationship quality is a crucial factor in maintaining supportive and safe placements [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eEffect of relationship quality on emotional and behavioural outcomes\u003c/h2\u003e \u003cp\u003eBased on the importance of the relationship quality between child and carer, it was expected that better quality of the relationship would be associated and predictive of lower emotional and behavioural difficulties for the child. However, the results from this study found that the quality of the child’s relationship with their foster carer did not predict later emotional and behavioural difficulties. Similarly, sex, age at entry to care and placement instability also did not predict later emotional and behavioural difficulties. The only predictor of later emotional and behavioural difficulties was baseline emotional and behavioural difficulties, with no differences in average difficulties between baseline and two and a half years in care into their time in care during the study.\u003c/p\u003e \u003cp\u003eThis is an important finding to consider, as to why when a child is placed in nurturing foster care do we not see improvement in their emotional and behavioural functioning over time. Research has shown that stable mental health profiles are the most common in care experienced children and young people and much less likely for children’s mental health trajectory to change over time in care [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Our findings show similar results. Another important consideration with children who have been abused and neglected is that as a group they are much more likely to have heritable neurodevelopmental conditions than their peers (not caused by abuse and neglect) [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Minnis [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] suggests that if the high rates of neurodevelopmental problems within this population are not due to the environment they are placed in, but more due to inherited difficulties, then it would not be expected that being placed in foster care would be able to ‘treat’ the difficulties, which again may speak to the stability of some of the emotional and behavioural difficulties measured in our study. This means that this group of children would require comprehensive mental health assessment and individualized treatment, and care placement alone, even when the quality of child-carer relationship is good or improves, is not sufficient to address emotional and behavioural difficulties.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStability in carer-child relationships\u003c/h2\u003e \u003cp\u003eThe lack of stability in the quality of the relationship between carer and child over time spent in care highlights the dynamic and evolving nature of relationships between foster carer and child. Nonetheless the relationship between carer and child improves over time spent in care, in part explaining the lack of stability. This is a hopeful finding for care experienced children, as it shows the ability to improve a relationship with a caregiver over time spent in care, irrespective of their mental health and initial relationship quality. This suggests that, whilst living in foster care, an environment which is hopefully stable and nurturing, and given the time, children are able to build connections with their caregiver and develop positive relationships. This is the first study we are aware of that has looked at this relationship over time using validated tools. It will be important to see how this relationship continues to change over a longer period of time in care, and for children at different developmental stages.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and future directions\u003c/h2\u003e \u003cp\u003eThis is a novel study that examined how the quality of carer-child relationship changes over a period of time a child is in foster care and how this relates to child mental health, in a representative sample of young children in care. Although the sample size in this study was smaller than initially anticipated, due to missing data on the variables of interest, there was still sufficient information to answer the questions of interest. Further, attrition commonly occurs in longitudinal research, and in this study, it may also have been influenced by the COVID-19 pandemic, which occurred during the data collection period. The sensitivity analysis conducted using the subsample with complete data at Time 1 and 2 suggests that there is no bias resulting from attrition or missingness. Further, as reported in the main trial paper, there were no differences in between those who completed follow ups from those who dropped out [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e "},{"header":"Conclusions and implications","content":"\u003cp\u003eOverall, the findings from this study highlight the variable nature of relationships between carer and child and how they evolve over time, finding no stability in individual relationships but an improvement in the group as a whole over 2.5 years. As the quality of the relationship does not predict emotional and behavioural outcomes, there must be other factors which are influencing the emotional and behavioural difficulties of children in foster care, with a small effect observed due to initial placement instability. This highlights a need for further longitudinal research to better understand these relationships, and how they might support improvements in emotional and behavioural wellbeing of children in foster care. The results from this study show that simply placing a child in foster care and removing them from a neglectful and/or abusive home environment, does not, by itself, improve their emotional and behavioural outcomes. This highlights the need for other measures to be put in place, including follow up assessments and the use of evidence-based treatment and management strategies which are tailored to care experienced children, in order to improve the long-term outcomes for this population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe BeST\u003csup\u003e?\u003c/sup\u003e trial was sponsored by NHS GG\u0026amp;C, coordinated on behalf of the National Institute of Health Research by Glasgow University Institute of Health and Wellbeing. The author has no competing interests to declare.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEthical Information\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe BeST\u003csup\u003e?\u003c/sup\u003e Trial was approved by the West of Scotland Research Ethics Service, Committee 3 (approval number 15/WS/0280) and this current study was covered within the project\u0026rsquo;s ethical approval [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Informed written consent was obtained from all carers and each child (participant) in the study was assigned a unique ID number to link their data throughout the trial in order to maintain confidentiality.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eR.S and J.R wrote the main manuscript text. H.M reviewed the manuscript of the text.K.C supported the preparation of the data and supported PIR-GAS training to rate the video recordings.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAs the findings of this paper are based on data from a larger trial, all data requests will have to be submitted to the chief investigator (H.M.) and then will be reviewed and considered by the Trial Management Group (TMG).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHornor G (2019) Attachment disorders. J Pediatr health care 33(5):612\u0026ndash;622\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrather W, Golden JA (2009) A behavioral perspective of childhood trauma and attachment issues: Toward alternative treatment approaches for children with a history of abuse. Int J Behav Consultation Therapy 5(1):56\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDepartment for Education (DfE) (2022a) Children looked after in England including adoption. London: Department for Education (DfE). Accessed 2024: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://explore-education-statistics.service.gov.uk/find-statistics/children-looked-after-in-england-including-adoptions\u003c/span\u003e\u003cspan address=\"https://explore-education-statistics.service.gov.uk/find-statistics/children-looked-after-in-england-including-adoptions\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScottish Government (2023a) Children's social work statistics Scotland: 2021 to 2022. Edinburgh: Scottish Government. Accessed 2024 from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gov.scot/publications/childrens-social-work-statistics-scotland-2021-22/\u003c/span\u003e\u003cspan address=\"https://www.gov.scot/publications/childrens-social-work-statistics-scotland-2021-22/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNICE guideline, Looked- after children and young people (2021) Accessed 2022 from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nice.org.uk/guidance/ng205\u003c/span\u003e\u003cspan address=\"https://www.nice.org.uk/guidance/ng205\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFelitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Marks JS (1998) Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 14(4):245\u0026ndash;258\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiming KW, Akin B, Brook J (2021) Adverse childhood experiences and foster care placement stability. Pediatrics, 148(6), e2021052700\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTurner, M., Beckwith, H., Duschinsky, R., Forslund, T., Foster, S. L., Coughlan, B.,\u0026hellip; Carloe Schuengel, P. (2019). Attachment difficulties and disorders. InnovAiT, 12(4), 173\u0026ndash;179.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowlby J (1969) \u003cem\u003eAttachment and loss\u003c/em\u003e (No. 79). Random House\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRibera LB, Longobardi C, Prino LE, Fabris MA (2023) Secure attachment to mother and children\u0026rsquo;s psychological adjustment: The mediating role of pet attachment. Anthrozo\u0026ouml;s 36(2):279\u0026ndash;293\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eColonnesi C, Draijer EM, Jan JM, Stams G, Van der Bruggen CO, B\u0026ouml;gels SM, Noom MJ (2011) The relation between insecure attachment and child anxiety: A meta-analytic review. J Clin Child Adolesc Psychol 40(4):630\u0026ndash;645\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrumariu LE, Kerns KA (2010) Parent\u0026ndash;child attachment and internalizing symptoms in childhood and adolescence: A review of empirical findings and future directions. Dev Psychopathol 22(1):177\u0026ndash;203\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVasileva M, Petermann F (2018) Attachment, development, and mental health in abused and neglected preschool children in foster care: A meta-analysis. Trauma Violence Abuse 19(4):443\u0026ndash;458\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliveira, P., Barge, L., Stevens, E., Byford, S., Shearer, J., Spies, R., \u0026hellip; Fearon,P. (2022). Children in foster care with symptoms of reactive attachment disorder:feasibility randomised controlled trial of a modified video-feedback parenting intervention.BJPsych Open, 8(4), e134.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRom\u0026aacute;n M, Palacios J, Minnis H (2022) Changes in Attachment Disorder symptoms in children internationally adopted and in residential care. Child Abuse Negl 130:105308\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuttmann-Steinmetz S, Crowell JA (2006) Attachment and externalizing disorders: A developmental psychopathology perspective. J Am Acad Child Adolesc Psychiatry 45(4):440\u0026ndash;451\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLohr WD, Jones VF (2016) Mental health issues in foster care. Pediatr Ann 45(10):e342\u0026ndash;e348\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHillen T, Gafson L (2015) Why good placements matter: Pre-placement and placement risk factors associated with mental health disorders in pre-school children in foster care. Clin Child Psychol Psychiatry 20(3):486\u0026ndash;499\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEngler AD, Sarpong KO, Van Horne BS, Greeley CS, Keefe RJ (2022) A systematic review of mental health disorders of children in foster care. Trauma Violence Abuse 23(1):255\u0026ndash;264\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVanschoonlandt F, Vanderfaeillie J, Van Holen F, De Maeyer S, Robberechts M (2013) Externalizing problems in young foster children: Prevalence rates, predictors and service use. Child Youth Serv Rev 35(4):716\u0026ndash;724\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCullen GJ, Yule C, Walters D, O\u0026rsquo;Grady W (2022) Mental health outcomes of youth in-care: Investigating the effect of general strain and self-control theories. Child Adolesc Soc Work J 39(4):409\u0026ndash;423\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMishra AA, Schwab-Reese LM, Murfree LV (2020) Adverse childhood experiences associated with children\u0026rsquo;s patterns of out of home placement over time and subsequent negative outcomes during adolescence. Child \u0026amp; youth care forum, vol 49. Springer US, pp 247\u0026ndash;263\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDelaville E, Pennequin V (2020) Foster placement disruptions in France: Effects on children and adolescents\u0026rsquo; emotional regulation. Child Adolesc Soc Work J 37(5):527\u0026ndash;536\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBederian-Gardner, D., Hobbs, S. D., Ogle, C. M., Goodman, G. S., Cord\u0026oacute;n, I. M., Bakanosky,S., \u0026hellip; NYTD/CYTD Research Group. (2018). Instability in the lives of foster and nonfoster youth: Mental health impediments and attachment insecurities. Children and Youth Services Review, 84, 159\u0026ndash;167.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGuire A, Cho B, Huffhines L, Gusler S, Brown S, Jackson Y (2018) The relation between dimensions of maltreatment, placement instability, and mental health among youth in foster care. Child Abuse Negl 86:10\u0026ndash;21\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFernandez E (2008) Psychosocial wellbeing of children in care: A longitudinal study of outcomes. Child Indic Res 1(3):303\u0026ndash;320\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProctor LJ, Skriner LC, Roesch S, Litrownik AJ (2010) Trajectories of behavioral adjustment following early placement in foster care: Predicting stability and change over 8 years. J Am Acad Child Adolesc Psychiatry 49(5):464\u0026ndash;473\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrawford K, Fitzpatick B, McMahon L, Forde M, Miller S, McConnachie A, Minnis H (2022) The Best Services Trial (BeST?): a cluster randomised controlled trial comparing the clinical and cost-effectiveness of New Orleans Intervention Model with services as usual (SAU) for infants and young children entering care. Trials 23(1):1\u0026ndash;16\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoodman R (1997) The Strengths and Difficulties Questionnaire: a research note. J Child Psychol Psychiatry 38(5):581\u0026ndash;586\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBriggs-Gowan MJ, Carter AS (2006) \u003cem\u003eBrief Infant Toddler Social Emotional Assessment (BITSEA)\u003c/em\u003e [Database record]. APA PsycTests. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/t14990-000\u003c/span\u003e\u003cspan address=\"10.1037/t14990-000\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCroft S, Stride C, Maughan B, Rowe R (2015) Validity of the strengths and difficulties questionnaire in preschool-aged children. Pediatrics 135(5):e1210\u0026ndash;e1219\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoodman R (2001) Psychometric properties of the strengths and difficulties questionnaire. J Am Acad Child Adolesc Psychiatry 40(11):1337\u0026ndash;1345\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarter AS, Briggs-Gowan MJ, Jones SM, Little TD (2003) The infant\u0026ndash;toddler social and emotional assessment (ITSEA): Factor structure, reliability, and validity. J Abnorm Child Psychol 31:495\u0026ndash;514\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZero to Three/National Center for Clinical Infant Programs, Arlington VA (1994) Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. ERIC Clearinghouse, Diagnostic Classification, pp 0\u0026ndash;3\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026uuml;ller, J. M., Achtergarde, S., Frantzmann, H., Steinberg, K., Skorozhenina, O., Beyer,T., \u0026hellip; Postert, C. (2013). Inter-rater reliability and aspects of validity of the parent-infant relationship global assessment scale (PIR-GAS). Child and Adolescent Psychiatry and Mental Health, 7, 1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosseel Y (2012) Lavaan: An R package for structural equation modeling and more. Version 0.5\u0026ndash;12 (BETA). J Stat Softw 48(2):1\u0026ndash;36\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuan KH, Bentler PM (2000) 5. Three likelihood-based methods for mean and covariance structure analysis with nonnormal missing data. Sociol Methodol 30(1):165\u0026ndash;200\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKline RB (2005) Principles and practice of structural equation modeling. Guilford Press\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaguire D, May K, McCormack D, Fosker T (2024) A Systematic Review of the Impact of Placement Instability on Emotional and Behavioural Outcomes Among Children in Foster Care. J Child Adolesc Trauma, 1\u0026ndash;15\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinnis H, Bryce G, Phin L, Wilson P (2010) The Spirit of New Orleans: translating a model of intervention with maltreated children and their families for the Glasgow context. Clin Child Psychol Psychiatry 15(4):497\u0026ndash;509\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsif N, Breen C, Wells R (2024) Influence of placement stability on developmental outcomes of children and young people in out-of-home care: Findings from the Pathways of Care Longitudinal Study. Child Abuse Negl 149:106145\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller L, Randle M, Dolnicar S (2019) Carer factors associated with foster-placement success and breakdown. Br J social work 49(2):503\u0026ndash;522\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiller RM, Fraser A, Denne M, Bauer A, Halligan SL (2023) The development of young peoples\u0026rsquo; internalising and externalising difficulties over the first three-years in the public care system. Child Maltreat 28(1):141\u0026ndash;151\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDinkler L, Lundstr\u0026ouml;m S, Gajwani R, Lichtenstein P, Gillberg C, Minnis H (2017) Maltreatment-associated neurodevelopmental disorders: A co‐twin control analysis. J Child Psychol Psychiatry 58(6):691\u0026ndash;701\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinnis H (2023) Science into policy for the benefit of children: the Bucharest early intervention project. Am J Psychiatry 180(8):528\u0026ndash;529\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrawford, K., Young, R., Wilson, P., Deidda, M., Forde, M., Millar, S., \u0026hellip; Minnis,H. (2025). Infant mental health services for birth and foster families of maltreated pre-school children in foster care (BeST?): a cluster-randomized phase 3 clinical effectiveness trial. Nature medicine, 1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-child-and-adolescent-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ecap","sideBox":"Learn more about [European Child \u0026 Adolescent Psychiatry](http://link.springer.com/journal/787)","snPcode":"787","submissionUrl":"https://submission.nature.com/new-submission/787/3","title":"European Child \u0026 Adolescent Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Foster care, placement instability, mental health, carer-child relationship quality","lastPublishedDoi":"10.21203/rs.3.rs-6828302/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6828302/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEarly relationships between a caregiver and their child set the foundations for many aspects of the child\u0026rsquo;s development [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Exposure to abuse or neglect can negatively impact the security and stability within these early relationships [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The aim of this project was to characterise the association between carer-child relationship quality and child\u0026rsquo;s mental health over time.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData for 220 children, collected between 2011\u0026ndash;2022 as part of the Best Services Trial (BeST\u003csup\u003e?\u003c/sup\u003e) were used. Relationship quality was assessed using Parent-Infant Relationship Global Assessment Scale (PIR-GAS), and child emotional and behavioural difficulties was assessed using the Strengths and Difficulties Questionnaire (SDQ) and The Infant Toddler Social Emotional Assessment (ITSEA). Data was examined from two time points, a few weeks after entering care and after 2.5 years.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe quality of the carer-child relationship did not predict emotional and behavioural outcomes for the child at a later time point. Nonetheless, we found that overall children had significantly better relationships with their carers at the 2.5 year follow up than at baseline.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis highlights a need for specific tailored interventions for care experienced children, to support their emotional and behavioural needs and improve long term outcomes.\u003c/p\u003e","manuscriptTitle":"A longitudinal study examining the effect of carer-child relationship quality on child’s emotional and behavioural difficulties while in foster care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-01 06:24:51","doi":"10.21203/rs.3.rs-6828302/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-15T21:17:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-05T10:45:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"83068922854393760288816372531840318598","date":"2025-08-21T02:48:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62737843833793318125201392886685826173","date":"2025-08-19T13:45:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330451048320988126551606612680714576391","date":"2025-08-15T20:20:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-13T07:37:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277842121355305904732405814189573577260","date":"2025-06-26T07:54:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-23T22:25:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-07T04:33:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-07T04:30:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Child \u0026 Adolescent Psychiatry","date":"2025-06-05T10:33:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-child-and-adolescent-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ecap","sideBox":"Learn more about [European Child \u0026 Adolescent Psychiatry](http://link.springer.com/journal/787)","snPcode":"787","submissionUrl":"https://submission.nature.com/new-submission/787/3","title":"European Child \u0026 Adolescent Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"3f46105f-ca43-41e9-8c3f-43ada9b24d42","owner":[],"postedDate":"July 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:11:36+00:00","versionOfRecord":{"articleIdentity":"rs-6828302","link":"https://doi.org/10.1007/s00787-025-02900-9","journal":{"identity":"european-child-and-adolescent-psychiatry","isVorOnly":false,"title":"European Child \u0026 Adolescent Psychiatry"},"publishedOn":"2025-11-10 15:58:31","publishedOnDateReadable":"November 10th, 2025"},"versionCreatedAt":"2025-07-01 06:24:51","video":"","vorDoi":"10.1007/s00787-025-02900-9","vorDoiUrl":"https://doi.org/10.1007/s00787-025-02900-9","workflowStages":[]},"version":"v1","identity":"rs-6828302","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6828302","identity":"rs-6828302","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}