Caregivers’ experiences of therapeutic
support for children exposed to
developmental trauma
Megan Middlemiss, Lisa Caygill, Sarah Craven-Staines and Joyce Powell
Megan Middlemiss is
based at the South Durham
CAMHS, Tees Esk and
Wear Valleys NHS
Foundation Trust, Durham,
UK. Lisa Caygill is based at
the School of Social
Sciences and Law,
Teesside University,
Middlesbrough, UK.
Sarah Craven-Staines is
based at the Teesside
University, Middlesbrough,
UK. Joyce Powell is based
at the Children and Young
People’s Services, Tees
Esk and Wear Valleys NHS
Foundation Trust, Durham,
UK.
Received 4 February 2021
Revised 6 October 2021
Accepted 8 February 2022
The authors would like to thank
the caregivers who took part
in the study, for without them this
research would not have been
possible. The authors appreciate
their openness and honesty
when sharing their stories
and remain inspired by their
compassion and resilience. The
authors also give thanks to the
professionals and services that
supported recruitment. The
authors hope that together they
have produced something
valuable.
PAGE 212 j MENTAL HEALTH REVIEW JOURNAL j VOL. 27 NO. 2 2022, pp. 212-225, © Emerald Publishing Limited, ISSN 1361-9322
Abstract
Purpose – Exposure to trauma in childhood can have lasting impacts upon development and
psychological well-being. Services can be sought to help young people heal from their experiences;
however, literature suggests that their care may not always be trauma-informed. This paper aims to
generate a theory to explain caregivers’ experiences of accessing mental health and therapeutic
services for young people exposed to developmental trauma.
Design/methodology/approach – A constructivist grounded theory approach was used, using an
iterative process of data collection and analysis. Nine individuals including foster carers, adoptive
parents and a special guardian were interviewed following purposive and theoretical sampling.
Techniques of initial, focused and theoretical coding, alongside constant comparative analysis were
used to develop the end theory.
Findings – The theory demonstrates that multiple factors can impact upon caregivers’ experiences
when accessing support for young people exposed to trauma. Six themes emerged documenting
caregivers’ journeys from the decision to seek support to the ending of service involvement. Barriers,
challenges and positive experiences are described. Results are contextualised through consideration of
wider organisations and systems.
Originality/value – The theory highlights challenges caregivers face when accessing mental health and
therapeutic support for young people exposed to developmental trauma. It provides new insights into
what caregivers consider to be trauma-informed experiences of care in these settings. Tentative
recommendations are provided in the hope of improving future care.
Keywords CAMHS, Looked after children, Trauma-informed care, Developmental trauma,
Parents, Carers, Grounded theory
Paper type Research paper
xposure to trauma in childhood has the potential to impact on psychological well-
E being and functioning throughout the lifespan, particularly if experienced within the
context of a caregiving relationship (Crittenden, 2006). Experiences of trauma can
be direct, such as interpersonal abuse, or affect the young person’s environment in which
they live, for example, through witnessing parental domestic violence (van der Kolk et al.,
2009). Statistics indicate that exposure to abuse and/or neglect is the primary reason
children are taken into care, accounting for 63% of the looked after population (DfE, 2019).
For some young people trauma can prevail, as the transition into care can be emotive and
distressing. Especially for those who experience multiple placement moves, thus a succession
of transitions and losses (Golding, 2007; Stanley et al., 2005). When experiences and impacts of
trauma are multiple and prolonged, literature defines this as either type II, complex, interpersonal
or developmental trauma (Kisiel et al., 2014). For the purpose of this research, “developmental
trauma” is preferred, as it encompasses wide-ranging experiences of childhood trauma, with
specific reference to those occurring in caregiving relationships (van der Kolk et al., 2009).
DOI 10.1108/MHRJ-02-2021-0010
The mental health needs of children living in care are complex, as they may experience
inattention, hyperactivity, emotional and self-esteem difficulties, alongside attachment and
relational difficulties (Tarren-Sweeney, 2008; van der Kolk et al., 2009). Thus to help children
heal from the impacts of developmental trauma, safe, supportive environments and
caregiving relationships are imperative (Golding, 2007). Appropriately skilled services, such
as Child and Adolescent Mental Health Services (CAMHS), may also be required to support
the recovery process. However, research suggests that there may be challenges in
accessing these (Rao et al., 2010).
For children who have experienced developmental trauma, barriers can be encountered, as
presenting concerns are rarely consistent with diagnostic criteria (Ratnayake et al., 2014).
This is problematic as an enquiry by the House of Commons Education Committee (2016)
found that although CAMHS differs across localities, many hold medicalised service criteria.
The enquiry also noted that due to a climate of reduced funding, specialist teams for
children who are looked after had often been “abolished”.
Further barriers can exist when accessing mental health services, as foster carers have
reported feeling unheard when trying to explain their young person’s difficulties (e.g. how
they develop due to early neglect and abuse, separation, loss and adjustment in the care
system). They then found long waiting times, particularly for specialist services. York and
Jones (2017) explained how this risks disengagement, leaving families to cope alone.
Caregivers describe how parenting children exposed to trauma is rewarding, although they
can face challenges which impact upon their own well-being (Blythe et al., 2014). This
included re-enactment of past trauma (the compulsive repetition of past traumatic
relationships in the context of a new relationship; Delaney, 2006) and secondary trauma
(caregivers’ emotional distress leading to burnout; Hannah and Woolgar, 2018). In turn,
caregivers recognise a need for support for themselves which is not often available (York
and Jones, 2017).
This seems particularly important as children with developmental trauma often face difficulties
in learning, concentrating and social interaction thus, accessing education can bring
challenges (Barratt, 2012). Research indicates that children with histories of maltreatment,
have lower educational achievement and higher rates of absences, compared to children
without such histories (Stagman and Cooper, 2010). Moreover, exclusion rates are higher
among adopted children in comparison to the general school population (Armstrong-Brown
and White, 2015). This in turn places further burden upon caregivers.
Placements can be at risk if caregivers feel stressed or unable to cope; leading to further
exacerbation of the child’s mental health difficulties (Hannah and Woolgar, 2018). Holistic
support is needed from appropriately skilled therapeutic services to aid good psychological
health and resilience in caregivers (Silver et al., 2015). Caregivers have reported finding
interventions helpful when they were involved in the treatment process. This provided them
with insight into their young person’s feelings reducing their own parental-anxiety and
helplessness around how to foster recovery between sessions (Williamson et al., 2019).
It has also been found that adolescents engaged with mental health services generally
appreciate occasions when professionals liaise with their teachers to explain their difficulties
and discuss helpful strategies (Coyne et al., 2015). Further research suggests enhancing
teacher’s knowledge of trauma has positive impacts (McIntyre et al., 2019). Currently, the
government is working to ensure a multiagency approach for all children who experience
difficulties with their mental health, aiming for every school and college to have a
designated mental health lead by the year 2025 (DoH and DfE, 2017).
In summary, there is a duty for the systems around a young person and their caregivers to
work in partnership, holding an integrative approach that acknowledges the experiences
and impacts of developmental trauma. This requires mental health professionals, social
care and education to maintain a holistic view of the children they support, considering past

VOL. 27 NO. 2 2022 j MENTAL HEALTH REVIEW JOURNAL j PAGE 213

 and current experiences at home, school and other environments (House of Commons
Education Committee, 2016).

Purpose of study
Exposure to developmental trauma can have profound impacts upon well-being and
functioning across the lifespan. Due to the complexity and impact of secondary trauma
upon caregivers, support from mental health and therapeutic services are often required.
However, services are not always considered to be operating in ways that meet their
systemic needs. Emerging literature suggests a paradigm shift, for services to become
trauma-informed, seeking to create positive therapeutic alliances, engender trust and safety
and promote choice and empowerment for trauma survivors (Sweeney and Taggart, 2018).
Central to the ethos of trauma-informed care is involving those with lived experiences in the
development (Sweeney and Taggart, 2018). Caregivers are in an ideal position to provide a
perspective of accessing mental health and therapeutic services, specifically for their
young people who have exposure to developmental trauma. This can illuminate barriers,
challenges and positive practices due to their frequent role in navigating their young
person’s journey of seeking and receiving support.

Study aims
The research aimed to interview caregivers’ about their experiences of accessing
mental health and therapeutic services, within the NHS and Local Authority, for their
young person who had experienced developmental trauma. This is a unique population
in which the holistic experience of mental health care is under researched, specifically
from caregivers’ perspectives. Grounded theory (GT) was used to develop a theoretical
model detailing what helps and hinders a trauma-informed approach to mental health
care.

Method
GT was applied, using an inductive approach. The method allows for the development of a
theoretical framework that is grounded in the data gathered. This provides space for new,
contextualised theories, which are uninfluenced by pre-existing analytical constructs
(Charmaz, 2014).
Constructivist GT is underpinned by a social constructivist perspective, where reality and
knowledge are actively constructed through social situations, relationships and language.
This acknowledges that the researcher is inherently part of the world being studied, such as
their background, beliefs and research practices. Techniques are in place to ensure
reflexivity and validity such as respondent validation, although constructivist GT holds the
fundamental perception that there is not one truth, instead there are multiple truths
(Charmaz, 2014).

Research design
Semi-structured interviews were used for data collection following principles of
constructivist GT (Charmaz, 2014). Interview schedules sought to gather the holistic
experiences of accessing services. They were modified through the data collection
process to allow for further investigation in emerging areas of meaning and
importance. Interviews were conducted individually, between the lead researcher
and participant, either at the participant’s home, or a local authority or NHS setting of
their choice.

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Participants
Recruiting sites included three CAMHS and a Local Authority therapeutic service for
children who are looked after in the North East of England. All participants were caregivers
of children who had experiences of developmental trauma.
Purposive sampling was first used, followed by theoretical sampling to assist identification of
new participants to saturate developing categories. Nine people participated in the research
(eight female and one male). The sample included five foster carers, three adoptive parents
and one special guardian. The age of the young people in their care ranged from 9 to 16 years
old, having been in their care from 2 to 14.5 years. Theoretical sampling and constant
comparative analysis continued until theoretical sufficiency was reached.

Procedure
Potential participants were informed of the study via gatekeepers (involved professionals)
using a participant information sheet. If interested, they contacted the lead researcher to
discuss and arrange participation. Interviews were conducted in a sensitive a manner and
the well-being of participants was monitored throughout. All interviews were then
transcribed verbatim by the lead researcher. Procedures surrounding informed consent
and right to withdraw were maintained.
Prior to the study taking place, ethical approval was first obtained from the University Ethics
Board. Approval was then obtained from the Heath Research Authority, attending their
panel and discussing any ethical issues that may arise, followed by the Local Authority
Research Approval group. This was to enable both NHS and local authority recruitment.
Alongside this, the research adhered to the Data Protection Act (1998) and the British
Psychological Society’s Code of Ethics and Conduct (BPS, 2009). For example, in
maintaining confidentiality and ensuring participants had an understanding of if/when this
would be broken in regards to risk and safeguarding.

Data analysis
All aspects of analysis and interpretation of data were informed by the constructivist GT
approach (Charmaz, 2014). This included transcription followed by three levels of coding
(initial, focused then theoretical). The constant comparative method was used to reach the
point of theoretical sufficiency. Although the first author (MM) took the lead on this,
triangulation was embedded into the analysis with the other authors (SCS, LC and JP). This
included comparison of our own individual coding from transcripts and the development of
themes that constitute to the end GT. Keeping memos, journals and diagramming aided the
whole analysis process.

Results
The GT is presented diagrammatically in Figure 1, titled after a participant’s quote: “having
to get into the ring with a professional boxer after you’ve just finished a marathon”. The
quote is a metaphor, with “The Marathon” representing the experience of seeking support
and “The Boxing Ring” experiences of accessing support. Through the data analysis
process, this journey notably was evident within a number of other participant’s narratives.
It was felt by researchers that the quote provided a visual and tangible way to contextualise
complex experiences held within the transcripts. Following which, a decision was then
made to extend the use of metaphors, for example, adding “The Dance”. This was felt to
provide contrast to “The Boxing Ring”, whilst representing the relational nature of the
themes within it as a term familiar to attachment theory and literature around children looked
after (Goldsmith, 2010; van Gulden and Vick, 2005).

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 Figure 1 The end grounded theory: “having to get into the ring with a professional boxer
after you’ve just finished a marathon”

Multiple
The World Around arenas

Fist-to-fist
The Boxing Ring The wrong
The Marathon division
Between
rounds
The fight

The Parent-Carer
Experience
Loss

The starting line

The finish line

Stuck at the

False start
Moving Forward Empowerment

gate
Hope for the
future
Taking the
lead
In sync
Joining the
dance
The Dance
A close hold
An alternative
route

Engaging the Joining of the

audience worlds

The model depicts six categories in total; those within the grey oval contain caregivers’
experiences of accessing mental health and therapeutic services. Categories which overlap the
grey oval indicate an interaction with the wider systems and organisations in their young
people’s lives.
Eight, of nine, participants provided feedback on the developed model. There was
particular reference to the metaphors used in the feedback, finding the categories
resonated with and captured their experiences. No amendments were suggested:
I feel honoured that you have listened so well to what we said, I feel you have given us a chance
to be heard. (P2)

I love the fact you’ve used the analogy as the basis of the title and your model. I was really glad to
see the’World Around’ aspect - I think it sets families’ experiences in a more realistic context. (P4)

The parent–carer experience

Parenting a young person who has experienced trauma although rewarding can be difficult.
Participants conveyed love and affection, alongside challenges. These most often arose in
connection to the trauma their child experienced:
I couldn’t love him more, he’s just incredible [. . .] he’s also very challenging and tiring, living with
a child with attachment difficulties is knackering [. . .]. (P4)

She’d be chucking things at us, breaking stuff, I mean you’ve never heard a door slam like that,
she ended up breaking her door. (P7)

Caregivers described experiences of secondary trauma, having strong emotional bonds

with their young person and witnessing their distress:
I know she’s my foster child but she’s my child. It’s hard seeing my child in that emotional turmoil. (P2)

I love them and to know that whatever’s happened to them has happened to them, it’s horrific.
(P9)

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The marathon

The starting line. Caregivers explained their decision to seek support, often they felt at a
loss of how best to support their child after exhausting their own resources:
We just didn’t have a clue [. . .] what to do. (P1)

To get to a point where you’re going to CAMHS, you’ve got to be desperate [. . .] because you are
admitting to yourself you can’t do it on your own, you can’t do it as a parent and that is a big thing
for a parent to admit. (P8)

Stuck at the gate. However, accessing mental health support for their child frequently led to
challenges. One of which was when gatekeeping services dismissed their requests:
I’ve asked the doctor for help and when I’ve phoned social services they don’t want to know. (P5)

Caregivers described a lack of compassion towards their needs, situation and young
person when communicating with gatekeeping professionals across a range of universal
services:
I was sort of grabbing photos of him saying “this is who we’re talking about here. (P4)

On occasions when referrals were made, caregivers again encountered obstacles due to
processes in place, leading them to feel lost in the system:
They said that our children were too complex for them [CAMHS]. Erm [. . .] that it didn’t lie with
them. At the time that was absolutely horrific, terrifying [. . .]. (P3)

False start. After navigating gatekeeping services, some caregivers described initial
contact with mental health and therapeutic services as disheartening when informed they
were managing their child’s difficulties well enough. This portrayed a message that no
further help was available:
It was said that we were probably managing her well enough and that she didn’t need CAMHS.
(P2)

Conversely, some caregivers felt criticised or that their young person’s needs were
minimised when told that their child was not experiencing distress:
We came away from that and I just thought we’ve failed [. . .] we thought we had strong
boundaries, you have to have with a child like that [. . .] I was desperate when I went in and I was
destroyed when I came out [. . .]. (P8)

An alternative route. When services became inaccessible need for support remained,
leading participants to seek alternative provisions, although this was not without concern:
It’s really tempting to just clutch at straws to be honest and you could end up accessing
something that’s really quite inappropriate, something that’s not evidence based and it could
end up causing more harm, just leaving people vulnerable. (P4)

The finish line. Participants’ journeys of accessing services were often long and arduous,
like running a marathon. This risked exhaustion, physically and mentally, yet they
persevered. When a professional listened, empathised and validated their experiences they
felt they reached “the finish line”. This brought relief, that they were now able to access
support for their young person:
Then she said briefly tell me your story, what has got you to here and I told her it all [. . .] and
that’s when she just said ‘I’m so sorry’. She was the first person in 11 years who had said that [. . .]
and that changed everything for me. (P3)

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 The boxing ring

Fist-to-fist. In initial appointments with services, caregivers often felt obligated to share past
experiences of trauma to provide understanding of their child’s presenting problems. Some
experienced this multiple times, with multiple professionals:
I had to speak to someone over the phone and regurgitate everything, then they passed it on to
someone else who I then had to go through the whole process again, then we had to go into a
meeting with the social worker and I had to do it all again. Then the young person was invited
along and he had to go through it all as well. (P1)

The experience of this for both caregivers and their children is emotional and risks
re-traumatisation:
The conversation that took place in front of my son was horrific [. . .] and by the end of it [. . .] I did
have to say ‘I think we’re done here’ [. . .] he had folded in half and his forehead was on his knees.
(P3)

The wrong division. Caregivers felt focus on outward signs of distress hindered access to
appropriate intervention as professionals may not perceive there to be a mental health
concern as their child’s difficulties were hidden:
She’s very good at social masking, so you wouldn’t know to see her. (P8)

Many participants felt mental health services needed a greater understanding of trauma:
I think they just need more [. . .] more training, that different backgrounds make a massive
difference on how you can recover. (P2)

Between rounds. Caregivers described how they were often unaware of the emotional
impacts of appointments, leaving them at a loss of how best to support their child between
sessions:
What you’re handing them is a grenade kind of disguised as an apple and anything could
happen. (P3)

Additionally caregivers found that they were often separate to the intervention:
Whilst I’m going through this and nobody has said ‘are you okay? How is this playing out on you?’
(P9)

The fight. Overall caregivers felt it was a “fight” to access and receive support from
services, needing to consistently advocate for their young person:
My biggest shock throughout my journey has been that my fight has been with the
services whose sole purpose of existence is to help children like mine [. . .] you can’t
believe your fighting people whose job, the only reason for their job is to help children like
yours. (P3)

Caregivers reflected upon their journey of accessing support, likening this to running a
marathon, then being faced with another challenge in the form of “fighting” with mental
health professionals to get their children’s needs met:
Which was just like [. . .] having to get into the ring with a professional boxer after you’ve just
finished a marathon, because I had just got up. (P3)

I wouldn’t have dreamt the system was like this [. . .] I think it is disheartening to think as a foster
carer you are putting your all in to change this kid’s life and you haven’t got the support to help
you. (P9)

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The dance

Taking the lead. Caregivers found it helpful to have the opportunity to meet with
professionals initially on their own. This enabled relevant information and history to be
shared without having an adverse impact on the child:
It’s not because you’re saying something awful about him, but he can’t hear that [. . .] it would
cause him such problems if you decided to say it in front of him. (P4)

They also found it helpful when they had regular opportunities to share information with the
professionals:
At CAMHS I have meetings with the psychologist just me and him, where I say this is what’s
going on what he [young person] doesn’t need to know about [. . .]. (P5)

In sync. Caregivers described positive experiences when professionals were able to

recognise impacts and presentations of developmental trauma, having a shared view of
presenting concerns:
You felt that you were being listened to and that people had some background knowledge. They
don’t expect you to tell them stuff that they already know. (P1)

They know how to help, is just [. . .] you know I could just cry with relief even thinking about it now.
(P4)

Joining the dance. When their young person was engaged in support caregivers embraced
being involved in some way, even if brief. This enabled caregivers to contain their young
person and further support the therapy:
If he is having a bad day, or if he is having a moment we can [. . .] instantly refer to what he knows
[. . .]. (P1)

I get loads of feedback off the psychologist, be it by text, email or phone call, a lot of it and then
when the psychologist feels she needs to we’ll do a session or come in at the end of a session.
(P6)

A close hold. Caregivers relished when services acknowledged their role and supported the
secondary impacts of trauma. This had positive impacts on their well-being, stabilising
challenging situations including potential placement breakdown:
This time last year if it wasn’t for CAMHS [. . .] I don’t know, I don’t think I could have been, I
couldn’t take any more [. . .] and they were guiding me, they’ve always put me on the right road
for help. (P5)

The world around

Multiple arenas. Caregivers explained that challenges experienced in mental health settings
also exist in other systems such as school and social care. They noted that a lack of
understanding of trauma in these areas could exacerbate difficulties, again needing to
“fight” for their young person:
The more she was getting detentions and isolations and punishments at school the worse things
were becoming at home [. . .]. (P8)

Engaging the audience. Caregivers sought a link between mental health services and
school. Often they found that they were solely trying to share an understanding of their
child’s difficulties and valued when mental health professionals advocated alongside them:

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 I really felt I could have done with some support because you feel like you’re going into the lion’s
den [. . .] that would be really helpful, someone to just walk in with you and say the things you may
forget or reinforce what you’re saying. (P8)

Joining of the worlds. Participants described the importance of having the whole system
around the child involved and approaching their care with a shared understanding and
approach:
You might have a fantastic CAMHS worker and have great sessions there and then you’ve got to
go to school and nobody understands you, there’s no point. So it has to be everyone. (P2)

If one part of the system doesn’t work, the whole system doesn’t work [. . .]. (P9)

Moving forward

Loss. An aspect of engaging with services is the inevitable loss this can bring when
involvement comes to an end:
To suffer another loss no matter how small it is it’s huge in their lives, ‘cos just somebody else
doesn’t want them. They don’t see losses as ‘well that persons had to go’ it’s ‘well that person
doesn’t want to be with me’. (P2)

Caregivers found it helpful when this was recognised by services and thought was put into
endings to support these feelings:
She got a lovely letter and a little drawing, she was young then, you know and it was made into
the best ending that you could get for an ending. (P2)

Empowerment. For caregivers, experiences of seeking support often underpins their whole
journey, thus they may be apprehensive about the ending of support. Empowering them as
a family is essential, highlighting growth, change and resilience:
I’ve got this huge fear of thinking but if you stop seeing us and we need you again, I can’t face, I
mean I would do it if I had to do it, but the idea of having to face, having to go back through any
of that to try and access it again at a later date [. . .]. (P4)

Hope for the future. Despite mixed reflections of service experiences, caregivers often
reported change and recognition of moving forward, seeing a brighter future:
When you look at the bigger picture and everything she’s been through and obviously had to
relive through disclosure and police investigation, I think she’s probably coped with it very well
[. . .] maybe we’re the ones that didn’t cope with it very well [laughs]. (P6)

Discussion
The end GT suggests that for young people exposed to developmental trauma, accessing
timely and appropriate mental health and/or therapeutic support can be challenging.
Caregivers highlighted how multiple barriers exist, from seeking to experiencing support
and typically arose due to lack of understanding around presentations of trauma. Ultimately
needs are left unmet, risking re-traumatisation. However, when caregivers experienced
professionals and services which were trauma-informed and compassionate this enabled
healing.
Each theme can be situated within existing literature, adding depth to understanding. The
“parent–carer experience” illustrates the myriad of feelings associated with parenting a
young person who has experienced developmental trauma. Descriptions are reflective of
Pickin et al. (2011), who conveyed how loving bonds develop between carers and young
people. Thus, when caregivers witness their child in distress, this can risk secondary

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trauma. Indeed, research indicates that parent–carer well-being is most affected when
caring for children who have a range of emotional and behavioural difficulties (Harding
et al., 2018).
Participants found themselves continuously striving to meet their child’s needs to alleviate
distress, which often required adjustment to their own lives. Often when caregivers reached
the point of seeking help they felt desperate, due to the child’s difficulties and impact upon
themselves (Pickin et al., 2011). Bonfield et al. (2010) found that carers only perceived a
need for help when their child’s difficulties were particularly severe and they were struggling
to cope.
Within “The marathon”, participants described first contacting gatekeeping services.
However, barriers were often experienced such as limited understanding of developmental
trauma or stringent organisational processes. Williamson et al. (2019) also described how
parents voiced their concerns to their GP but referrals were not immediately made. These
findings contradict those of York and Jones (2017), who noted generally good access to
mental health services and instead barriers commence once in the system.
Findings can be contextualised through the socio-political landscape. It is well publicised
that GPs are under increasing pressures, particularly due to underfunding of NHS services.
Inherently this leads to greater demand and workload which is intensified through a
shortage of staffing. Similarly, there are pressures on children’s social care, as the number
of children taken into care has almost tripled relative to the rate of population growth. The
consequence of working in these emotive and demanding environments may lead staff to
operate in standardised ways to prevent burn-out, yet this has the potential to exacerbate
the distress of young people and their caregivers (British Medical Association, 2018).
When referrals were made to mental health or therapeutic services, for some caregivers,
challenges remained. Caregivers recalled being told that their child’s difficulties were too
complex or behavioural, leaving them feeling overwhelmed and helpless. In this study,
these experiences were most relevant to participants who accessed a CAMHS rather than
the specialist therapeutic service. This suggests that CAMHS may too lack an
understanding of the range of presentations associated with developmental trauma
(Callaghan et al., 2017).
“The marathon” conveys that families are already in significant need when help is sought.
Difficulties were exacerbated when a barrier was encountered through a professional’s
approach and/or organisational processes. As a result, services need greater awareness
and understanding of developmental trauma and how it presents in children. Indeed,
caregivers in this study described reaching “the finish line”, a place where they were able to
access support, feeling heard, empathy and validation from professionals. These
experiences are synonymous to the ethos of trauma-informed care and demonstrate that
services have the potential to operate in ways which do adequately meet the needs of this
population (Sweeney et al., 2016).
“The boxing ring” and “The dance” are presented as two separate but interconnected
categories, as they provide contrasting experiences of mental health and therapeutic
services. Caregivers described that when professionals focused on difficulties and reasons
for accessing support, this frequently led to a problem saturated narrative, internalised
within the child. Moreover, this approach put children and caregivers in positions of
needing to share their trauma history to someone new, which can increase feelings of
vulnerability (Coyne et al., 2015).
In contrast, positive experiences occurred when caregivers had an opportunity to speak to
professionals alone, sharing an understanding whilst protecting their child, again echoed in
Coyne et al.’s (2015) study. Clinically, this suggests children may not need to be seen
initially as safety and building therapeutic relationships can be facilitated with the caregivers
(Marmarosh, 2017). Caregivers described that when interventions are not sensitive to their

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 child’s needs, they disengage. This is important as York and Jones (2017) recognised when
children disengage from support they are often not followed up. This reinforces the burden
that is then placed back on caregivers.
When young people are engaged in support, some caregivers felt separate to the
therapeutic process. They acknowledged confidentiality, but found requests for updates
dismissed. Equally when they wished to share insight of their own, they were left feeling
unheard. This is reflected in other research, where professionals have not appreciated the
knowledge caregivers can impart (York and Jones, 2017). When this happens, caregivers
described how they had to “fight” to be heard, to get appropriate support. As a result, a
proportion of caregivers remain absent in the provision of mental health care for children,
despite recommendations (NICE, 2015).
This research illuminated challenges faced in mental health services can be mirrored in
social care and educational settings. For example, caregivers reported that teachers
typically perceive behaviours that challenge to be a choice, so how they respond can
heighten children’s distress. More so when combined with school processes (e.g. detention
and exclusion), this risks increasing feelings of shame; a pertinent emotion experienced by
children with trauma histories (Golding, 2007). Thus the education system can be difficult
for children who have experienced developmental trauma (Armstrong-Brown and White,
2015).
Caregivers felt the link between mental health services and education needed to be
stronger, as when an understanding of trauma was shared by mental health professionals to
school, caregivers felt supported and adaptions could be made. This reinforces previous
research, which highlighted the importance of establishing good systems of communication
between the two (Stanley et al., 2005). It is understood that when teachers have a greater
understanding of trauma, they are more motivated to work in trauma-informed ways
(McIntyre et al., 2019). This is essential to consider within government strategy to improve
mental health in schools (DoH and DfE, 2017).
The ending of a therapeutic relationship can trigger complex feelings relating to early
attachment and loss. In this study, caregivers felt endings were well managed when this
was considered by professionals. Using a relational approach during the ending process is
essential to ensure that the child feels safe and has an experience of a “good enough”
ending. Marmarosh (2017) proposed that if endings are successful, transformation occurs,
where a person internalises the therapeutic relationship and develops new ways to view
themselves and others.
Endings also hold emotional significance for caregivers. They worried that without a service,
problems might return and difficulty in accessing support may reoccur. Services need
ensure endings are timed appropriately, highlighting the progress made. This is in
adherence to trauma-informed care, where empowerment and compassion are key
(Sweeney et al., 2018).

Implications for clinical practice

This research offers recommendations that can be applied and implemented to improve
clinical practice. Furthermore, all can be applied to the ten key principles of trauma-
informed care as outlined by Sweeney et al. (2018). For example:
䊏 Seeing through a trauma lens: To recognise the widespread prevalence of
developmental trauma and the range of clinical presentations associated with it,
including the systemic impact on caregivers.
䊏 Preventing trauma in the mental health system: To deliver care reflective of “the dance”
and “moving forward” categories.

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䊏 Collaboration and mutuality: To work in collaboration with caregivers and their child,
acknowledging and valuing their expertise and views. Also, the need for integrated
working across services.
Such recommendations require investment organisationally, where an understanding of
trauma is infiltrated through processes and policies alongside investment in workforce
development. This will create a trauma-informed culture (CQC, 2018). Training would help
to increase professionals’ awareness and knowledge of trauma, increasing ability to make
sense of presentations of trauma, including the impacts and support needed for their
caregivers. Access to clinical supervision and consultation would further allow professionals
to reflect and tailor their care (Sweeney et al., 2016).
It is important to acknowledge that many services are in crisis due to the increasingly high
numbers of referrals and staffing shortages (CQC, 2018). Thus, services may be trying to
meet demand, evidence outcomes and adhere to government and commissioners’
requirements. However, it seems likely that the current organisational solutions applied
perpetuate problems within the system. For example, lead to isolated working rather than
the integrative approach of services working together. Greater investment within mental
health services is needed to ensure services are safe and trauma-informed for their staff
and those who access them. More so, ensuring the voice of caregivers is embedded within
future organisational developments.

Limitations and future recommendations

The study had a relatively small sample with limited diversity (e.g. eight of nine participants
were female and all were White British living in the same geographical area). Replication of
the study across different areas of the UK with increased diversity could strengthen the
model. Also, applying alternative recruitment strategies as a proportion of caregivers were
not represented. For example, those not accessing a service, biological parents and
residential staff. Future research could also explore the young person’s perspective.
Trauma-informed care is on the organisational agenda of the NHS trust from which
participants were recruited. This potentially biases results, however, this was a relatively
new organisational change and participants’ duration in service exceeded its introduction.
Participants were also recruited from a specialist therapeutic service for looked after and
adopted children. Inherently, there is greater awareness of trauma in this setting which may
account for some experiences described.
Within constructivist GT it is considered that the model is one understanding of the data and
that a different researcher may arrive at a different end point. Authors MM, LC and JP have
worked in CAMHS and a specialist therapeutic services for looked after and adopted
children, choosing to conduct this research due to a pre-existing interest. This may bias the
analysis and contextualising of results, however with reflexive measures and triangulation in
place this was hoped to be minimised. Additionally, author SCS was felt to add an objective
perspective as their field of expertise and work falls outside of children’s services.

Summary
This research and developed model can be used to inform and improve child and
adolescent mental health and therapeutic services. It captures the challenges caregivers
face when accessing support for their children, enabling predictions to be made as to what
experiences other caregivers may encounter. Moreover, the research offers insight into
positive and trauma-informed experiences of care which can be used and built upon. As
the theory is contextualised within the wider systems caregivers and children access, the
findings may be further useful.

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Corresponding author
Sarah Craven-Staines can be contacted at: S.Craven-Staines@tees.ac.uk

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