For children and young people living in care, a secure and safe living environment plays a crucial role in their social and emotional development (Varnish et al., 2025), particularly given the maltreatment they may have experienced prior to entering care.
When the legal responsibility for a child or young person is transferred from their parents to a local authority, they are often placed to live with a relative, friend or approved foster carer, in residential homes or supported accommodation (Anthony et al., 2026; Department for Education, 2025). While local authorities are responsible for ensuring that a child or young person in care receives a permanent placement, this is not always the reality, and many children and young people enter placements of varying lengths, causing placement instability.
Moving from one placement to another can interfere with several aspects of a child and young person’s life, as it often means they need to change schools, leading to additional disruptions in friendships and relationships (Maguire et al., 2024). As a result, children and young people may also battle feelings of rejection, uncertainty, and have difficulty forming trusting relationships with adults (Eltink et al., 2025).
There is evidence to suggest that mental health difficulties are a risk factor of placement instability (Varnish et al., 2025). While the predictors of placement instability have been researched, the effect of placement instability on mental health difficulties still requires further consideration. The current systematic review and meta-analysis conducted by Sparks and colleagues (2026) sought to examine this relationship further.
Methods
The authors identified relevant papers by searching four databases. The specific search terms were identified through previously published studies and reviews on similar topic areas, and attempted to identify studies that (a) involved children aged 0 to 18 years, who must have experienced time in care, (b) measured a mental health outcome using a total, internalising or externalising difficulties score, (c) measured the association between placement instability and the mental health outcome, and (d) were peer-reviewed and published in English.
Studies were excluded if they were a randomised controlled trial or used a non-observational design, and where mental health difficulties were measured as a predictor of placement instability.
Titles and abstracts and then full texts were screened, with 10% double screened at both stages. For the included papers, data was extracted on key study characteristics, sample characteristics, measure of placement instability, mental health outcomes, analysis and effect. A random effects meta-analysis was conducted on a subset of studies.
The quality of the studies was assessed using the Crowe Critical Appraisal Tool (CCAT; Crowe, 2013). Seven studies were rated as high quality, fourteen as moderate quality and one as poor quality.
Results
Twenty-two studies were identified as relevant for the review, including a total of 17,318 children and young people in care aged 0 to 18 years. Half of the studies were conducted in the USA (n = 11), and there was considerable variation in how studies measured placement instability. While some studies measured placement instability by counting the number of moves, other authors coded placement instability into groups. The time frames in which studies measured the number of placements moves also varied; for example, some studies measured only during the specific study period, whereas others did not explicitly state the time frames.
To examine the association between placement instability and mental health outcomes in children and young people in care, the results from the studies were split into the following groups based on the how each paper measured mental health:
- Total mental health difficulties (an overall score of mental health)
- Internalising difficulties (emotional problems)
- Externalising difficulties (behavioural problems)
Total mental health difficulties
Eight studies looked at the effect of placement instability on total mental health difficulties and found that higher placement instability was associated with poorer overall mental health. However, a meta-analysis could not be conducted.
Externalising difficulties
Eighteen studies looked at the effect of placement instability on externalising outcomes. After accounting for initial mental health difficulties, child age and sex, most studies found that higher placement instability was associated with greater externalising difficulties.
Furthermore, 13 studies were included in the meta-analysis. The association between placement instability and externalising difficulties was small but significant (r = 0.14, 95% CI [0.11 to 0.18], p < .001).
Internalising difficulties
Fourteen studies examined the effect of placement instability on internalising outcomes. After accounting for initial mental health difficulties, child age and sex, most studies found that higher placement instability was associated with greater internalising difficulties.
Ten studies were included in the meta-analysis, with a small but significant effect found for the association between placement instability and internalising difficulties (r = 0.14, 95% CI [0.12 to 0.17], p < .001).
Conclusions
The current systematic review and meta-analysis provides evidence to support that placement instability is significantly associated with mental health difficulties in children and young people in care. Specifically, more frequent placement moves were associated with greater mental health difficulties. The authors concluded that:
This review has evidenced that above and beyond many other factors (such as initial mental health, age, and sex), placement instability has a negative, albeit small, effect on mental health difficulties of [care experienced children and young people]. Providing stable and secure placements should be a priority in order to ensure the best outcomes for [care experienced children and young people].
Strengths and limitations
This study has several strengths. Importantly, this review addresses a key gap in the literature by looking at whether placement instability is associated with the mental health of children and young people in care. Previous research has mostly focused on the reverse relationship, whether mental health difficulties predict placement instability.
The review was pre-registered in PROSPERO and conducted in line with PRISMA guidelines, increasing its transparency. The initial search was completed in December 2023 and updated in January 2025, ensuring that the findings reflect the most recent evidence available. Drawing on 22 studies with a combined sample of 17,318 children and young people in care provides a substantial evidence base, increasing our confidence in the findings.
Fifteen studies were longitudinal, allowing examination of how placement instability relates to mental health outcomes over time. This helps clarify the direction of the relationship, although it cannot establish causality. Most studies also controlled for important confounding variables, including age, sex and initial mental health difficulties, with associations often remaining significant.
However, several limitations should be considered:
- There was considerable variation in how studies measured placement instability and the time frames used. This makes direct comparisons difficult because studies were not necessarily measuring the same thing.
- The review did not account for adverse experiences prior to entering care. This is an important potential confounding factor, as greater exposure to maltreatment has been associated with higher levels of internalising symptoms (Moussavi et al., 2022).
- Ethnicity, placement type, length of time in care and disabilities were not consistently accounted for and may be important in understanding this relationship (Heady et al., 2023; Longshaw, 2023).
- Only one study relied solely on young people’s self-reports of mental health difficulties. Most used carer or parent reports, while others used teacher or social worker reports. Young people’s own perspectives are particularly important for understanding their emotional difficulties.
- Half of the studies were conducted in the USA, meaning the findings may not be directly applicable to the UK care system (Varnish et al., 2025).
- Finally, only 10% of studies were double screened during study selection, increasing the risk of eligible studies being missed or incorrectly included.
Overall, while this review draws on a substantial evidence base, its observational design means that causality cannot be established.
Implications for practice
Although the pooled effects from the meta-analysis are small, the findings suggest that placement instability is associated with poorer mental health outcomes among children and young people in care. Given the vulnerability of this group, even small associations are important to consider and may help inform policy and practice.
The findings are particularly important alongside evidence of a bidirectional relationship between placement instability and mental health difficulties (Varnish et al., 2025). Previous studies have mainly focused on how emotional and behavioural difficulties play a role in placement disruption, while this review provides evidence of an association in the opposite direction. Together, these findings support the possibility of a cycle which, without appropriate intervention, may become difficult to disrupt.
Qualitative work by Morgan et al. (2025) examined how the needs of children and young people with social work involvement are characterised in their mental health case notes. One theme was that young people were often rejected from services due to not having a “stable base”. Placement instability can therefore become a barrier to accessing appropriate support, potentially creating an additional layer within the “cycle of inequity” (Hiller et al., 2025).
The UK Trauma Council’s National Recommendations for Change aim to increase access to evidence-informed mental health services for children in care in England (Hiller et al., 2025). Recommendation 14 encourages clinicians not to reject a young person from a service due to placement instability. Instead, clinicians should work collaboratively with the young person and their social care team to identify appropriate support options. This recommendation is particularly relevant given the findings of this review.
Despite its limitations, this review represents an important step towards understanding the relationship between placement instability and mental health outcomes. Future research should identify ways to promote placement stability. Susannah Bowyer’s previous blog explored a systematic review identifying protective factors, including foster carers’ skills and personal characteristics, and keeping siblings together.
It is also important to incorporate the views of children and young people in care and their carers. Giving a voice to underserved populations is essential for understanding how best to address their needs. At the same time, broader systemic changes are needed to address the potential cycle between placement instability, limited access to support and worsening mental health difficulties.
Ultimately, children and young people should not be denied mental health support because their placements are unstable. Supporting placement stability and ensuring access to appropriate mental health care should be priorities for services working with this population.
Statement of interests
Charlotte Ransom and Rasanat Nawaz have no conflicting interests to declare.
Edited by
Dr Nina Higson-Sweeney.
Links
Primary paper
Rosa Sparks, Gary Kainth, Helen Minnis, & Jala Rizeq (2026). A systematic review and meta‐analysis examining the impact of placement instability on the mental health outcomes of care experienced children and young people. JCPP Advances, 6(3). https://doi.org/10.1002/jcv2.70099
Other references
Anthony, R., Willis, S., Haslam, Z., Morgan, K., & Evans, R. (2026). Mental health and well-being-related social support for care-experienced children and young people: A scoping review of type, source, and quality. Trauma, Violence, & Abuse. https://doi.org/10.1177/15248380261437098
Bowyer, S. (2015). How do we ensure foster placement stability for children? National Elf Service.
Department for Education. (2025). Children looked after in England including adoptions [Statistical release]. Explore education statistics. https://explore-education-statistics.service.gov.uk/find-statistics/children-looked-after-in-england-including-adoptions
Eltink, E. M. A., Waaijenberg, A., Broers, M., van Anrooij, M., van Rooij, F. B., Stams, G. J. J. M., & Assink, M. (2025). The prevalence of placement breakdown in foster care: A meta-analysis. Children and Youth Services Review, 171, 108203. https://doi.org/10.1016/j.childyouth.2025.108203
Heady, N., Watkins, A., John, A., & Hutchings, H. (2023). Prevalence of neurodevelopmental disorders (NDDs) in looked after children (LAC) versus children that are not looked after (non-LAC) and adverse outcomes: A systematic review and meta-analysis [Preprint]. Research Square. https://doi.org/10.21203/rs.3.rs-3344908/v1
Longshaw, A. (2023). Factors influencing mental health outcomes of looked after and accommodated children [Doctoral thesis, University of Glasgow].
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. Journal of Child & Adolescent Trauma, 17(2), 641–655. https://doi.org/10.1007/s40653-023-00606-1
Morgan, T., Crozier-Roche, F., Graham, D., Smith, J., Drayak, T., Mary, S., Cossar, J., Mannes, J., Pilimatalawwe, D., Parker, P., Coughlan, B., Hood, R., Hutchinson, D., Woolgar, M., & Duschinsky, R. (2025). The social must be stabilised: How are the social needs of young people with social work involvement characterized in their mental health case notes? Social Science & Medicine, 374, 118052. https://doi.org/10.1016/j.socscimed.2025.118052
Moussavi, Y., Wergeland, G. J., Bøe, T., Haugland, B. S. M., Larsen, M., & Lehmann, S. (2022). Internalizing symptoms among youth in foster care: Prevalence and associations with exposure to maltreatment. Child Psychiatry & Human Development, 53(2), 375–388. https://doi.org/10.1007/s10578-020-01118-x
UK Trauma Council. (2025). National recommendations for change [Report].
Varnish, C., Phillips, A. R., Tallam Laxman, S., Maxwell, N., Halligan, S. L., & Button, K. S. (2025). The relationship between placement instability and mental health among care-experienced children and young people: UK systematic review and meta-analysis. The British Journal of Psychiatry, 1–10. https://doi.org/10.1192/bjp.2025.10375