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Articles

Children’s perspectives on contact with birth parents: a mixed-methods systematic review

Barns perspektiver på kontakt med biologiske foreldre: En systematisk litteraturgjennomgang

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ABSTRACT

This mixed-methods systematic review asks what is known about children’s perspectives on contact with birth parents when in out-of-home care. To address this question 37 studies were coded to identify children’s experiences and thoughts regarding contact with their parents. Data synthesis was performed in three stages. The frequency of the identified factors across all included research was determined and qualitative and quantitative syntheses were performed. The results reveal that children hold thoughts and views on several aspects of contact with their birth parents, and the breadth of variation in their attitudes and wishes regarding contact is great. However, the study's main findings indicate that children want more contact when their relationship with their parents is positive. Parental behaviour prior to and during contact seems to affect children’s perceptions of contact, and we suggest that contact should be facilitated in a way that contributes to positive relationships and creates good experiences for children.

ABSTRAKT

Denne systematiske litteraturgjennomgangen utforsker kunnskapsgrunnlaget i omsorgsplasserte barns perspektiver på kontakt og samvær med biologiske foreldre. Databasesøk ble gjennomført og 37 studier kodet for å identifisere barns erfaringer og tanker om kontakt med foreldrene. Datasyntese ble utført i tre trinn. Frekvensen av de identifiserte faktorene på tvers av inkludert forskning ble presentert og det ble utført kvalitative og kvantitative synteser. Resultatene avdekker at barn har tanker og synspunkter om ulike aspekter ved kontakt med biologiske foreldre, og det er stor variasjon i holdninger og ønsker for kontakt og samvær. Hovedfunnene fra studien indikerer imidlertid at barn ønsker økt kontakt når forholdet til foreldrene er positivt. Foreldres oppførsel før og under samvær ser ut til å påvirke barns oppfatninger av kontakten, og studien foreslår at det bør legges til rette for en kontakt mellom barn og foreldre som bidrar til å fremme positive relasjoner og skape gode opplevelser for barna.

Introduction

Children in care are at risk of various mental disorders and are reported to have poor outcomes in several aspects of their later lives on average (Meltzer, Citation2010; Mihalec-Adkins et al., Citation2020; Sacker et al., Citation2022). In addition to traumatic childhood experiences, these children must deal with the loss of their parents and might face difficulties related to separation, ambivalent loyalties, and attachment (Cornbluth, Citation2007). Most European countries have implemented legislation promoting contact between children in out-of-home care and birth parents. Research suggests that having supportive relationships with birth parents when living in care is associated with good mental health and is significant to the stability of care (Cheung et al., Citation2017; Coakley et al., Citation2007; Maluccio et al., Citation1993). However, relationships between birth parents and children have also been associated with conflict and found to be a primary reason for placement disruption (Taylor & McQuillan, Citation2014; Chateauneuf et al., Citation2018; Van Holen et al., Citation2020).

This literature review seeks to draw attention to children’s perspectives regarding contact with birth parents when in out-of-home care. By collecting and systematizing existing knowledge on children’s experiences with contact this article aims to make it more accessible and easily applicable for further investigation. To our knowledge, there is no systematic overview in the literature that provides easily accessible data on this topic, and we argue that shedding light on and making this knowledge available is an important contribution to the research field. To that end, this article applies the findings to answer the following research question:

What is known about children’s perspectives on contact with birth parents when in out-of-home care?

Methods

Selection criteria

This systematic review was conducted in accordance with the Prisma (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (Mother et al., Citation2009). When selecting research, four criteria for inclusion were defined. Included studies were required to (1) be peer reviewed and published, (2) have a publication date between 2000 and March 2023, (3) be published in English, Swedish, Danish or Norwegian and (4) involve children’s own experiences with out-of-home placements. Retrospective studies of former foster children also qualified. It was not required that the sole purpose of the included research be to explore children’s experiences related to contact with birth parents as long as the research articles provided relevant data.

As for exclusion criteria, publications were excluded if they (1) did not include children’s perspective; (2) involved children removed from their birth parents due to disabilities or adoption, or unaccompanied refugee minors; or (3) were ineligible publication type such as books, book chapters, reports or dissertations.

Search strategy

The research question was determined using the PEO (population, exposure and outcome) strategy. In the current study, the population is ‘children in out-of-home care’, exposure is ‘contact with birth parents’ and outcome is the ‘children’s perspectives’. Different combinations of keywords were tested. As there is no uniform definition of contact between children and birth parents, the term ‘contact’ was not included in the string to ensure inclusion of all relevant articles regardless of the way parental contact was described. Thesaurus searches were performed to control for hierarchical subject lists, resulting in additional words being added. Eventually, the following search string was performed, with adjustments in syntax adapted to the individual databases:

Key term 1: ((Foster N2 (famil* OR child* OR son* or daughter* OR placement*)) OR ‘substitute care*’ OR ‘Child placement*’ OR ‘Out of home placement’ OR ‘Out of home care’ OR ‘Looked after children’ OR ‘Children in care* OR adolescent*’) N5 (thought* OR opinion* OR experience OR perspective* OR perception* OR attitude* OR view* OR feeling* OR beliefs)

AND

Key term 2: (‘Biological parent*’ OR ‘Birth parent*’ OR Birthparent* OR kin OR kinship OR ‘Biological root*’ OR ‘Parent–child relationship’ OR ‘Mother–child relationship’ OR ‘Father–child relationship’ OR family OR families).

The search strategy was planned under the supervision of a specialist librarian, and search strings were proofread prior to conducting searches.

Systematic searches were performed in SocINDEX, PsycINFO, ASSIA, Scopus and Academic Search Ultimate in March 2023 using Boolean search methods. A supplementary search was performed in Google Scholar, and reference lists were screened. Experts in the field were also contacted for further suggestions.

Study selection

A total of 3,369 records were identified through the database searches. The process of selecting full texts was conducted by both the author and an expert in the field separately, and disagreements were discussed. Eventually 37 articles were included in the study. (See ).

Figure 1. Flow chart of the study retrieval and selection process.

Figure 1. Flow chart of the study retrieval and selection process.

Data collection and synthesis

Qualitative and quantitative meta-syntheses were conducted on the included research. Four studies used a mixed methods approach. However, as only qualitative results were relevant in three of the four mixed-methods studies, qualitative findings were included in the qualitative synthesis and the quantitative findings of the fourth study were included in the quantitative synthesis.

In the first stage of the coding process the included articles were read thorough to ensure familiarity with the data (McTavish et al., Citation2022). All descriptions regarding contact that were identified during this process were extracted. The ‘descriptions’ refer to all relevant findings identified in the included literature (findings about contact between children/birth parents from children’s perspective, such as children’s experiences, attitudes, wishes and feelings towards contact with birth parents) regardless of the main findings of each article. A total of 252 descriptions were identified. Corresponding descriptions across studies were combined which gave a total of 145 unique descriptions. Extracting and combining the relevant findings of the included research, gave insight to the frequency of the unique descriptions that children have given regarding their experiences of contact with birth parents across the literature. The coding was performed in Excel and checked by two coders to ensure agreement.

In the second stage of the coding process the quantitative findings were separated from the qualitative findings and searched for corresponding outcomes. However, as only a few of the included studies were quantitative, and these varied in terms of study aim and approach, no corresponding outcomes were identified, and the result of the quantitative synthesis is therefore a presentation of relevant findings seen in context with each other.

The third stage of the coding process pertained to the qualitative synthesis and involved searching for themes in the data. Themes were identified by bringing together components of experiences, perspectives, and views embedded in the data (Noyes et al., Citation2015). Data with similar topics were extracted, defined and labelled according to theme. The findings were coded into the following themes: (1) children’s attitudes towards contact with birth parents; (2) barriers to contact; (3) framework for contact; (4) feelings and thoughts about contact in general; and (5) feelings prior to, during and after contact.

Quality appraisal

Quality appraisals were conducted using CASP checklists (Critical Appraisal Skills Programme [CASP], Citation2018) for qualitative research and the step-by-step guide by Cathala and Moorley (Citation2018) for quantitative. The quality of mixed methods research was assessed using the tools in combination. Most of the articles were assessed to be of high quality. However, some shortcomings were present across studies. Common weaknesses included lack of ethical considerations in qualitative research, lack of quality appraisals in reviews and insufficient details about data collection and method in quantitative research ().

Figure 2. Critical appraisal of included studies with a qualitative methodology. *Studies with a mixed-method methodology are marked in grey. (See the CASP – tool for full questions). (1) Was there a clear statement of the aims of the research? (2) Is a qualitative methodology appropriate? (3) Was the research design appropriate to address the aims of the research? (4) Was the recruitment strategy appropriate to the aims of the research? (5) Was the data collected in a way that addressed the research issue? (6) Has the relationship between researcher and participants been adequately considered? (7) Have ethical issues been taken into consideration? (8) Was the data analysis sufficiently rigorous? (9) Is there a clear statement of findings? (10) Is the research valuable?

Figure 2. Critical appraisal of included studies with a qualitative methodology. *Studies with a mixed-method methodology are marked in grey. (See the CASP – tool for full questions). (1) Was there a clear statement of the aims of the research? (2) Is a qualitative methodology appropriate? (3) Was the research design appropriate to address the aims of the research? (4) Was the recruitment strategy appropriate to the aims of the research? (5) Was the data collected in a way that addressed the research issue? (6) Has the relationship between researcher and participants been adequately considered? (7) Have ethical issues been taken into consideration? (8) Was the data analysis sufficiently rigorous? (9) Is there a clear statement of findings? (10) Is the research valuable?

Figure 3. Critical appraisal of included reviews. *(See the CASP -tool for full questions). (1) Did the review address a clearly focused question? (2) Did the authors look for the right type of papers? (3) Do you think all the important relevant studies were included? (4) Did the review's authors do enough to assess quality of the included studies? (5) If the results of the review have been combined, was it reasonable to do so? (6) Were the results clear? (7) Are the results precise? (8) Can the results be applied to the local population? (9) Were all important outcomes considered? (10) Are the benefits worth the harms and costs?

Figure 3. Critical appraisal of included reviews. *(See the CASP -tool for full questions). (1) Did the review address a clearly focused question? (2) Did the authors look for the right type of papers? (3) Do you think all the important relevant studies were included? (4) Did the review's authors do enough to assess quality of the included studies? (5) If the results of the review have been combined, was it reasonable to do so? (6) Were the results clear? (7) Are the results precise? (8) Can the results be applied to the local population? (9) Were all important outcomes considered? (10) Are the benefits worth the harms and costs?

Figure 4. Critical appraisal of included studies with a quantitative methodology. *Studies with a mixed-method methodology are marked in grey. (1) Is the choice of subject clearly explained? (2) Is there information on existing knowledge about the topic? (3) Is the data analysis sufficiently explained and appropriate? (4) Are sufficient details about the method provided for the study to be replicated? (5) Is the data collection clearly explained? (6) Is the data collection systematic, objective, precise, repeatable, valid, and reliable? (7) Is information about sample size provided? (8) Are the results clearly presented? (9) Is the data analysis without errors? (10) Does the discussion demonstrate how the authors interpreted their results and how they contribute to new knowledge in the area?

Figure 4. Critical appraisal of included studies with a quantitative methodology. *Studies with a mixed-method methodology are marked in grey. (1) Is the choice of subject clearly explained? (2) Is there information on existing knowledge about the topic? (3) Is the data analysis sufficiently explained and appropriate? (4) Are sufficient details about the method provided for the study to be replicated? (5) Is the data collection clearly explained? (6) Is the data collection systematic, objective, precise, repeatable, valid, and reliable? (7) Is information about sample size provided? (8) Are the results clearly presented? (9) Is the data analysis without errors? (10) Does the discussion demonstrate how the authors interpreted their results and how they contribute to new knowledge in the area?

Findings

Included research

The included research is presented in .

Table 1. “included research”.

Frequency of findings

Of the 145 unique descriptions of contact between children and birth parents the five most frequently found in the research were that (1) children want more contact with their birth parents, (2) children miss their birth parents (3) children feels rejected by their birth parents, (4) children feel good about having contact with their birth parents and (5) children are concerned about their birth parents ().

Figure 5. Frequency of findings.

Figure 5. Frequency of findings.

Qualitative synthesis

Attitudes towards contact with birth parents

Large variations in attitudes concerning contact were found. However, most of the studies provided specific information about children explicitly wanting contact with their parents. Children considered biological relationships and maintained contact to be important (3, 7, 10, 29, 33), and five studies found that children with no contact wanted to reconnect with their parents (2, 4, 12, 15, 36). Studies also suggested that some children want contact despite being exposed to traumatic and abusive experiences in the past (2, 4).

One study found that the absence of contact when children clearly desire it can be problematic and potentially damaging (31). However, although several studies found that contact with biological parents was important to children, one study found that parental contact was described in positive terms only when it was by choice (29). Distress and anger were described in relation to forced contact, and one study found a negative impact from pushing contact regardless of circumstances (29). The same study also found that young children tend to accept unwanted parental contact because they feel they have little choice (29), while another study found that children also felt forced by social services to have contact (33).

Despite findings that children want to maintain relationships with their parents, several studies also found that for many children, contact feels problematic (2, 6, 8, 23, 32) and that children might not want to have contact with their parents (8, 12, 33). In total, 10 studies touched on the topic of children not wanting contact (2, 3, 6, 7, 8, 12, 22, 23, 29, 32), and findings suggest that some do not consider biological relationships important (3, 8).

Barriers to contact

Some of the studies presented findings illustrating barriers to children’s ability to be in contact with their parents. One study found that some children experienced contact as traumatic and therefore impossible to maintain (18). However, the same study also found that some children may prefer increased continuity of relationships as a way to reduce trauma. One issue raised in several studies was that contact can be difficult due to parents not showing up or prioritizing it (22, 24, 36). Two of the studies that highlighted this barrier found that children feel ‘sad’ when their parents do not have time for contact visits (22, 24). Parents showing up to contact visits intoxicated was found to be another reason why contact had to be cancelled (33). A total of five studies found that children feel upset when contact is unreliable due to cancellations or parents not showing up (16, 22, 24, 32, 33).

Framework for contact

It appears from the included research that children have thoughts and opinions on different aspects of what contact with their parents should comprise in practice. One study found that dissatisfaction with social workers was related to inaction with regards to requests concerning contact, such as significant delays between requests for assistance organising contact and action by social workers (36). Another study found that giving children the opportunity to express their feelings regularly contributes to their overall experience of contact (33).

Two studies provided information about the best setting for contact, suggesting that children preferred to have contact visits other places than at an office (23). Parental contact was only described in positive terms when it was conducted in an informal setting (29). As to frequency of contact, children’s opinions varied from wanting more or longer contact visits (4, 5, 6, 7, 9, 12, 13, 14, 15, 16, 23,) to wanting fewer visits (24).

As to the content of contact visits, two studies found that some children did not consider the content of visits important (13, 23). However, another study found that children want to do activities at contact visits, and yet another study found that children have preferences for certain activities. Positive contact visits were described in terms of shared activities that generated memories (29), and the activities that evoked the strongest positive feelings were gatherings such as birthday parties, New Year’s celebrations, walking and going to the zoo (23). Other preferred activities of children when having contact visits were ‘going to the park’, ‘amusement park’, ‘zoo’ and ‘going to the sea’ (23).

Feelings and thoughts about contact

Findings from the included research suggest that children tend to miss their parents (4, 6, 12, 13, 14, 15, 24, 32) and long for attachment with them (4, 7). Children were found to believe that their birth family would be able to help them with their struggles in life (4, 5), and they reported receiving social and emotional support from their parents (5, 19). Some children talked to their parents about problems (5) and had a strong sense of loyalty towards them (17). A total of seven studies found children to be worried and concerned about their parents when they were not in touch (2, 12, 14, 15, 16, 19, 31).

Despite several findings revealing good feelings among children regarding contact in general, children were also found to have negative experiences of contact (23, 33). Seven studies suggested that children felt rejected by their parents (4, 8, 12, 24, 25, 29, 33). Some children expressed feelings of hate towards their birth parents (8) and wanted to avoid contact visits (6, 7, 8, 22, 23). Children described contact visits as overshadowed by conflicts and problems and adapted themselves during the visits to avoid conflict or awkward situations (12).

Feelings prior to, during and after contact

The included research suggests that children experience both positive and negative feelings prior to contact visits. One study in particular demonstrated concrete feelings prior to contact. The positive feelings mentioned were ‘feeling positive’, ‘feeling beautiful’, ‘[a] feeling of excitement’ and ‘[a] feeling of happiness’ (23). The same study also reported negative feelings prior to contact. Children reported having ‘negative feelings’ and ‘feeling angry’, and a second study found that children reported ‘feeling afraid’ before contact visits (22). A third study found that children felt ‘nervous’ prior to contact (36). Two studies touched on the topic of feelings during contact visits. Positive findings included children feeling positive, describing visits as interesting and feeling happy and joyful during visits (23). Among the negative findings, research suggested that children worried that their parent would ‘act ridiculous’ (22) and conflicts with parents or between adults caused fear and discomfort (23). Some children were found to have ambivalent feelings about contact (23, 24), and some children reported not feeling anything or not caring about visits (23).

Two positive feelings after contact visits were highlighted in the research. Children reported feeling happy after visits (6, 23), and one study found that children felt ‘relaxed’ (6). However, among negative feelings, children were found to feel sad, angry, worried, lonely, afraid or guilty after visits (6). The same study also found that children felt upset after visits, which was supported by two other studies (6, 12, 16). Research also suggested that children felt disappointed after visits (12).

Quantitative synthesis

Of the eight included quantitative articles, a majority presented findings supporting contact between children and birth parents (20, 26, 27, 28, 30). A study from 2016 found that children generally had a positive view of contact visits and perceived more warmth/communication than criticism/rejection from their parents (20). Children were found to be joyful and happy when meeting their parents (26), and the majority wanted either to maintain or to increase the frequency of contact visits (27). Findings suggested that consistent and frequent contact was directly related to attachment security towards birth parents (30). A study from 2015 found that the wellbeing of foster children increased with strong attachment towards both foster parents and birth parents, although children reported significantly stronger attachment to their foster parents compared to their birth parents (34). However, studies also suggested that contact had a marginally significant effect on depression and externalizing behaviour (28), and one study suggested that children who rarely had contact with their birth parents were less likely to have symptoms of mental health problems (21) and a had a greater sense of wellbeing in their foster family (11).

Discussion and implications

The current study was conducted to explore the research on children’s perspectives on contact with their birth parents when in out-of-home care. The results reveal that children hold thoughts and views on several aspects of contact with their birth parents, and the breadth of variation in their attitudes and wishes regarding contact is great (Morrison et al., Citation2011; Sen & Broadhurst, Citation2011). However, the study's main findings indicate that children want more contact when their relationship with their parents is positive. Parental behaviour prior to and during contact seems to affect children’s feelings about and experiences of contact (Van Holen et al., Citation2022; Skrobić, Citation2016; Morrison et al., Citation2011). Failure to show up -or cancellations of visits by parents was associated with difficult feelings for children, such as the feeling of rejection (Moyers et al., Citation2006). The fact that children feel rejected when their parents do not show up might also underline the importance of having contact with parents. Missing and worrying about parents was found to preoccupy children during the time between contact visits with their parents (Ie et al., Citation2022; Baker et al., Citation2016). The kinds of negative emotions children described when waiting for the next contact arrangement might cause stress and potentially impact the children’s daily life and psychological health. More research should be conducted to increase knowledge about the reasons for cancellations. Exploring parents’ perspectives on why they cancel contact visits and their suggestions to reduce cancellations could have important implications for practice.

While some findings are more significant than others across the research, there are large variations among the children who have been studied, and ambiguous results make it challenging to issue clear recommendations for practice. However, the most important lesson that emerges from this study is that contact should be facilitated in a way that creates positive experiences for children (Kiraly & Humphreys, Citation2013). Because positive parental behaviour is crucial to children’s experiences, suggestions for practice includes working to facilitate situations where children and birth parents meet in a way that contributes to positive relationships. Social workers should work to enable parents to be good visitation parents. Effort could be put into to communicating to parents how sudden cancellations might impact their children. Furthermore, social workers should seek to gain an understanding from the child and the biological parents on how the contact visits should be arranged to promote the building of positive relationships. As the research reveals great differences in what children want in terms of contact with their birth parents and children's situations vary greatly, effort should be made to explore children’s perspectives on all aspects of contact with their birth parents. Children should also be thoroughly informed about when they might expect to meet their parents again and how their parents are doing to address their concerns (Larkins et al., Citation2015). In this way, social workers could possibly contribute to lowering children’s stress in between contact arrangements.

Although quantitative research suggests that less contact has a positive impact on mental health and externalizing behaviour (Fawley-King et al., Citation2017; McWey et al., Citation2010), we cannot conclude that children would not benefit from a relationship with their birth parents. Fewer contact visits might increase children’s ability to find their place in the foster home, however; the included studies shows that children can have advantage of positive relationships with birth parents (McWey & Mullis, Citation2004; Moyers et al., Citation2006). Social workers could potentially work on finding ways for children and parents to be in contact that do not interfere with the child's ability to settle into the foster home. Increased knowledge about the conditions for contact visits, including how they can be organised in ways that are beneficial for children and how parents can be supported in being good visitation parents, is needed.

Limitations

This review is based on peer reviewed articles and grey literature has not been included. Moreover, handling a large proportion of articles and data in Endnote and Excel could potentially lead to human error and unwanted exclusion of articles.

Conclusion

Understanding factors associated with contact between children in out-of-home care and birth parents from the children’s perspective is crucial for safeguarding children’s participation rights and secure the best interests of the child. This mixed-methods systematic review has brought attention to children’s attitudes and experiences with contact as they appear in the research.

Declaration of competing interest

The author report there are no competing interests to declare.

Acknowledgments

Camilla Thorvik: Supervision in search strategy planning. Proofreading search. Hilde Anette Aamodt: Screening records for inclusion/exclusion and coding. Oddbjørg Skjær Ulvik: Supervision.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Iselin Huseby-Lie

Iselin Huseby Lie is a social worker and PhD candidate at the Department of Social Work, Faculty of Social Sciences, Oslo Metropolitan University, Norway. Her primary areas of interest include children's rights, child protection, participatory practices within professional social work, and quantitative research. Huseby Lie has broad experience in international social work in sub-Saharan countries, and her research focuses on social work with children from a global perspective, specifically examining how international children's rights are addressed in various contexts.

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