Children and young people who experience more frequent changes in care placement are more likely to have mental health difficulties, according to a systematic review and meta-analysis by Sparks and colleagues.
The review examined 22 studies involving 17,318 children and young people aged 0 to 18 who had experience of being in care. Its findings showed small but statistically significant associations between placement instability and both externalising and internalising difficulties.
What the review found
Externalising difficulties can include behaviours directed outward, while internalising difficulties describe problems such as emotional distress that may be directed inward. Eighteen studies examined externalising difficulties. A meta-analysis of 13 studies found a small association with placement instability, measured as r = 0.14, with a 95% confidence interval of 0.11 to 0.18.
Fourteen studies examined internalising difficulties. The meta-analysis of 10 studies also found a small association, with r = 0.14 and a 95% confidence interval of 0.12 to 0.17.
Most studies examining these outcomes accounted for children’s initial mental health difficulties, age and sex. Fifteen of the included studies were longitudinal, meaning they followed participants over time. However, the evidence was observational and cannot show that placement moves caused the mental health difficulties.
Eight studies examined overall mental health. Higher placement instability was associated with poorer overall mental health in these studies, but the results could not be combined in a meta-analysis.
Why stability may matter
The source notes that repeated placement moves can disrupt schooling, friendships and relationships. They may also be associated with feelings of rejection and uncertainty, as well as difficulty forming trusting relationships with adults.
The review describes a possible two-way relationship: mental health difficulties could contribute to placement instability, while instability could also be linked with later difficulties. This remains a possibility rather than an established causal explanation.
Limits of the evidence
The studies differed in how they defined and measured placement instability, and in the time periods they examined. The review did not account for adverse experiences before children entered care, which could affect both placement stability and mental health.
Other factors, including ethnicity, placement type, time spent in care and disability, were not consistently considered. Only one study relied solely on young people’s own reports of mental health difficulties; most used reports from carers or parents, while others used teachers or social workers.
Half of the studies took place in the United States, so the findings may not transfer directly to the UK care system. The source also notes that only 10% of studies were double screened during study selection, which may have increased the risk of eligible studies being missed or included incorrectly.
Implications for support
The review authors said stable and secure placements should be a priority for care-experienced children and young people. The source also stresses that children and young people should not be denied mental health support because their placements are unstable.
Recommendation 14 of the UK Trauma Council’s 2025 National Recommendations for Change encourages clinicians not to reject a young person from a service because of placement instability. Instead, services are encouraged to work with the young person and their social care team to identify appropriate support options.
For readers, the central message is about the importance of continuity and accessible support—not a prediction of any individual child’s mental health. Placement history is one part of a much wider set of experiences and circumstances.
Key takeaways
- The review included 22 studies involving 17,318 children and young people in care aged 0 to 18.
- More frequent placement moves were associated with greater externalising and internalising difficulties.
- The associations were small but statistically significant in the meta-analyses.
- The observational evidence cannot establish that placement instability causes mental health difficulties.
What this means
Placement changes can affect important parts of a child’s life, including education, friendships and relationships with adults. The findings support attention to stability and continued access to mental health support, while recognising that the review does not establish a direct cause-and-effect relationship or predict outcomes for any individual child.
What the evidence cannot tell us
- The observational study designs mean causality cannot be established.
- Studies varied considerably in how they measured placement instability and the time frames used.
- The review did not account for adverse experiences before children entered care.
- Ethnicity, placement type, length of time in care and disabilities were not consistently accounted for across studies.
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