RESEARCH ARTICLE Open Access

The key therapeutic factors needed todeliver behavioural change interventions todecrease risky substance use (drug andalcohol) for looked after children and careleavers: a qualitative exploration withyoung people, carers and front line workersHayley Alderson1* , Rebecca Brown1, Alex Copello2, Eileen Kaner1, Gillian Tober3, Raghu Lingam4† andRuth McGovern1†

Abstract

Background: Looked after children and care leavers have an increased risk of drug and alcohol use compared totheir non-LAC peers. Despite high prevalence rates within this population, looked after children are reported toshow low levels of engagement in services resulting in unmet needs emerging from substance use. This paperreports on the initial formative phase of a pilot feasibility randomised controlled trial; SOLID (Supporting LookedAfter Children and Care Leavers In Decreasing Drugs, and Alcohol) that aimed to adapt two evidence-basedpsychosocial interventions, Motivational Enhancement Therapy and Social Behaviour and Network Therapy, whichwill aim to reduce substance misuse by looked after children.

Methods: We conducted qualitative semi-structured interviews and focus groups with 19 looked after childrenaged 12 to 20 years old, 16 carers and 14 professionals across four local authorities in the North East of England.The data gathered were analysed and then presented within co-production workshops inclusive of 13 youngpeople and 14 professionals (drug and alcohol practitioners and social workers). Findings were used to adapt andrefine the interventions prior to the trial.

Results: Overall findings suggested that whilst original components of both interventions were feasible to deliverand acceptable, specific process areas were highlighted including: increased emphasis upon therapeuticrelationships, the benefits of using creative non-traditional methods of engagement and identification of treatmentgoals wider than those narrowly focused on substance misuse.

Conclusion: This paper provides an example of methods used to collect multiple perspectives to refine and co-develop interventions to reduce drug and alcohol use in the specific population of looked after children.

Trial registration: ISRCTN80786829 (first registered 06.06.2016- prospectively registered).

Keywords: Looked after children, Drugs and alcohol, Social work, Intervention

* Correspondence: Hayley.alderson@newcastle.ac.uk†Raghu Lingam and Ruth McGovern are Joint last authors.1Institute of Health and Society, Newcastle University, Newcastle Upton Tyne,UKFull list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Alderson et al. BMC Medical Research Methodology (2019) 19:38 https://doi.org/10.1186/s12874-019-0674-3

BackgroundOne in every 156 children in the UK is looked after by thestate [1]. These looked after children and care leavers (hence-forth denoted as LAC in this text) have often experiencedmultiple forms of abuse and neglect. They have an increasedrisk of drug and alcohol use compared to their non-LACpeers. For example, 25% of LAC in foster care and 42% ofLAC in residential care drank alcohol at least once a month,compared to 9% of young people not looked after [2]. A na-tional survey of care leavers showed that 32% smokedmarijuana daily [3] compared to a recent estimate of 5% ofyoung people aged 16–24 years in the general population [4]and data from 2012 showed 11.3% of LAC aged 16–19 yearshad a diagnosed substance use problem [5]. In addition,LAC have almost fivefold increased odds of at least onemental health diagnosis compared to their non-LAC peers(disorders including anxiety, depression or behavioural disor-ders) (OR: 4.92; 95% CI: 4.13, 5.85), further increasing theirrisk of substance use and poor life chances [6].LAC have often experienced family breakdown, neg-

lect and abuse prior to entering care and have had littleor no control in many aspects of their lives includingtheir living arrangements or ‘placements’. This level ofdisruption often contributes to distrust of and lack ofengagement with professional services [7], resulting inthe needs of LAC often being unmet. The National Insti-tute for Health and Care Excellence (NICE) [8] and theChief Medical Officer specifically highlighted LAC as avulnerable group of young people who needed effective in-terventions to reduce their risky drug and alcohol use [9].However, there is a lack of research adapting interventionsfor use with LAC and assessing their effectiveness at scale.This paper provides a case study for developing inter-

ventions with this ‘hard to reach’ group of young people,it draws on their views and lived experiences to ensurethe interventions are salient. We aimed to establishwhether the Motivational Enhancement Therapy (MET)and Social Behaviour and Network Therapy (SBNT) in-terventions were feasible and acceptable to adapt in rela-tion to LAC and other key stakeholders. The adaptationprocess occurred through a series of stages, which wereall qualitative in nature. The steps taken are documentedand we present qualitative research findings that illus-trate how insights from LAC and care providers influ-enced the adaptation and manual development of ourtwo evidence based interventions to reduce drug and al-cohol use and to be delivered in mainstream alcohol anddrug treatment services.

MethodsStep 1: Selecting interventions for adaptationMotivational Enhancement Therapy (MET) and Social Be-haviour and Network Therapy (SBNT) are existing interven-tions that have been shown to be effective in decreasing

substance use in a range of participants including adoles-cents [10–12]. MET is a client centred, directive counsellingapproach developed as a concentrated version of motiv-ational interviewing (MI) [13]. The basic assumption ofMET is that the motivation and responsibility for change liewithin the client, and it is the therapist’s role to create an en-vironment to enable the client to change. A review by Car-ney and Myers (2012) has shown that MI and MET haveshown promise for adolescents with problematic substanceuse [14–16].SBNT is a systematic counselling approach, which utilises

cognitive and behavioural strategies to help clients build so-cial networks supportive of positive behaviour change in rela-tion to their substance use and goal attainment [17]. LACare often engaged in substance misusing social networks,which reinforce their risk taking behaviours. NICE have rec-ommended family interventions when working with youngpeople presenting with complex needs such as substancemisuse and mental health [8]. However, for LAC, it is un-likely that the more traditional family interventions would befeasible given the potential for family fragmentation andbroken relationships within this complex group. As such,SBNT offers an alternative intervention with potential to gal-vanise a supportive network for the child that can also drawfrom social support beyond the immediate family.However, whilst both MET and SBNT have been shown

to be effective at reducing substance use, less is knownabout their effect with young people who are looked afterby the Local Authority and likely to have more fragmentedfamily relationships. The nature of social networks andhow they differ for LAC within the looked after system isparamount to understanding how to effectively engageand work with this group of young people.

Step 2: Developing a theory of change modelIn accordance with guidance from the Medical ResearchCouncil (MRC) on developing complex interventions [18],we commenced the adaptation of the interventions bybuilding a theory of change model relating to our targetpopulation. The central vulnerabilities of LAC, is the ab-sence of appropriate family support and supervision andthe life experiences which led to their placement withincare. Based on existing theory we predicted that an inter-vention seeking to decrease substance misuse by thisgroup would need to address these wider social and envir-onmental determinants. We developed Behaviour Deter-minants Intervention (BDI) models for each intervention,to identify how the research team visualised the proposedchange pathways for the interventions, highlighting thedeterminants for change and key behaviours targeted bythe intervention.Within MET, the therapist could employ strategies to build

and strengthen motivation by eliciting self-motivationalstatements from the LAC and that in doing so, the LAC

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could resolve the inherent ambivalence about their substancemisusing behaviour [10]. When developing the BDI modelwe thought MET would strengthen motivation but we alsothought that it would be helpful to provide personalisedfeedback to assist the young person to consider risks and tipthe decisional balance. We were also aware that risks and de-cisions may differ somewhat from those of adults e.g. theyare more likely to be acute or shorter term such as friendshipdifficulties or regretted sex rather than abstract future orien-tated risks such as high blood pressure, to really explore thereasons for change.Within SBNT, the therapist could employ cognitive and

behavioural strategies to help LAC build social networks tohelp shape positive behaviour change in relation to their goalattainment [17]. When developing the BDI model wethought SBNT could encourage LAC to recognise potentialbroader, informal networks of support outside of traditionalcaregivers. Social network support is key in helping peopledeal with problem behaviours inclusive of substance misuse.We were aware that networks of support available to LACwould differ from children and young people residing withinmore traditional biological families.Semi structured topic guides were developed to discuss

the assumptions inherent within the logic models (Figs. 1and 2) and to explore the key behavioural and motivationaldomains that the interventions should address. Qualitativeresearch was undertaken to increase our understanding ofthe needs of this group of LAC.

Step 3: Qualitative studyQualitative interviews and focus groupsWe used qualitative methods to establish whether theMET and SBNT interventions were perceived as feasibleand acceptable and to adapt them in relation to LACand other key stakeholders. We proposed to carry outindividual 1:1 interviews with LAC and carers and focusgroups with professional participants. In reality, forpragmatic reasons we conducted a combination of indi-vidual interviews, dyad interviews and focus groups de-pending on participant’s availability. Table 1 shows themethods used to recruit participants and provides thedemographics of the study participants involved in thefirst round of qualitative work.Qualitative interviews were carried out with a purposive

sample of 19 LAC. The LAC were identified by their socialworkers within each local authority area, who acted as thegatekeeper. Social workers provided the research teamwith contact details for LAC whom had agreed to be con-tacted. The research team then contacted eligible partici-pants (LAC aged 12–20 years, screened positive for beingat risk of substance use, able to provide informed consentand residing in the study area) to discuss the research andarrange an appropriate time to visit and conduct an inter-view. The purposive sample aimed to ensure diversity withregards to age, exposure to drug and alcohol use andplacement type. The final sample was representative of theLAC population so far as there was an equal mix of male

Fig. 1 BDI Theory of change model

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and female participants and a range of placement typesacross the different local authority areas as identified inTable 1. Sixteen carers, inclusive of a mixture of fostercarers and residential children’s home workers supportingLAC were involved in 13 individual interviews and a focus

group with 3 participants. The carers were identified bythe social worker to ensure diversity of sample in terms ofcarer type (i.e. foster carer/ family member/ residentialworker), the participant demographics are identified inTable 1. Furthermore, it is important to acknowledge that

Fig. 2 BDI Theory of change model SBNT

Table 1 Qualitative participants

Qualitativemethod

Participant group Number ofparticipants

Gender Placement type/job role Substance use

Individualinterviews

LAC 19 F = 9, M =10

Foster care = 5Residential care = 8Independent/supported living= 5Living with biological parent =1

Current/previous substance use= 16Never used substances = 3

Carers 13 F = 8, M = 5 Foster carers = 6Residential workers = 4Supported living workers = 2Biological parent = 1

Drug and alcoholworkers

3 F = 1, M = 2 Service manager = 1Drug and alcohol worker = 2

Dyad interviews Social workers 4 F = 4 LAC managers = 2Social workers = 2

Focus groups Drug and alcoholworkers

5 F = 3, M = 2 Service manager = 1Drug and alcohol worker = 4

Social Workers 4 F = 3, M = 1 Senior Social workers = 3Social worker = 1

Carers 4 F = 3, M = 1 Foster carers = 4

Total participants 52

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the carers were a mixture of those caring for LAC inter-viewed as part of the study and those who were recruitedfor an interview independent to a LAC. Interviews werethe preferred method used with LAC and carers (fosterand residential) as interviews covered sensitive issues andexplored personal experiences of drug and alcohol use,barriers and facilitators to engaging with services and anyrecommendations for service improvements. The focusgroup with carers emerged incidentally and for pragmaticreasons as one carer was part of an already establishedsupport group that we were invited along to, 3 membersof that group agreed to participate in a group interview.Interviews were also carried out with 3 drug and alcohol

workers whom had previously delivered SBNT as part of aprevious trial [12]. These interviews aimed to build uponprevious knowledge and experience of delivering METand SBNT to young people and contribute towards adapt-ing the treatment manual for the LAC population.Focus groups and dyadic interviews were held with profes-

sionals. Two focus groups were held, one with 4 LAC socialworkers and one with 6 specialist young people’s drug andalcohol workers. This was complimented with two furtherdyad interviews with social work staff. The focus groups anddyad interviews enabled us to discuss the original compo-nents and principles behind the MET and SBNT interven-tions and whether they perceived them to be relevant toLAC. They also enabled us to explore the broader thera-peutic approaches required to work with LAC, the feasibilityof delivering the interventions to LAC and consider potentialbarriers to delivering the interventions at scale. Data werecollected until data saturation was reached.Written informed consent was obtained for all partici-

pants, inclusive of assent from LAC under 16 years of ageand consent from their corporate guardian. Information re-garding the consent procedure and interview process can befound in the SOLID protocol paper [19]. Interviews werecarried out by experienced qualitative researchers, they wereaudio recorded and transcribed verbatim. Transcripts wereanonymised and identifiable participant details with a partici-pant key were stored separately. Pseudonyms are used withinthis paper to maintain participants’ anonymity.

Step 4: Qualitative analysis and findingsA preliminary thematic analysis was conducted on thedata available from the qualitative interviews and focusgroups, in preparation for the intervention developmentworkshops with professionals and young people beforefinalising the adapted MET and SBNT manuals.Transcripts were thematically analysed [20], in practice this

entailed a line by line coding process and then analysiswithin a given transcripts and across the dataset as a whole.Analysis was an iterative process, using the constant com-parative method [21], in order to identify key themes andconcepts. Qualitative software (NVIVO 10) aided the

organisation of thematic codes. The data were comparedacross the three participant groups (i.e. LAC, professionalsand carers) with similarities and differences beinghighlighted. Further, we compared and contrasted the mainthemes within the BDI models described above in order tochallenge the existing models in order to refine and adaptthe existing versions of the interventions. In the first in-stance, data were analysed by both RB and HA in order toensure inter-coder consistency and agreement. The mainthemes and findings were presented to the wider multidis-ciplinary team (RL, RM, AC, GT, and EK) whom have ex-pertise in a variety of backgrounds including: public health,social care, social science, drug and alcohol use, and clinicalpsychology. HA and RB then finalised the themes and mainfindings in order to develop recommendations for the adap-tation interventions. Again, these were presented to thebroader team for discussion in preparation for the interven-tion development workshops which are described in moredetail below.The quotes included in this paper came from young

people who have experienced receiving drug and alcoholtreatment interventions and/or LAC accessing other ser-vices for support surrounding ‘help seeking’ behaviour.Additionally, opinions were sought from professionalswho have experienced delivering interventions and en-gaging with the LAC population.

Key themes and how they influence manual adaptationAt the outset of this attempt to co-produce and adapt twodistinct intervention manuals for SBNT and MET, topicguides were written to focus on each intervention separ-ately and in its own right. What became apparent as anemergent finding is that less emphasis was placed on thespecific intervention being delivered and more importancewas placed on the ‘key therapeutic factors’ and genericprocesses of working with LAC. Therefore, the main find-ings focused on ‘therapeutic relationships’ and ‘engage-ment and challenges of working with LAC’, which arerelevant regardless of the intervention being delivered.The themes and subthemes that emerged from the

data within each of these categories are described belowand the discussion section outlines how the data collec-tion influenced our manual and training adaptation.

Theme 1: Therapeutic relationshipsThe qualities of trust and genuine care were the two mainsub- themes that emerged regarding what underpinned asuccessful therapeutic relationship. Participants, inclusive ofprofessionals and LAC themselves highlighted the import-ance of building a therapeutic relationship when workingto reduce substance misuse. The LAC’s ability to confide inprofessionals and trust the substance misuse practitionerwas a recurrent theme. Whilst trust is recognised as a ne-cessary condition for any caring relationship, it was

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reported to be particularly important for LAC, whose expe-riences leading up to their placement in care may have im-pacted upon their ability to trust others. Professionalsacknowledged that LAC often experience disorganised anddifficult attachment. This included repeated experiences oftheir essential needs going unmet, relationship breakdownand abandonment, being let down and broken promises.Professionals displayed a clear understanding of these com-plex attachment issues and discussed the need to ‘earn’trust when engaging with LAC;

“You need to put in the groundwork initially. I thinkwith teenagers you need to gain their trust, you need towork for it. Because if they have been hurt, which theywill have been, they will try to push you away. Theywon’t want to trust you.” (Carly, Social worker, focusgroup)

Further, LAC described seeking qualities such as reli-ability, empathy and partiality, which may have beenqualities missing in their early attachments. Practitionerswere expected to act in particular ways in order to dem-onstrate their trustworthiness. Typically this involvedthe practitioner being reliable; a quality which practi-tioners reported could be communicated to the LAC inmultiple ways within the interaction. One foster carerdescribes displaying their reliability in terms of beingavailable 24/7, he is permanently ‘on call’ if a young per-son needs him, he states;

“it is not a job because there is no job that makes youwork 24 hours a day, 7 days a week and 365 days ofthe year, but this one does” (James, Foster carer, focusgroup).

Professional and LAC participants reported that thepractitioner’s reliability must be consistent as any incon-sistency is likely to build mistrust.

“Just by keeping to your word, even little things likekeeping your appointments and attending on time,looking into things when you say you’re going to…”(Susan, Social Worker, focus group).

From the perspective of LAC, engaging with services de-pends fundamentally on the relationship between themselvesand their allocated worker. To facilitate the sense of a recip-rocal trustworthy relationship, young people explained theimportance of ‘working gradually’, wherein at least the firstcouple of interactions should be dedicated to building a rap-port and ‘engaging’ the young person prior to formal sessionscommencing. Additionally, this could be shown by profes-sionals not expecting young people to instantly make disclo-sures, but allowing a positive working relationship to develop

first. Self-disclosures where practitioners ‘trade’ personal in-formation were perceived to be beneficial to developing atrusting relationship, whereby the process of sharing infor-mation was not completely one sided. Some, examples thatyoung people provided for this were discussing a hobby thatthe practitioner enjoyed doing or talking about a pet theyhad. This level of disclosure enable a small ‘trade’ of personalinformation to be made without divulging any sensitive per-sonal information. LAC reported that such disclosure en-hanced their sense of connection to the practitioner as wellas their own safety to disclose information.

“When you work with someone you have to build abond up first, before you can open up to them…..It’s,well the way I’ve done is just ask questions aboutthem, and then if they tell you, then you know well ifthey’ve told me this then I can tell them that”(Sophie,17, YP interview).

A further quality that LAC sought but did not always feelthat they received was that of ‘genuine care’. LAC describedhaving multiple contacts with professionals, with much ofthe care a child usually receives from a loving family beingprovided by a professional who is employed to provide suchcare. The corporate parenting role dictates that safeguardingand risk management take precedent over the provision ofemotional support. However, many social workers describedgoing ‘above and beyond’ their role and being available out-side of their contracted working hours in an attempt to showthey care for the young people in their care.

“Myself and his YOT worker had agreed between usthat we would have our phones on 24/7. So that if hewanted to get in touch and check in we knew he wasokay. So we did, we took turns and he did check inand he did arrange to meet up which was really good”(Steph, Social worker, focus group)

LAC were acutely aware of the corporate parentingrole fulfilled by the professionals and highlighted the im-portance of practitioners (professionals and foster carers)whom made them feel like they ‘genuinely’ cared abouttheir welfare. Despite being in a paid position to providecare for young people, foster carers reinforced their at-tempts to provide the same level of care and support tothe children and young people they foster/care for in thesame way they would treat their own biological children.

“Any child that comes to live with me, I know they arenot mine, however I will work with them, I will playwith them, I will live with them and I will doeverything to my best ability in every area, in everyarena because I want what is best for them.” (Liz,foster carer, interview).

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For LAC, Genuine care involves professionals ‘beingavailable’ when needed, showing empathy, perseveranceand providing support (emotional and practical) which feelsunconditional. For the young people, genuine care was de-scribed as stemming from personal investment rather thana professional obligation or remuneration.

“Like Josie talks to me, not like I’m just someone shehas to work with, she talks to me like she cares”(Carla, 17, YP interview)

From the perspective of LAC, a further way of profes-sionals showing that they cared for a young person was totake a non-judgemental approach and to show uncondi-tional positive regard to the young people under their careregardless of the information they were disclosing. Thiswas reinforced by professionals and foster carers, whomreported LAC disclosing information to them regardinghistorical experiences. Foster carers described having torespond in a sensitive and non-judgemental way.

“We had a young man who had been abused by afamily member. He was feeling guilty himself about itand thought that we would feel disgusted that thingslike that had been done. It is letting him see that weare not disgusted. Straight away, I have heard all ofthis before, you are not the only one. It is not yourfault.” (Carol, female, foster carer, focus group).

This was important to LAC as some participants feltthat they may be judged because of their experiencesleading up to them being placed in care and elected tonot engage for fear that practitioners would not be ableto ‘cope’ with their experiences.

“…my family is ‘f…. up’…really ‘f….. up’. And if I satthere and told someone they’d probably run a mile,they probably would. So that’s why I’ve never reallyopened up to anyone, cause if I did they probablywould run away, do you know what I mean?” (Ewan,17, YP interview)

The above examples highlight the specific skills necessaryto facilitate a therapeutic relationship. Both LAC and profes-sional identified additional practical issues and challengesthat needed to be address within the adapted manuals.

Theme 2: Engagement and challenges of working withlooked after childrenThere was a consensus from all perspectives that trad-itional one-to-one counselling style interactions are oftenunproductive for LAC. Typically this was experienced asoverly formal for LAC who might find this type of inter-action difficult to engage with. Young people commented

on how they found it harder to participate in ‘traditional’formally structured sessions.

“It was like in a room…and like there’s a table thereand it had like little seats round, and like, he was juston about things. Do you know, he didn’t make it verygood, like, he didn’t make it very fun and enjoyablekind of thing. It was just like, boring. He was justwriting things down that I was saying basically and itjust upset me. He just kept on going over it and over itand over it, he was like “so how did that feel? Bla blabla.” I didn’t really feel comfortable” (Isabelle, 13, YPinterview)

The ability for practitioners to work creatively and usevisual strategies such as the ‘node-link mapping’ used inthe International Treatment Effectiveness Project (ITEP)and mood cards whilst staying true to the intervention de-livery was deemed a successful strategy to engage LAC.

“That are not many young people who you’ll get to thepoint where you’re doing that one to one counsellingreally. It is few and far between. You’re being creative…”(Adam, drug and alcohol worker, focus group).

Many LAC wanted other strategies and approaches tobe used to help them connect with professionals, maintainconcentration and become more involved in sessions.

“Writing it down or doing it like arts and crafts waybecause I don’t like just talking and having conversationscause I just get a bit bored and lose track, then I’ll startfiddling about.” (Abbie, 18, YP interview)

A further approach deemed necessary when working withLAC was to explicitly acknowledge the complexities of theirlife due to them being in the care system. This enables a holis-tic approach to be taken within sessions. LAC identified it wasimportant that goals did not focus solely around substanceuse. They valued discussions that recognised the difficultiesoccurring within their lives and facilitated a personalised ap-proach to be taken to meet their needs. Professionals alsoclearly identified that a bespoke approach has to be taken;

“I think what’s coming out here is that with the kids wework with, the drug and alcohol issue is over there, if youlike, and a whole raft of other issues are here. As workerswe’re dealing with all of these here and that tends to sortthe drug and alcohol issues out quite naturally” (Laura,Drug and alcohol worker, focus group)

Frequent placement changes resulted in inconsistentand fragmented support networks for LAC. The transientnature of the LAC population can result in young people

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being eager to find friends even if that results in becominginvolved in unhealthy friendships.

“So they might, you know, have contact with theirbrothers or sisters, you know, it is just they get movedaround, and when they are moved around they arevulnerable, they are desperate to have friends or theyare desperate to have somebody to call their own……people get attracted to them who are, I would say, notthe type of kids I would want my kids to knock aroundwith” (Liz, foster carer, Interview).

This was highlighted as a challenge when workingwith LAC. Whilst social support networks is an expli-cit component of SBNT, LAC and practitioners recog-nised the central part that social interaction andsupport for change plays in any resolution of sub-stance misuse problems.

“It is quite sad sometimes when they haven’t gotanybody in the family, not even an uncle or a cousinor somebody who they can put down as a supportreally” (Steph, social worker, focus group).

The challenges of finding appropriate network memberswas explored, in many interviews LAC struggled to identifysomeone they felt they could turn to, feelings of not havingsupport or the need to be self-sufficient was verbalised;

“My boyfriend and his friends, and there’s a few ofmy friends. Actually they’ve got their own lives aswell, they’ve got their own houses and theirpartners and they’re all settling down as well, so…there’s not really many people there. When youthink about it though, how many of them can youturn to if you’ve got a problem? Cause there’s nota lot” (Abbie, 18, YP interview).

When young people did identify positive support, itwas often people outside of the traditional family sup-port network as would be expected within the LACpopulation. This in itself could be challenging due tothe identified sources of support often being profes-sionals whose ability to provide ongoing or out ofhours support is not always practical as would bepossible from a more traditional family member.

“There’s two main people I’ve got in my life whichprovides me with support. One’s my boss, he’s a farmmanager, I work with him most days. Another person isthe manager of [name of school], he owns the companyand he helps quite a lot by, when I moved out of herethe first time, he’s the one that made me come back, andlet me get my head back” (Philip, 17, YP interview).

Step 5: Co-production of intervention manualsThe preliminary findings from the qualitative interviews andfocus groups were presented within a series of interventionfinalisation workshops that took place to co-produce thefinal intervention manuals. Five workshops were conducted,one with professionals (n= 14) all of whom had been in-volved in step 3 of the process earlier. Four workshops tookplace with young people (n= 13), none of whom had beeninvolved in the study previously, Table 2 provides the demo-graphics of the study participants involved in the qualitativefinalisation workshops.Within the professional workshops, participants were split

into two separate groups and asked to consider either theMET or SBNT intervention and discuss what the final man-uals should ‘look like’. The workshops with young people in-cluded both LAC (n= 5) and non-LAC (n= 8) whom had allexperienced accessing specialist drug and alcohol treatment.The decision to include non-LAC was made as we had diffi-culty identifying LAC who had previously been in treatmentand were still contactable. We wanted to ensure we hadmaximum variation of young people whom had experienceof accessing drug treatment agencies to discuss the devel-oped interventions. We held multiple workshops to enableparticipants to be involved in each active study site withouthaving to travel long distances to take part. The workshopswere all held within the well-established young people’s drugand alcohol services involved in the study so participantswere in a familiar environment. The workshops provided anopportunity for the research team to present the preliminaryfindings to participants and then work collaboratively toco-produce the final manuals.Verbatim quotes were used to identify areas of import-

ance and to facilitate discussion between researchers andparticipants. Table 3 identifies the themes discussedwithin the workshops and the resulting recommenda-tions for intervention development.Within each theme, areas of potential intervention

adaptation were discussed and the findings from the quali-tative interviews, focus groups and workshops have re-sulted in a number of adaptations being made to themanualised interventions. Participants (inclusive of profes-sionals and LAC) made recommendations regarding theneed for additional resources such as worksheets and ex-ercises to be available to support the training of drug andalcohol workers and to complement the adapted manuals.Practitioners requested appointment cards that identifiedappointments were for SOLID as opposed to the usualtreatment services and a pre-treatment session was re-quested to enable practitioners to attempt to build a rap-port prior to commencing sessions.The MET intervention originally consisted of three ses-

sions and was increased to six to enable more time for atherapeutic relationships to be built. The SBNT interven-tions originally consisted of eight sessions and was reduced

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to six sessions, in an attempt to keep the sessions focusedand in turn keep LAC interested and engaged in the workbeing done. However, as the interventions are delivered tomeet the young person’s needs, they could be completed inless than six sessions if appropriate. If more than six ses-sions were required, LAC would be referred into tier 3structured services for further work to take place.Drug and alcohol practitioners are encouraged to con-

sider a range of approaches within sessions including amixture of the traditional therapeutic approach, sessionsinclusive of creative writing, arts and crafts and/or thecompletion of more formal worksheets. Allowing a flexibleapproach to be used in the interventions is hoped to resultin LAC engaging with practitioners using a method theyfeel comfortable with.Following the workshops, thematic analysis of the work-

shop data took place. The qualitative data collected acrossthe different stages of the formative work were analysedseparately in the first instance. However, the data from theinitial set of qualitative interviews and the workshop datawere also considered in conjunction with each other to es-tablish where findings from each stage converged, offeredcomplimentary information on the same issue and whereany data appeared to contradict each other. Once analysishad been completed the final adaptation of both manualstook place. To ensure rigour within the analysis process, anumber of strategies were used. We used the professionalworkshops as a forum to member check our data, 10 of the

professional participants were respondents from whom thedata were originally obtained. The data were presented atstudy management meeting to allow colleagues to discussthe data and ongoing communication took place betweenthe on the ground researchers developing the manuals andthe intervention authors Professor Alex Copello (SBNT)and Dr. Gillian Tober (who has adapted both MET andSBNT for other clinical trials) to ensure the core compo-nents of each approach were retained throughout the adap-tation process.

Discussion/resultsThe current paper gives a step by step guide, based on theMedical Research Council (MRC) framework, of how todevelop and adapt complex interventions [18] using theSOLID study as a case example. The paper focused specif-ically on the process of the interventional developmentand highlights how the interventions were adapted to re-flect the practicalities of working with a LAC population,often presenting with complex needs. The formative workexplored multiple contextual components associated withbeing involved in the care system and participants dis-cussed issues such as stigma, power and lack of control.As far as possible, the manual addressed these issues, spe-cifically revising the training and manuals to focus on theissues of practitioners building trust, providing genuinecare, being non-judgemental, working creatively and hav-ing treatment goals wider than substance misuse. Whilst

Table 2 Qualitative Finalisation workshop participants

Qualitativemethod

Participantgroup

Number ofparticipants

Gender Placement type/Job role Substance use

FinalisationWorkshop

Professionals 14 F = 10,M = 4

Drug and Alcohol worker = 9Social Worker = 1Project support workers = 4

YoungPeople

13LAC = 5Non-LAC =8

F = 7,M = 6

Living with biological family = 6 Non-LACLiving in supported accommodation due tofamily breakdown due to drug use = 1 Non-LACLiving with grandparents due to familybreakdown due to drug use = 1 Non-LACSupported accommodation = 3 LACResidential care = 1 LACFoster care = 1 LAC.

All 13 participants were currently in/or hadpreviously attended specialist drug and alcoholservices

Totalparticipants

27

Table 3 Themes and subthemes and implication for manual adaptation

Theme Subtheme Implications

Therapeuticrelationships

Time and reciprocal self-disclosureGenuine careNon- judgemental approach

Practitioners to make contact with LAC and to have a pre-treatment sessions to engagethe YP to build up a rapport and encourage a relationship prior to commencing work.Therapists to have the option to make safe self-disclosures within the sessions.

Engagement andChallenges

The need to use creative methodsto enhance engagement.YP inability to recognise supportTreatment goals wider thansubstance use.

Resources were developed to complement each session within the MET and SBNTmanuals. The resources provided a worksheet and suggested activities to work in a creativeway with LAC.The original criteria for a ‘network member’ was made more flexible to enable lesstraditional members to engage with sessions and act as a support.Treatment goals could be wider than substance misuse alone.

Alderson et al. BMC Medical Research Methodology (2019) 19:38 Page 9 of 12

it is outside of this process paper to explore the contextualcomponents in depth, a linked paper focusing on the ‘con-ceptualisation of care’ goes some way to acknowledgingthe important components of care (Brown R, Alderson H,Kaner E, McGovern R, Lingam R. "There are carers, andthen there are carers who actually care" Conceptualiza-tions of care among looked after children and care leaver,social workers and carers. Submitted).

Key adaptationsKey adaptations made were: the need to focus upon over-coming insecure attachments and mistrust that LAC haveexperienced by default of being involved in the care systemand the need to be more flexible with social network mem-bers due to the fragmented nature of available support net-works and repeated broken relationships. In a practical sensethe need to use creative non-traditional methods to engageLAC who are known to have lower educational achieve-ments than their peers and to overcome their repeated ex-posed to new workers and services due to moving into newplacements. Finally, the need for treatment goals to be widerthan substance misuse alone to accommodate the diverseneeds of LAC whom are known to have higher rates ofco-morbid mental health problems and higher levels ofrisk-taking behaviours such as drug and alcohol misuse. Itwas essential that a LAC’s needs should be addressed holis-tically as substance misuse rarely happens in isolation butoften interacts with a wider set of problems.Trust was a recurring theme on behalf of LAC and pro-

fessionals. Many studies have shown that maintaining anddeveloping positive relationships are highly important toLAC [22–25]. Young people in our study reported want-ing to build relationships slowly, supporting McLeod’s(2010) argument that young people need time to get toknow their workers before they feel comfortable sharingtheir personal thoughts and feelings [26]. One likely ex-planation for this is the likelihood of a LAC experiencingdisorganised attachment patterns due to having previousviolations of trust such as rejection from their birth family,repeated broken relationships, broken promises and beinglet down in the past [27, 28]. The SBNT approach withinthis study attempted to establish a broader support net-work that would facilitate the emergence of positive rela-tionships that could continue beyond the interventiondelivery. In effect the supportive therapeutic relationshipwas between the young person and their trusted adult, thisrelationship was facilitated by the drug and alcoholworker. This is the key difference between SBNT andMET. This approach would help to negate against any un-intended consequences that may occur when the treat-ment episode finishes and the practitioner element of thecare relationship ends. To facilitate and encourage trustbetween the practitioner and the LAC it was suggestedthat practitioners could make ‘safe self-disclosures’ within

sessions. Furthermore, a pre-assessment session was writ-ten into the manual to enable practitioners to contact theyoung person and have an informal ‘chat’ with them priorto commencing any sessions. The pre-assessment sessionallowed the practitioner to discuss with the young persontheir preferred way to engage inclusive of preferred times,days, methods of engagement and to arrange their first ap-pointment. For both the MET and SBNT approaches, It isimportant to consider the ‘ethic of care’ concept. Practi-tioners need to understand the relational aspects presentwithin the lives of LAC as the nature of care is complexand in fact LAC often define care by its absence [29].There is a need to understand that care may be experi-enced by LAC as oppressive as for many young people thereceipt of statutory care is involuntary [30].The current qualitative study highlighted the importance

of LAC feeling respected and having their voices heard. Thistranslated within the workshops to a co-produced interven-tion wherein the LAC sets the agenda and pace of work.This is a common finding of research into young people’s ex-perience of service usage [23, 26] and LAC in particular havebeen found to want choice, control and more involvement indecision making [27, 29, 31], perhaps because they havelacked control in other areas of their lives. It was thereforerecommended that practitioners work in a person centredway to attempt to address the stated needs of LAC.In response to feedback, hand-outs and worksheets

were developed to complement each session and the man-ual identified how activities could be used to keep LACengaged both within and between sessions. Due to LAChaving lower levels of functional literacy, the use of cre-ative/visual approaches enables LAC to express theirthoughts and felling more easily [32, 33]. The trainingwith practitioners acknowledged that traditional counsel-ling style sessions may be abandoned to opt for a more in-formal setting such as a coffee shop or fast food restaurantas long as confidentiality could be upheld. Approachessuch as Multisystemic therapy (MST), Multidimensionalfamily therapy (MDFT) and Functional family therapy(FFT) have shown that the ability to be flexible regardingthe time, place and frequency of client contact is crucial toimproving engagement and retention [12, 34, 35].The manual and training were adapted to acknowledge

that LAC may struggle to adhere to one of the traditionalcriteria of a ‘network member’, that of a network member be-ing ineligible if they ‘have an alcohol or drug misuse problemthemselves’. This may be problematic as it is known that25% of LAC in foster care and 42% of LAC in residentialcare drank alcohol at least once a month [2] 32% smokedmarijuana daily [3] and 11.3% of LAC aged 16–19 years hada diagnosed substance use problem [36]. This alongsideplacement instability and multiple broken relationshipsmakes maintaining positive support networks problematic[29, 37] which as identified above reinforces the benefits of

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delivering the adapted SBNT intervention. Additionally, thelimited ability of LAC to identify sources of support, evenwhen support was actually available, reinforced what theadapted SBNT intervention was trying to achieve, that ofhelping LAC to identify sources of support currently withintheir life.The manual still identifies an ideal network member how-

ever the training discussed scenarios when the criteria canbe amended to enable LAC to bring a supportive individualto sessions. The manual emphasised the importance forLAC to sustain engagement by widening the reach of theintervention beyond the traditional family. This was signifi-cant as young people presenting with substance use prob-lems often come from disrupted families and traditionalsystemic family approaches may be problematic to deliver insuch situations [38]. The manual stressed that the networkcould be extended to include supportive peers, or other fig-ures perceived as being important by the LAC including e.g.teachers, social workers or possibly wider family memberssuch as grandparents, all of the latter with potential to pro-vide sustained and more secure attachments. The ability ofsupport network to be inclusive of broader and more infor-mal networks is important, especially for LAC who receiveprimary care outside of the more ‘traditional caregivers’ [29].Finally, both interventions reinforced the recognition for

practitioners to be flexible and responsive to the young per-son’s needs by designing the manuals in such a way thattopics did not have to run in a set order, practitioners couldorganise sessions and deliver the content in a way best suitedto the young person. Regarding SBNT, the original approachof having core and elective topics is designed to allow a flex-ible approach to be taken, this was emphasised when devel-oping the manual for LAC. Literature identifies that it iscrucial to ensure that interventions address issues of concernfor the young person rather than following a strict plan thatdoes not address their needs [34]. Additionally, the manualsenabled practitioners to have the flexibility to focus on theyoung person’s identified goal regardless of whether it wasspecifically to address their substance misuse. It was essentialthat a young person’s needs should be addressed holisticallyas substance misuse rarely happens in isolation but it ofteninteracts with wider problems [39, 40]. The rationale for thisdecision was that if other areas of concern for the young per-son were addressed it may by default impact positively upontheir levels of substance use.

ConclusionTo our knowledge this is the first study to describe theprocess of intervention adaptation with LAC, carers, drugand alcohol workers and social workers to refine and developtwo evidence based behaviour change interventions. Overallfindings highlight the importance of co-production with thisgroup of young people and suggested that whilst originalcomponents of both interventions were feasible to deliver

and acceptable, specific adaptations had to take place. Keyareas included increased emphasis upon therapeutic relation-ships, the benefits of using creative non-traditional methodsof engagement and identification of treatment goals widerthan those narrowly focused on substance misuse. Thispaper provides an example of using the MRC framework tocollect multiple perspectives to refine an intervention to de-crease drug and alcohol use and support mental health ofLooked after Children in the UK at scale.

AbbreviationsBDI: Behaviour Determinant Intervention; FFT: Functional family therapy;ITEP: International Treatment Effectiveness Programme; LAC: Looked afterchildren and care leavers; MDFT: Multidimensional family therapy;MET: Motivational Enhancement Therapy; MI: Motivational Interviewing;MRC: Medical Research Council; MST: Multi systemic therapy; NICE: NationalInstitute for Health and Care Excellence; PPI: Public and Patient Involvement;PR: Parental Responsibility; SBNT: Social Behaviour and Network Therapy;SOLID: Supporting Looked After Children and Care Leavers In DecreasingDrugs, and Alcohol); UK: United Kingdom; YSBNT: Youth Social Behaviourand Network Therapy

AcknowledgementsWe thank all Local Authority areas for their participation in this study, and allparticipants for giving their time to participate in interviews and/or focusgroup discussions.

FundingSOLID is funded by NIHR Public Health Research Programme, trialRegistration number ISRCTN80786829 (first registered 06.06.2016). Thefunders have received regular reports from the lead author on progress ofthe study. The funders have not been involved in the design of the study,data collection, data analysis, interpretation of data, or the writing of thismanuscript.

Availability of data and materialsThe datasets used and/or analysed during the current study are availablefrom the corresponding author on reasonable request.

Authors’ contributionsRL, RM, EK and AC are co-applicants and are responsible for designing the re-search. RL was the original, EK is the current Principle investigator and HA isthe project co-ordinator of the SOLID pilot feasibility trial. HA, RB and RMhad responsibility for completing the qualitative research. HA, RB, RM, ACand GT have responsibility for intervention development and adaptation.All authors have made an intellectual contribution to this research paper. HAwrote the first draft of the paper and all authors (RB, AC, EK, GT, RL and RM)have input into drafts and have read and approved the final version of themanuscript.

Ethics approval and consent to participateThe study has been granted a favourable ethical opinion by Newcastle andNorth Tyneside 1 NRES Committee (16/NE/0123). Newcastle University actedas trial sponsor. The SOLID Management Group have been responsible forensuring the appropriate and timely implementation of the trial. A TrialOversight Committee has been appointment to oversee trial progress withparticular attention paid to recruitment, retention, adherence to trialprotocol, participant safety and any new information deemed relevant to theresearch question.Written informed consent was obtained for all participants, inclusive ofassent from LAC under 16 years of age and consent from their corporateguardian.

Consent for publicationNot applicable.

Competing interestsThe authors declare that they have no competing interests.

Alderson et al. BMC Medical Research Methodology (2019) 19:38 Page 11 of 12

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Author details1Institute of Health and Society, Newcastle University, Newcastle Upton Tyne,UK. 2School of Psychology, University of Birmingham, Birmingham, UK.3Leeds Addiction Unit, 19 Springfield Mount, Leeds, UK. 4Faculty of Medicine,University of New South Wales, Sydney, Australia.

Received: 2 July 2018 Accepted: 7 February 2019

References1. Department for education, Statistics. Looked-after children and looked-after

children and adoption. London: Department for Education; 2017.2. Meltzer H. The mental health of young people looked after by local

authorities in England. London: H.M.S.O; 2003.3. Ward J, Henderson Z, Pearson G. One problem among many: drug use

among care leavers in transition to independent living. London: HomeOffice, Research, Development and Statistics Directorate; 2003.

4. Office for National Statistics, Drug misuse. Findings from the 2016/2017crime survey for England and Wales. London: ONS; 2017.

5. Blyth, L., Outcomes for Children Looked After by Local Authorities inEngland, as of 31 March 2012. 2012, Office of National Statistics.

6. Ford T, et al. Psychiatric disorder among British children looked after bylocal authorities: comparison with children living in private households. Br JPsychiatry. 2007;190:319–25.

7. Webb E. Children and the inverse care law. Br Med J. 1998;316:1588–91.8. National Institute of Clinical Excellence, Interventions to reduce substance

misuse among vulnerable young people: Evidence Update April 2014. 2014.9. Department of Health England, Annual report of the Chief medical officer 2012. Our

children deserve better: prevention pays. 2013, Department of Health: London.10. Lundahl BW, et al. A meta-analysis of motivational interviewing: twenty-five

years of empirical studies. Res Soc Work Pract. 2010;20(2):137–60.11. Tevyaw T, Monti P. Motivational enhancement and other brief interventions

for adolescent substance abuse: foundations, applications and evaluations.Addiction. 2004;99(2):63–75.

12. Watson, J., et al., Youth Social Behaviour and Network Therapy (Y-SBNT)adaptation of a family and social network intervention for young peoplewho misuse alcohol and drugs- a randomised controlled feasibility trial.2017. 21(15).

13. Miller WR, A. Zweben, Carlo DSW, Di Clemente C, Rychtarik RG,, MotivationalEnhancement Therapy Manual: A Clinical Research Guide for TherapistsTreating Individuals With Alcohol Abuse and Dependence. Project MATCHmonograph series ed. M.E. Mattson. 1999: NIH publication.

14. Dennis ML, Funk R, et al. Cross-validation of the alcohol and cannabis usemeasures in the global appraisal of individual needs (GAIN) and timelineFollowback (TLFB; form 90) among adolescents in substance abusetreatment. Addiction. 2004;99(2):120–8.

15. Carney T, Myers B. Effectiveness of early interventions for substance-usingadolescents: findings from a systematic review and meta-analysis. SubstAbuse Treat Prev Policy. 2012;7:25.

16. McCambridge J, Strang J. The efficacy of single-session motivationalinterviewing in reducing drug consumption and perceptions of drug-related risk and harm among young people: results from a multi-site clusterrandomized trial. Addiction. 2004;99:39–52.

17. Copello A. Social behaviour and network therapy for alcohol problems.London: Routledge; 2009.

18. Medical Research Council, Developing and evaluating complexinterventions: New guidance. 2006, MRC: London.

19. Alderson, H., et al., Supporting looked after children and care leavers in decreasingdrugs, and alcohol (SOLID): protocol for a pilot feasibility randomised controlled trialof interventions to decrease risky substance use (drugs and alcohol) and improvemental health of looked after children and care leavers aged 12 -20 years: studyprotocol. Pilot and feasibility studies, 2017. 3(25).

20. Braun V, Clarke V. Using thematic analysis in psychology. Qualitativeresaerch in psychology. 2006;3(2):77–101.

21. Donovan J, Sanders C. Key issues in the analysis of qualitative data in healthservices research. In: Bowling A, Ebrahim S, editors. Handbook of health

research methods : investigation, measurement and analysis. Maidenhead:Open University Press; 2005. p. 515–32.

22. Morgan R. Children’s caremonitor: children on the state of social care inEngland. London: OFSTED; 2014.

23. Duncalf Z. Listen up! Adult care leavers speak out. The views of 310 careleavers aged 17–78. Manchester: The care Leavers Association; 2010.

24. Selwyn J. Children and young people's views of being in care: a literaturereview. Bristol: University of Bristol; 2015.

25. Timms J, Thoburn J. Your shout!: A survey of the views of 706 children andyoung people in public care. London: NSPCC; 2003.

26. Mcleod A. ‘A friend and an equal’: do young people in care seek theimpossible from their social workers? Br J Soc Work. 2010;40:772–88.

27. Gaskell C. If the social worker had called at least it would show they cared. Youngcare leavers perspectives on the importance of care. Child Soc. 2010;24(2):136–47.

28. Hiles D, et al. Young people’s experience of social support during theprocess of leaving care: A review of the literature. Child Youth Serv Rev.2013;35:2059–71.

29. Holland S, et al. How was your day? Learning from experience: Informingpreventative policies and practice by analysing critical moments in careleavers life histories. Cardiff: Cardiff University; 2010.

30. Collins, S., Ethics of care and statutory social work in the UK: criticalperspectives and strengths. Practice, 2017: p. 1–16.

31. Jobe A, Garin S. ‘If kids don’t feel safe they don’t do anything’: youngpeople’s views on seeking and receiving help from children's social servicesin England. Children and Family Social Work. 2012;18(4):429–38.

32. Barlow J. Using educational drama to improve outcomes for Looked afterChildren. Scot J Resid Child Care. 2011:11(1).

33. Slayton S, D'Archer J, Kaplan F. Outcome studies on the efficacy of arttherapy: a review of findings. Art Ther. 2010;27(3):108–18.

34. Henggeler S, et al. Eliminating (almost) treatment dropout of substanceabusing or dependent delinquents through home-based multisystemictherapy. Am J Psychiatry. 1996;153:427–8.

35. Sexton T, Alexander J. Functional Family Therapy Clinical Training Manual.Baltimore: Casey Foundation; 2004.

36. Blyth, L., Outcomes for Children Looked After by Local Authorities inEngland, as of 31 March 2013. 2013, Office of National Statistics.

37. Selwyn J, Saunders H, Farmer E. The views of children and young people onbeing cared for by an independent foster-care provider. Br J Soc Work.2010;40(3):696–713.

38. Boys A, et al. Psychiatric morbidity and substance use in young peopleaged 13-15 years: results from the child and adolescent survey of mentalhealth. Br J Psychiatry. 2003;182:509–17.

39. Public Health England. Specialist substance misuse services for youngpeople: a rapid mixed methods evidence review of current provision andmain principles for commissioning. London: PHE; 2017.

40. Kipping R, et al. Multiple risk behaviours in adolescence. J Public Health.2012;34(suppl_1):i20–30.

Alderson et al. BMC Medical Research Methodology (2019) 19:38 Page 12 of 12