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KFP RESEARCH PROPOSAL

Knowledge for Practice (KFP) Project

Ashlee Johnstone, Abigail Patschorke, and Leigh Ann Tanner

College of Social Work, University of South Carolina

SOWK352: Social Work and Scientific Inquiry

30 April 2023
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Part I: Separation Anxiety in Foster Care

Description of the Problem

Meeting the needs of children in the United States has become a national priority. Giving

our youth the resources needed to succeed within this country is vital for a prosperous nation. A

key component of this is knowing what foster care is. Foster care is the temporary custody or

guardianship of children whose parents are deceased or unable to care for their children

adequately. Foster care is intended to be a temporary situation, but for some, it is long-term,

eventually aging out of the system and left to survive on their own. This can result in the

development of many mental health issues stemming from their past and reflecting upon their

experience in the foster care system.

A specific mental health issue that sticks out within the foster care system is separation

anxiety. Separation anxiety disorder is the anxiety provoked in a child by separation or the threat

of separation from home or an attachment figure. The foster care system has been known to

cause mental health problems. It is imperative to recognize that there is a problem with the foster

care system and the mental health of children is at risk.

Significance of the Problem

Prevalence of Separation Anxiety

The U.S. Department of Health and Human Services, Administration for Children and

Families 2020 report stated a total of 407,493 children are in foster care as of September 30,2020

(Administration on Children, Youth, and Families, 2021). Although this is a decrease from the

426,566 children in foster care in 2019, there is still a global crisis of children and adolescent

mental health (Administration on Children, Youth, and Families, 2021). The rate of childhood

anxiety has increased from 11.6% before COVID-19 to 19% post-pandemic. Childhood mental
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health is on an incline, which places foster children at a greater risk of developing mental health

disorders, such as separation anxiety disorder.

Approximately 60% of children placed in foster care have a lifetime prevalence of mental

health disorders, and almost half of them present with clinically significant mental health

difficulties during foster care (Engler et al., 2020). A study that examined the prevalence of

mental disorders in 6- to 12-year-old foster children showed that out of the 279 children in the

sample population living in foster families for at least five months, 21, 7.5% met the criteria for

Separation Anxiety Disorder (Lehmann et al., 2013).

Effect on Children in Foster Care

The National Institute of Mental Health suggests that children exposed to the child

welfare system have a greater need for mental health services (Bruskas, 2008). Their sample of

foster children showed that almost half exhibited clinical signs of mental health issues, only 4%

received mental health care and 84% did not receive any. There is a greater need to understand

the perceptions and experiences of foster children to avoid the development of clinical mental

disorders, including separation anxiety disorder (Bruskas, 2008).

The development of separation anxiety has been linked to biological, psychological, and

environmental vulnerabilities (Eisen et al., 2007). Separation anxious events, such as foster

placement, are environmental vulnerabilities in children (Eisen et al., 2007). Psychological

vulnerabilities such as attachment also greatly impact foster children and are associated with

insecure-ambivalent resistant (anxious) parent-child attachments (Eisen et al., 2007). Insecure

anxious attachment develops when an infant's needs are not met by their caregiver. This may

result in the child's placement into foster care, putting the children in foster care at risk of

developing a separation anxiety disorder.

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Significance of Separation Anxiety to Foster Children

Children who have experienced trauma, such as parental separation, are more likely to

exhibit externalizing behavior upon their foster placement, including disruptive behaviors,

impulse control, and conduct disorders. Not addressing these externalizing behaviors is a risk

factor for an increased number of foster home placements, leading to a decreased likelihood of

parental reunification (Engler et al., 2020).

Separation anxiety has short-term and long-term effects on children with separation

anxiety (Eisen et al., 2007). It was reported that 73% of children between the ages of seven and

thirteen suffer from panic attacks. They also experience exacerbated fears of being alone, and

abandonment causes the child to avoid certain areas of their home, become the shadow of their

caregivers, protest parental separation, and avoid attending events on their own, resulting in

social isolation. Somatic complaints and fear of psychical illness are other effects caused by

separation anxiety. Frequent headaches, stomach aches, and muscle/joint pain have been reported

in between 10% and 30% of children. Somatic complaints are typically in response to anticipated

anxiety, and physical symptoms are exaggerated to gain attention or postpone separation (Eisen

et al., 2007).

Proposed Research

Purpose of the Study

The purpose of this study is to specifically identify how common it is for children in

foster care to develop separation anxiety disorder. It will also be important to recognize how

separation anxiety disorder can affect children who grow into adults. This can affect future

relationships between family, friends, and partners. We will identify the causes of separation

anxiety and how foster care plays a role in intensifying that disorder.
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Significance of Proposed Research

Need for Further Research. The statistics regarding separation anxiety in children within the

foster care system highlight the need for further research. Separation anxiety can show up in

several ways and it is important to be aware of the multiple signs of this in foster care children.

Illinois Child Welfare Agency, Camelot Care, speaks to this in saying, “For children in foster

care, Separation Anxiety can manifest in a number of ways, from behavior and sleep issues to

headaches and nausea. Children may seem sad and withdrawn, overly fearful, or easily agitated.”

These symptoms can be easily overlooked, and further research will increase awareness of the

disorder, its symptoms, and the necessary treatments for children in foster care.

Relation to Social Work. This topic is especially important in relation to Social Work because

social workers play a crucial role in the foster care system. They work to strengthen families and

identify permanent connections for children (NASW, 2023). Often in the foster care system, the

social worker is the child’s only picture of stability in their lives. In relating this topic to social

work practice, it is important that social workers in the foster care system are aware of the direct

impact the foster care system has on children developing separation anxiety disorder. In learning

more about the impact of this system, social workers within it will be more attentive to the

factors that increase the likelihood of developing separation anxiety. This attentiveness will help

social workers serve the children in the foster care system to the extent in which they deserve,

providing stability and safety when they need it most.

Impact on Service and Practice. By answering the research question, the information could

improve the way social workers and foster care parents care for children, which could improve

the overall development of the child. When the root of an issue is uncovered by learning what

factors are increasing the likelihood of separation anxiety disorder, interventions can be better
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planned to help children who are presenting symptoms. By using research that focuses on the

direct cause of separation anxiety in the foster care system to shape interventions, children will

be able to process what they have experienced and have healthier relationships as they grow into

adults.

Practice-Based Question

What characteristics of foster care cause separation anxiety disorder among children in

foster care?

Part II: Literature Review

The proposed study addresses what characteristics of foster care cause (or prevent)

separation anxiety disorder among children in foster care. Our literature directly reflects the

objective to see the development of children in foster care if separation anxiety occurs and how

to prevent or identify when these characteristics come into the picture. Our risk factors to

consider within our research are trauma of separation with stability, emotional attachment to the

foster family, and sibling relationships. The literature represented directly reflects these risk

factors and can help understand how to prevent further development within the foster care

system.

Trauma of Separation

Two studies suggested that the trauma of separation may be a risk factor for the

development of separation anxiety in foster children (Miranda et al., 2020; Palmer, 1990).

Miranda and colleagues (2020) conducted a cross-sectional qualitative research study exploring

the experiences of foster care alumni. They utilized narrative inquiry among six participants who

entered foster care between ages three and nine (Miranda et al., 2020). The sample was collected

through referral requests of adults from child welfare and foster care agencies in Northeast Ohio
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who had been placed in non-related foster care. They found that foster care does have long-term

implications on attachment, and the experience of being in foster care is generally perceived as

negative. However, due to the small sample size, there is not much data to test variability by

comparing experiences and outcomes. The need for a small sample size was due to resource

constraints causing a limited amount and time for interviews affecting the credibility of the

findings (Miranda et al., 2020).

Palmer (1990) conducted a cross-sectional mixed methods study to evaluate the use of

group treatment programs to resolve separation conflicts and their impact on placement stability.

They used purposeful sampling when selecting their sample of 46 foster children to receive

group treatment (Palmer, 1990). Focus groups were used to gather information on the treatment,

followed by narrative research to analyze the feeling and experiences of the children and the

reactions of the leaders. Their quantitative analysis was reported to be inconclusive, likely due to

multiple influences on placement stability that defy measurement (Palmer, 1990). Since these

studies (Miranda et al., 2020; Palmer, 1990) were conducted among predominately white

individuals, the implications of children’s experiences in foster care may not apply to other racial

populations.

Relationship to Foster Family

There are two studies found to examine emotional attachment to foster families as a risk

factor for separation anxiety disorder in children. The first study looks at the influence of foster

mothers’ investment and how that may affect a child’s representation of self and others

(Ackerman and Dozier, 2005). This study can be used to assess how a foster mother’s emotional

investment may affect the chances a child has of developing separation anxiety disorder. The

National Institute of Mental Health funded a longitudinal study that consisted of 39 mother-
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infant dyads as participants (Ackerman and Dozier, 2005). If infants had entered care between

birth and 20 months, they were included in the population studied. The study assessed foster

mothers’ investment when the children were 2 years old, and then assessed the child’s

representation of themselves and others when the children were 5 years old. They then used the

Separation Anxiety Test to examine the child’s ability to cope with separation from caregivers.

The study found that foster mothers who were more accepting of the children early in the

relationship had foster-children who showed more positive representations of themselves than

children whose foster mothers were less accepting and involved. It was also found that this

acceptance and involvement was associated with the way foster children cope with separation,

with higher levels of acceptance producing more positive coping in situations of separation.

(Ackerman and Dozier, 2005). Since this study was longitudinal and took place over the course

of a few years, there is a possibility that several factors could have affected the children’s

representation of themselves, as well as their performance on the separation anxiety test. The

study only considers the effects based on the mothers’ investment and leaves out any other events

that could affect the child’s development of separation anxiety disorder. There was also an issue

in the sample, as they originally planned for 120 children in the sample. Only 39 children

remained in the same foster family for the duration of the study, leading to a smaller sample size

(Ackerman and Dozier, 2005).

The second study examines how the attachment to the foster family can affect future

relationships with biological family or adopted parents. The study addresses the decision-making

process surrounding the choice of keeping attachment ties made with the foster family, or

reintegration with their biological family if possible (Gauthier, Fortin, and Je’liu, 2004). The

study follows an attachment clinic in Montreal that provides assessment and intervention to
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children ages 0–6-years-old, as well as their families attempting to prevent attachment disorders

(Gauthier, Fortin, and Je’liu, 2004).

A typical example of a day in the clinic is given in the article. The first step is the youth

protection workers meeting with the clinic staff to present the information on the child. After all

workers have the necessary information on the case, the child meets with the workers along with

their biological and foster parents. After conversation with both sets of parents, the foster parents

are asked to step out and the staff assess the child’s reaction to the separation. When the meeting

is over, the clinician and youth protection workers discuss the observations made of the child and

the youth protection worker validates any observation since they follow the case more closely.

The results are then separately presented to both parents with the emphasis that the decision is

made based on their perception of the child’s attachment ties, not the parents’ competency

(Gauthier, Fortin, and Je’liu, 2004).

The study found that if a child is well cared for in a foster family that is fully invested in

them, they are likely to have healthy attachment ties to them and develop at a regular pace

(Gauthier, Fortin, and Je’liu, 2004). The biggest weakness of this study would be that it takes a

clinical perspective instead of a research perspective. I think it would be stronger to research

what it looks like when children are reunited with their families versus those that stay in foster

care when positive attachment ties are formed.

Sibling Relationships within the Foster Care System

The first article presenting the chosen risk factor is, Sibling relationships of youth in

foster care: A predictor of resilience. This journal supports that sibling relationships within the

foster care system are among the most important. Having siblings interact with each other in the

foster care system with the possibility of separation is devastating. This can cause a high risk of
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separation anxiety disorder. However, it has been reported that a higher quality sibling

relationship can cause an overall lower depression rate (Wojciak, 2018). This study can be

slightly inaccurate due to a research gap. Two- thirds of foster care children have siblings, but

70% of them get separated in out-of-home placement (Wojciak, 2018). I think that the research

method used has flaws due to the population that was surveyed are those that have siblings with

them in the foster care system. To have an accurate statistic for this issue, all the kids within the

foster system with siblings would need to be surveyed. This would then give social workers more

of an inside view of how the children feel regarding separation or togetherness of siblings.

As for the sampling of foster care children in these situations, a random sample of all

U.S. families involved in the child welfare system was taken. I think that this is inaccurate

because not all the families would necessarily have siblings to relate to the survey. I think that

this population of interest does relate to our research, but I believe that the sample size would

have to be broader to get a consensus. I think that the strength of the research is that it is

thorough and very specific to the child welfare system. The methodology of the research is very

solid and clear to what they are specifically trying to figure out. I think it would be beneficial for

our research to create a larger sample size for a more accurate result of the effect of siblings’

attachment on separation anxiety.

Another article representing the presenting risk factor, is the Sibling relationships in

adoptive and fostering families: A review of the international research literature study. This study

is very similar to the first journal reviewed regarding siblings' relationship with separation

anxiety. This journal supports that sibling relationships within the foster care system is among

the most important. This journal finding uncovered the reality that if you have a sibling with you

in foster care this will make you happier than children with no siblings together in foster care.
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Evidence supports the conclusion that sibling placements are as stable as, or more stable than

placements of single children or separated siblings. It is important to note that placement moves

are a common feature of children’s experience.

Wulczyn and Zimmerman’s (2005) analysis of children’s experiences over a four-year

period showed some sharp variations in the placement of siblings with around half of siblings

completely separated at entry to care being fully reunited in care at a later p oint I think that the

research method used has flaws due to the population that was surveyed are those that have

siblings with them in the foster care system (Jones, 2015). To have an accurate statistic for this

issue, all the kids within the foster system with siblings would need to be surveyed. This study is

more about the placement of siblings together or separated and how that can affect a sibling's

relationship in the future. This is a beneficial study to look at regarding our research question

because it gives us insight on how the placement of siblings together or separate can affect

overall health for children. Again, there are some issues within the research due to not all siblings

being surveyed. A random sample of children in foster care could potentially have an outcome of

all children with siblings or an outcome of all children without siblings.

Rationale of Proposed Study

This proposed study contributes to the existing literature by overcoming the weaknesses

outlined above. Researchers have examined the experiences of children in foster care and how it

has affected their resilience (Wojciak, 2018; (Miranda et al., 2020). However, the research does

not examine possible risk factors that lead to the development of separation anxiety disorder. In

the proposed study, we examine how particular relationships in a child’s life and their separation

experience puts them at risk for separation anxiety disorder, likely affecting their future

relationships. This research is important to identify risk factors to be avoided within the foster
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care system during the separation process and placement decision. The current studies also lack

diversity in their samples, decreasing the generalizability of all foster care children, regardless of

race or setting. The proposed study will use a larger and more diverse sample population to

increase the generalizability of the research findings.

Part III: Methods

Research Design

We will conduct a qualitative study using narrative research to explore the lived experiences of

children in foster care. The study will analyze data collected from the stories and experiences of

children during their time in a foster placement through diary entries and interviews. The goal of

our study is to identify potential risk factors for the development of separation anxiety disorder

to address our EBP question, What characteristics of foster care cause separation anxiety disorder

among children in foster care?

Strengths and Weaknesses

We want to maintain the trustworthiness of our study by representing the perspectives of

our research participants as closely as possible to their lived experiences. There is the potential

for researcher and respondent bias, posing a threat to the trustworthiness of our study. Researcher

bias may result in the participant's stories, journal entries, and interviews being misinterpreted by

our researchers. Our participants may also alter their experiences to appear socially desirable.

These biases also pose a potential threat to the credibility of our study.

To enhance trustworthiness and establish credibility for our study we will utilize

prolonged engagement by collecting data through several interviews and various diary entries

over an extended period to ensure a complete understanding of the participant's experiences. Our

data collection through multiple sources also ensures trustworthiness through the use of
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triangulation. Another strategy we will use is peer briefing by meeting with experts in the mental

health field of children and adolescents and other qualitative researchers to discuss research

decisions and procedures.

Rationale

The lived experiences of children in foster care can be categorized as a complex and

sensitive issue, which is why a qualitative research design is the best option for our study

because of its special value for investigating complex and sensitive issues. Qualitative research

provides the appropriate methodology for understanding the participants' experiences during

their time in foster placement and enables us to study development patterns over time. Narrative

research allows us to understand the life of our participants by collecting data through interviews

and diary entries, then analyzing the data for patterns to help us identify the potential risk factors

for separation anxiety disorder.

Sampling Design

How will we do it?

We will look at the foster homes in South Carolina. Ideally the sample size would be 150

children who entered the system between ages of 18 months- 6 years old with a duration of

spending at least 6 months in their placements. This would happen by sampling the children

during their meeting with their social worker as required by the state.

Type of sampling

Non-probability sampling is nonprobability sampling involves the intentional selection of

certain participants to gather information about members of a specific group or people with

specific insight into a particular area. Purposeful sampling is when researchers who have a

definitive purpose in mind and are seeking specific pre-defined groups may use purposive
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sampling. Purposive sampling may be useful when proportionality isn't a concern and instead,

you're hoping to reach a targeted sample of a population quickly.

Rationale

These samples chosen will best fit our method. To accurately acquire data, this requires a

specific population and hope to reach a specific target audience.

Data Collection/Measurement

Variables Measured

In our study, we will collect data on children’s experiences in the foster care system regarding

their separation, relationships with foster family, and their connection to their biological families.

We will then assess if there are any symptoms of separation anxiety as a result of these

experiences.

Type of Intervention and Tools Used

The type of intervention we will use is an interview process, as well as assessing journal

entries the interviewees will write over the course of the process regarding their experiences. We

will begin the process with an initial interview, discussing the purpose of the process with the

interviewee and their foster parents. The child’s foster care social worker will conduct the

interview and provide them with the journal to keep their diary entries in. The questions asked in

the interview will be about the child’s separation, their relationships with members of their foster

families, and their current connection to their biological families. Some example questions would

include the following:

1. When was the child first placed in the foster care system?

2. How many different times has the child experienced separation?

3. How did the child cope with the separation they experienced?
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4. Does the child get along with each member of the foster family they are currently with?

5. How does the child feel when they are separated from their foster family for short periods

of time?

6. What role does the child take on within their foster family?

7. Does the child have any siblings?

8. Are the siblings of the child in the same foster family as the child?

9. How do the siblings act and feel when they are together versus not together?

10. Would the siblings rather be in the same foster families or different ones?

The children who are older will be asked questions like these directly, and the younger

ones will have their foster parents answer for them. The children will also receive a journal to

write in before meetings about their own experiences regarding these topics. The social worker

will give prompts to guide their journal writing process, and they will read it and discuss it in

depth at the time of their next meeting.

Timeline for Measurement

In terms of the timeline for our study, it will last around 3 years to see the children’s

growth throughout their years in the foster care system. The interview meetings with their social

worker would be once a month, where they would discuss the journal prompts from that month.

The social worker would assess symptoms of separation anxiety at each meeting based on what

they found in the meeting and journal entries.

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References

Ackerman, J. P. (2005). The Influence of Foster Parent Investment on Children's Representations

of Self and Attachment Figures. Journal of Applied Developmental Psychology.

https://www.sciencedirect.com/science/article/pii/S019339730500050X

Administration on Children, Youth and Families. (2021, October 4). The AFCARS Report.

Children’s Bureau. Retrieved February 17, 2023, from

https://www.acf.hhs.gov/sites/default/files/documents/cb/afcarsreport28.pdf

Benton, T. D., Boyd, R. C., & Njoroge, W. F. M. (2021). Addressing the Global Crisis of Child

and Adolescent Mental Health. JAMA Pediatrics, 175(11), 1108–1110.

https://doi.org/10.1001/jamapediatrics.2021.2479

Bruskas, D. (2008). Children in foster care: A Vulnerable Population at Risk. Journal of Child

and Adolescent Psychiatric Nursing, 21(2), 70–77. https://doi.org/10.1111/j.1744-

6171.2008.00134.x

Eisen, A. R., & Schaefer, C. E. (2007). The Nature of Separation Anxiety. In Separation Anxiety

in Children and Adolescents: An Individualized Approach to Assessment and Treatment

(pp. 3–15). essay, The Guilford Press.

Engler, A. D., Sarpong, K. O., Van Horne, B. S., Greeley, C. S., & Keefe, R. J. (2020). A

Systematic Review of Mental Health Disorders of Children in Foster Care. Trauma,

Violence, & Abuse, 23(1), 255–264. https://doi.org/10.1177/1524838020941197

Gauthier, Y., Fortin, G., & Jéliu, G. (2004). Clinical Application of Attachment Theory in

Permanency Planning for Children in Foster Care: The Importance of Continuity of Care.

Infant Mental Health Journal, 25(4), 379–396. https://doi.org/10.1002/imhj.20012

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Jones, C. (2015). Sibling relationships in adoptive and Fostering Families: A review of

International Research Literature. Children & Society, 30(4), 324–334.

https://doi.org/10.1111/chso.12146

Lehmann, S., Havik, O. E., Havik, T., & Heiervang, E. R. (2013). Mental Disorders in Foster

Children: A Study of Prevalence, Comorbidity and Risk Factors. Child and Adolescent

Psychiatry and Mental Health, 7(1), 39. https://doi.org/10.1186/1753-2000-7-39

McWey, L. M., Waid, J. & Wojciak, A. S., (2018). Sibling Relationships of Youth in Foster Care:

A Predictor of Resilience. Children and Youth Services Review, 84, 247-254.

Miranda, M., Tadros, E., & Molla, E. (2020). The Experience of Foster Care and Long-Term

Attachment. The American Journal of Family Therapy, 48(1), 87–106.

https://doi.org/10.1080/01926187.2019.1679053

News. NASW, National Association of Social Workers. (n.d.). Retrieved February 19, 2023, from

https://www.socialworkers.org/News/1000-Experts/Media-Toolkits/Foster-Care

Palmer, S. E. (1990). Group Treatment of Foster Children to Reduce Separation Conflicts

Associated with Placement Breakdown. Child Welfare, 69(3), 227–238. Retrieved April

5, 2023, from https://www.jstor.org/stable/45394089.

Understanding Separation Anxiety in Foster Care Children. Camelot Care Centers. (n.d.).

Retrieved February 19, 2023, from

https://camelotcarecenters.com/2019/08/23/understanding-separation-anxiety-in-foster-

care-children/
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