The Care Trajectories and Nature of Care Received by Children Aged 5–11 Who Are in Need of Therapeutic Residential Care

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this paper, I found it to be highly thought provoking and well presented, and a pleasure to review.

While I have no significant comments, I present four observations that may be considered by the authors in relation to the paper.

1. In the text and quotes provided in the findings, there appeared to be a theme of the use of 'informal' supports by foster carers to allow them to recuperate and continue to support the children in their care. I found this interesting and wondered if it might be picked up in the discussion section, as it seems significant additional evidence that foster carers are not supported/able to manage the round-the-clock care which the children require, and the use of 'informal' supports might be questioned in relation to their suitability in caring for these children.

2. There is brief mention of the conflation of 'institutional' and 'residential' care in the discusssion, but I thought this might be introduced in the introduction, and then discussed very briefly as one of the driving factors to make residential care a placement of 'last resort'.

3. There is mention in the findings of the choice which is made by foster carers as to which of two or more children they will continue to care for. The appropriateness or otherwise of foster carers being placed in this situation might also be mentioned.

4. The quotes provided to support sections can in some instances be very long in comparison to the analysis presented, and I wonder if it might be possible to reduce the number of quote provided in support of points (although the quotes are also very illuminating).

Otherwise there were a few minor typos which I noted:

1. Repeated 'were' in place of 'where' e.g. lines 175, 259 & 304

2. On line 259 it is unclear if the intended meaning of '"...directed at the main or female caregiver" is that behaviours were directed at the main carer, unless they were male, in which case they were directed at a female carer, or whether this is clarifying that the female carers were considered the 'main' carer.

3. on p18, quote A5 currently reads "...the reason she came to use was that..." which I believe should be "...she came to us was that..."

4. Line 541-2 reads "...caring for children who are either on the edge of residential care goes well beyond normative parenting experiences...". There is no second term at present to warrant the 'either'

Author Response

Thank you for taking the time to review this paper. Both your comments, and those of the other reviewer, were very helpful. I hope that through addressing them the paper presented is a much stronger piece of work than the original submission. I have provided details of how all of the suggested changes were addressed below.

[R1 Comment 1: "In the text and quotes provided in the findings, there appeared to be a theme of the use of 'informal' supports by foster carers to allow them to recuperate and continue to support the children in their care. I found this interesting and wondered if it might be picked up in the discussion section, as it seems significant additional evidence that foster carers are not supported/able to manage the round-the-clock care which the children require, and the use of 'informal' supports might be questioned in relation to their suitability in caring for these children.]

Thank you for raising this. I have added a short section into the discussion focussing on the potential harms that foster carers using informal supports could cause. These harms, including inappropriate parenting advice and privacy breaches, are used to reinforce the need for foster carers to recieve support from trained individuals. These chabges can be found in paragraphs 5 and 6 of the discussion.

[R1 Comment 2: "There is brief mention of the conflation of 'institutional' and 'residential' care in the discusssion, but I thought this might be introduced in the introduction, and then discussed very briefly as one of the driving factors to make residential care a placement of 'last resort'."]

Thank you for highlighting this. I have amended the introduction to provide more information about the differences between therapeutic and institutionalized care, as well as more clearly defining the types of residential care used within Scotland. The discussion has also been restructured slightly to focus on how foster carers fears over institutionalization are at odds with the therapeutic and relational approaches that are described as being used with the children. How the conflation of residential care and institutionalized care affects both perceptions of using residential for children, along with the gathering of outcomes data is also discussed. These changes can be found in paragraphs 2 and 3 of the introduction, and paragraphs 15-17 of the discussion.

[R1 Comment 3: "There is mention in the findings of the choice which is made by foster carers as to which of two or more children they will continue to care for. The appropriateness or otherwise of foster carers being placed in this situation might also be mentioned".]

I have added a comment in to the discussion about the inappropriateness of caregivers being put in the position of choosing which child to support into the discussion. In doing so i have added points around the need to ensure that foster carers who are alrrady caring for children who require therapeutic interventions should not be asked to provide additional care for other children in crisis. This change can be found in paragraph 6 of the discussion.

[R1 Comment 4: "The quotes provided to support sections can in some instances be very long in comparison to the analysis presented, and I wonder if it might be possible to reduce the number of quote provided in support of points (although the quotes are also very illuminating)."]

In line with this comment, and a comment from R2 about the number and length of quotes, I have reduced the number of quotes used. The length of some quotes have been reduced where it felt fhat to do so did not remove rich insights into lived experience and/or caregiving practices. I have also presented the quotes within the main body of the findings per the request of R2.

[R1 - general comments]
I have addressed the typographical errors that remained after restructuring the article. I have also added clarity around the use of violence towards female caregivers.

[R2 - "There are some places where the sentences must be revised. I think you could have shortened the article by narratively reporting on the results and not putting in all the responses. The essence of the themes would have made your argument better. You left the reader to jump up and down to see the quotes/ responses" and "The manuscript must be revised to shorten many of the sentences (some embrace an entire paragraph) - Please check the technical layout"].

Thank you for your feedback, it is really appreciated. I have taken the time to engage with the article and redrafted it in line with the areas marked on the review sheet as "can" and "must" be improved. In particular, I have reviewed and simplified the language used in the paper, including reducing the length of sentences. I have also reviewed and shortened the reference list, and double checked the accuracy of these. I have also revised the aims and structure of the findings so that the reader is provided with more clarity about what topics are being explored within the analysis. I hope that the extensive changes made to the article address your comments.

Reviewer 2 Report

Comments and Suggestions for Authors

There are some places where the sentences must be revised. I think you could have shortened the article by narratively reporting on the results and not putting in all the responses. The essence of the themes would have made your argument better. You left the reader to jump up and down to see the quotes/ responses.

Comments for author File: Comments.pdf

Comments on the Quality of English Language

The manuscript must be revised to shorten many of the sentences (some embrace an entire paragraph) - Please check the technical layout.

Author Response

Thank you for taking the time to review this paper. Both your comments, and those of the other reviewer, were very helpful. I hope that through addressing them the paper presented is a much stronger piece of work than the original submission. I have provided details of how all of the suggested changes were addressed below.

[R1 Comment 1: "In the text and quotes provided in the findings, there appeared to be a theme of the use of 'informal' supports by foster carers to allow them to recuperate and continue to support the children in their care. I found this interesting and wondered if it might be picked up in the discussion section, as it seems significant additional evidence that foster carers are not supported/able to manage the round-the-clock care which the children require, and the use of 'informal' supports might be questioned in relation to their suitability in caring for these children.]

Thank you for raising this. I have added a short section into the discussion focussing on the potential harms that foster carers using informal supports could cause. These harms, including inappropriate parenting advice and privacy breaches, are used to reinforce the need for foster carers to recieve support from trained individuals. These chabges can be found in paragraphs 5 and 6 of the discussion.

[R1 Comment 2: "There is brief mention of the conflation of 'institutional' and 'residential' care in the discusssion, but I thought this might be introduced in the introduction, and then discussed very briefly as one of the driving factors to make residential care a placement of 'last resort'."]

Thank you for highlighting this. I have amended the introduction to provide more information about the differences between therapeutic and institutionalized care, as well as more clearly defining the types of residential care used within Scotland. The discussion has also been restructured slightly to focus on how foster carers fears over institutionalization are at odds with the therapeutic and relational approaches that are described as being used with the children. How the conflation of residential care and institutionalized care affects both perceptions of using residential for children, along with the gathering of outcomes data is also discussed. These changes can be found in paragraphs 2 and 3 of the introduction, and paragraphs 15-17 of the discussion.

[R1 Comment 3: "There is mention in the findings of the choice which is made by foster carers as to which of two or more children they will continue to care for. The appropriateness or otherwise of foster carers being placed in this situation might also be mentioned".]

I have added a comment in to the discussion about the inappropriateness of caregivers being put in the position of choosing which child to support into the discussion. In doing so i have added points around the need to ensure that foster carers who are alrrady caring for children who require therapeutic interventions should not be asked to provide additional care for other children in crisis. This change can be found in paragraph 6 of the discussion.

[R1 Comment 4: "The quotes provided to support sections can in some instances be very long in comparison to the analysis presented, and I wonder if it might be possible to reduce the number of quote provided in support of points (although the quotes are also very illuminating)."]

In line with this comment, and a comment from R2 about the number and length of quotes, I have reduced the number of quotes used. The length of some quotes have been reduced where it felt fhat to do so did not remove rich insights into lived experience and/or caregiving practices. I have also presented the quotes within the main body of the findings per the request of R2.

[R1 - general comments]
I have addressed the typographical errors that remained after restructuring the article. I have also added clarity around the use of violence towards female caregivers.

[R2 - "There are some places where the sentences must be revised. I think you could have shortened the article by narratively reporting on the results and not putting in all the responses. The essence of the themes would have made your argument better. You left the reader to jump up and down to see the quotes/ responses" and "The manuscript must be revised to shorten many of the sentences (some embrace an entire paragraph) - Please check the technical layout"].

Thank you for your feedback, it is really appreciated. I have taken the time to engage with the article and redrafted it in line with the areas marked on the review sheet as "can" and "must" be improved. In particular, I have reviewed and simplified the language used in the paper, including reducing the length of sentences. I have also reviewed and shortened the reference list, and double checked the accuracy of these. I have also revised the aims and structure of the findings so that the reader is provided with more clarity about what topics are being explored within the analysis. I hope that the extensive changes made to the article address your comments.