How Young Adults with Serious Mental Health Diagnoses Navigate Poverty Post-emancipation: The Complex Roles of Community Mental Health Services & Informal Social Support.

Serious mental health diagnoses are prevalent among youth who "age out" of foster care by reaching the maximum age for child welfare service eligibility. Post-emancipation, little is known about how youth engage in community mental health services, or leverage informal social networks, to navigate independence. Twenty emancipating youth completed three interviews over 16 months. All emancipated into poverty; most lived alone and initially connected to adult community mental health teams. Four service use and informal support profiles emerged from analysis: (1) Navigators (n = 2) actively used mental health services and provided limited informal support; Treaders (n = 9) passively used mental health services and heavily exchanged informal support; Survivors (n = 5) used mental health services when in crisis and heavily provided informal support; and Strugglers (n = 4) avoided mental health services and took resources from informal connections. Findings have implications for both child and adult mental health and social service providers.

Reproductive coercion, intimate partner violence, and pregnancy risk among adolescent women with a history of foster care involvement.

BACKGROUND: The current study is the first to explore the prevalence of reproductive coercion among adolescent women currently or previously involved in the U.S. foster care system. Reproductive coercion (RC), a form of intimate partner violence (IPV) involving exertion of power over a partner by controlling their reproductive health and decision making, is a significant public health concern. Existing research on RC has primarily been conducted in either healthcare settings or on college campuses. Foster youth are disproportionately impacted by both adolescent pregnancy and interpersonal violence. RC may contribute to this elevated risk. METHODS: We conducted a cross-sectional survey in 2015 and 2016 of adolescent women (n=136), ages 16-24 years old, seeking services from youth-serving agencies affiliated with a child welfare system in Pennsylvania, United States. Participants completed measures assessing RC, experiences of physical and sexual violence, sexual behaviors, and pregnancy. We used multivariable logistic regression to assess associations between RC and study outcomes. RESULTS: The sample was predominantly African American (67.4%) and largely identified as something other than heterosexual (46.6%). Nearly one-third of the sample (30.1%) reported a history of RC, with the most common being male partners telling them not to use birth control. High rates of IPV (62.1%), lifetime pregnancy (43.4%), and unwanted pregnancy (30.9%) were also reported. RC was associated with significantly higher odds of IPV (Adjusted Odds Ratio (AOR) = 4.22, 95% Confidence Interval (CI): 1.60, 11.13), multi-perpetrator rape (AOR 3.56, 95% CI: 1.04, 12.24), pregnancy (AOR = 5.39, 95% CI: 2.14, 13.60), and unintended pregnancy (AOR 5.39, 95% CI: 2.04, 14.25). Young women reporting RC also had elevated odds for using alcohol or drugs before sex (AOR = 4.34, 95% CI: 1.72, 10.97) and having sex with a male partner 5 years or more older (AOR = 7.32, 95% CI: 2.84, 18.87). No significant differences emerged between RC and sociodemographic characteristics. IMPLICATIONS: These data suggest women involved in the U.S. foster care system, particularly women of color and/or LGBTQ+ identified who comprised the majority of participants in the current study, may be at an increased risk for experiencing RC and other forms of IPV associated with adolescent pregnancy. In addition to efforts to prevent IPV and sexual violence, assessment for RC, healthy relationships education, and access to sexual and reproductive health care may mitigate these risks and improve outcomes for these young women.

Perspectives of Youth Aging Out of Foster Care on Relationship Strength and Closeness in their Support Networks.

Research, practice, and policy focus on the importance of relationships with young people aging out of foster care, especially relational permanency. While previous research has examined these relationships, typically with mentors, foster parents, or biological parents, few have examined the quality of strong network ties within support networks. This study incorporated a network approach to understanding how youth discussed strong ties and defined closeness in relationships. Qualities of strong ties included stability, multidimensional support, advocacy, honesty and genuineness, commonalities, trust, and small interconnected core networks. Understanding qualities youth value in close relationships may help service providers in supporting and enhancing relational permanency from multiple sources of support for youth aging out of the foster care system.

Relative reductions in health care utilization among young adults before aging out of extended dependent coverage.

The 2010 Affordable Care Act extended dependent coverage for adult children up to age 26 in the USA. Since then, considerable studies have assessed its various impacts among young adults. However, little is known about whether there is any change in health care use when young adults age out of dependent coverage. This study examines health care consumption changes among young adults prior to their aging out process. I used data from a large insurance claim database and studied health care utilization of young adults under parents' coverage during a 2-year period in a difference-in-difference framework. I found that young adults had relative reductions in health services use, except ER visits, compared with individuals who stayed under parents' coverage. This pattern was the same for both male and females. Individuals with regular medical needs had greater relative reductions compared with those without regular medical needs. The relative reductions in health care use during the aging out process may have an important impact on young adults' health, especially for those with regular medical needs. More efforts could be made to help them maintain regular medical utilization during the transition.

Assessing Support Network Stability With Transition-Age Foster Youth: Measuring Change Over Time.

OBJECTIVE: This study uses the Support Network Assessment for Practice (SNAP) approach to measure the support provided to young people transitioning from foster care. METHODS: The SNAP was administered on two occasions, approximately 7 months apart, to a cohort of transition-age foster youth (n = 27). Analyses investigated measurement reliability and sensitivity to change for network-level characteristics as well as baseline factors associated with relationship stability. RESULTS: Most network-level indicators had strong test-retest correlations, and differences in mean scores over time also were detected, suggesting measurement sensitivity to change. Respondents were able to explain most observed changes in their networks, further suggesting reliable measurement. Stable relationships were those reported as stronger and providing more multifaceted support and those with family members and/or parent figures. DISCUSSION: The SNAP approach could be used to facilitate planning around support needs for youth transitioning out of foster care and to evaluate efforts to enhance support networks.

Defining and achieving permanency among older youth in foster care.

Permanency is a key child welfare system goal for the children they serve. This study addresses three key research questions: (1) How do older youth in foster care define their personal permanency goals? (2) How much progress have these youth made in achieving their personal permanency goals and other aspects of relational permanency, and how does this vary by gender, race, and age? and (3) What transition-related outcomes are associated with relational permanency achievement? Surveys were conducted with 97 youth between the ages of 14 and 20 currently in care. Over three-fourths of participants had an informal/relational permanency goal; however, only 6.7% had achieved their goal. Of eight additional conceptualizations of relational permanency assessed, the one associated with achievement of the highest number of key transition outcomes was Sense of Family Belonging. The transition outcomes with the most associations with permanency achievement were physical health and mental health. Relational permanency is a highly personal part of the transition process for youth in care, warranting personalized supports to ensure individual youths' goals are being addressed in transition planning. Permanency achievement may also provide a foundation for supporting youth in achieving other key transition outcomes.

Homelessness and Aging Out of Foster Care: A National Comparison of Child Welfare-Involved Adolescents.

The present study represents the first large-scale, prospective comparison to test whether aging out of foster care contributes to homelessness risk in emerging adulthood. A nationally representative sample of adolescents investigated by the child welfare system in 2008 to 2009 from the second cohort of the National Survey of Child and Adolescent Well-being Study (NSCAW II) reported experiences of housing problems at 18- and 36-month follow-ups. Latent class analyses identified subtypes of housing problems, including literal homelessness, housing instability, and stable housing. Regressions predicted subgroup membership based on aging out experiences, receipt of foster care services, and youth and county characteristics. Youth who reunified after out-of-home placement in adolescence exhibited the lowest probability of literal homelessness, while youth who aged out experienced similar rates of literal homelessness as youth investigated by child welfare but never placed out of home. No differences existed between groups on prevalence of unstable housing. Exposure to independent living services and extended foster care did not relate with homelessness prevention. Findings emphasize the developmental importance of families in promoting housing stability in the transition to adulthood, while questioning child welfare current focus on preparing foster youth to live.

ADVERSE CHILDHOOD EXPERIENCES AMONG YOUTH AGING OUT OF FOSTER CARE: A LATENT CLASS ANALYSIS.

Research has demonstrated that youth who age out, or emancipate, from foster care face deleterious outcomes across a variety of domains in early adulthood. This article builds on this knowledge base by investigating the role of adverse childhood experience accumulation and composition on these outcomes. A latent class analysis was performed to identify three subgroups: Complex Adversity, Environmental Adversity, and Lower Adversity. Differences are found amongst the classes in terms of young adult outcomes in terms of socio-economic outcomes, psychosocial problems, and criminal behaviors. The results indicate that not only does the accumulation of adversity matter, but so does the composition of the adversity. These results have implications for policymakers, the numerous service providers and systems that interact with foster youth, and for future research.

Tobacco Use among Foster Youth: Evidence of Health Disparities.

Youth aging out of foster care face a challenging road to independence. Following exposure to myriad risk factors such as abuse, neglect, parental substance use, and severe housing mobility, supportive services decrease upon exit from care, often increasing risk for substance use, homelessness, and unemployment. Although tobacco use is also highly prevalent, little attention has been paid to screening, assessment, and treatment of tobacco use in this vulnerable group. The current study (N = 116) reports on tobacco use prevalence, consequences, and co-occurrence with other substances in a sample of youth (ages 18 to 19) exiting the foster care system. In the face of an overall decrease in tobacco use among general population adolescents and young adults, results suggest disproportionate levels of lifetime, recent, and daily use among foster youth. Prevalence of recent tobacco use (46%) is nearly triple national rates, while daily smoking (32%) is almost four times that of general population young adults. Tobacco users were more likely than non-users to drink (70% vs. 40%) and to smoke marijuana (72% vs. 25%). We strongly encourage researchers and practitioners to increase attention to this tobacco-related health disparity.

"I Want Everybody to Know as Much of My Life Story as They Can": Life Stories of Former Foster Youth.

The power of stories shared by young people in foster care is well-documented. Largely left unexplored is a story of foster care that is told within a fuller context of the life course. Using narrative and life history methods, this study sought to retrospectively identify and connect life experiences in histories of young people and explore how systems are portrayed. Twelve adults formerly in foster care completed three interviews each and nominated six professionals from foster care for an interview. A three-phase analytical process identified and displayed themes across six developmental stages. Results suggest that life stories contained adversities that were: (1) intergenerational, (2) chronic, (3) complex, and (4) structural. The participants intentionally acted to try to mitigate adversities by accessing opportunities for prosocial pathways. These exploratory findings challenge child welfare policy and practice to attend to young people's life stories and their conceptions of systems that advance well-being.

How different are their experiences and outcomes? Comparing aged out and other child welfare involved youth.

This paper adds to the growing body of research examining the experiences of youth aging out of the child welfare system. Through a comparison of youth aging out with two other groups of child welfare-involved youth-those whose families received child welfare services but were never placed out of home and those who were in out-of-home placement but did not age out-it presents a profile of their care careers and other system involvement (e.g., mental health, justice system). Analyses indicate that young people aging out of care have experienced significant amounts of time in out-of-home placement, a great deal of placement instability, and high levels of other system involvement. In general, their involvement is more extensive than that of the two comparison groups. However, the justice system involvement of youth who experienced out-of-home placement but did not age out is just as high as that of youth who have aged out. This finding highlights the importance of devoting resources not only to youth aging out of care but also to similarly-aged young people with prior child welfare involvement.

Mental Health and Substance Use Disorders among Foster Youth Transitioning to Adulthood: Past Research and Future Directions.

At a time when there is increasing attention being given to systematically integrating the well-being of children with the goals of safety and permanence in child welfare, little is known about the psychosocial functioning of foster youth transitioning to adulthood from substitute care. This article systematically reviews 17 peer-reviewed articles and/or research reports to identify lifetime and past year prevalence rates of mental health disorders and service utilization. At ages 17 or 18, foster youth are 2 to 4 times more likely to suffer from lifetime and/or past year mental health disorders compared to transition aged youth in the general population. Findings show that mental health service use declines at ages when the prevalence rate of mental health disorders is peaking. The findings of this review suggest the need to focus future efforts in three main areas: 1) Setting a common research agenda for the study of mental health and service use; 2) Routine screening and empirically supported treatments; and 3) Integration and planning between child and adult mental health service systems.

Aging Out of Dependent Coverage and Health Insurance Trends, 2014-2019.

OBJECTIVE: To examine changes in health insurance coverage when adults age out of dependent coverage at age 26 after the implementation of most Affordable Care Act (ACA) provisions. Our analysis also documented differences by sex, race and ethnicity, and state Medicaid expansion status. METHODS: We used a regression discontinuity design and the 2014-2019 American Community Survey to estimate coverage changes (uninsured, any private, employer-sponsored coverage, direct purchase, and Medicaid) at age 26. Our main sample consisted of adult citizens aged 22-29 years. RESULTS: Uninsurance increased by 2.7% points [95% CI; 1.8-3.4] at age 26, which was driven by a significant decline in any private insurance (3.7% point decrease). Young adults experienced a smaller increase in the uninsured rate on turning age 26 in states that expanded in 2014 compared to nonexpansion states (2.2% and 3.2% point increases, respectively), but the difference was not significant (P = .07). Changes in the uninsured rate at age 26 did not differ significantly by sex or race and ethnicity. CONCLUSIONS: The 2010 dependent coverage provision led to more coverage options among young adults and in turn the uninsured rate declined among a population historically among the most likely to lack coverage. The 2014 Medicaid and Marketplace expansions reduced the uninsured rate even further among young adults. Despite important progress, our findings for 2014-2019 were similar to previous studies using pre-ACA data suggesting that coverage loss remains a risk when adults age out of dependent coverage at age 26.

Substance Use Among Current and Former Foster Youth: A Systematic Review.

Substance use tends to escalate across adolescence and into young adulthood, and can be intensified by experiences with trauma and maltreatment, mental illness, and exposure to parental alcohol and drug use. Despite the disproportionately high levels of these variables among youth placed in the foster care system, relatively few studies have focused on the measurement of substance use in this vulnerable population. The current review summarizes the published literature on alcohol and drug outcomes for current and former foster youth. Specifically, prevalence of use and diagnoses are presented separately, as well as a review of risk and protective factors. Discussion of results addresses limitations and suggestions for improvement in the measurement of these outcome variables.

Conceptualizing the Step-Down for Foster Youth Approaching Adulthood: Perceptions of Service Providers, Caseworkers, and Foster Parents.

Studies find considerable movement between residential treatment and less restrictive foster home settings, with approximately half of foster youth who are stepped down eventually returning to a higher level of care. Very little is known about the step down for foster youth who are approaching adulthood in locked residential facilities. A qualitative study of stepping down a small sample of foster youth, as perceived by team members delivering a model of treatment foster care, is presented. These findings reveal the dimensions of stepping down foster youth at the onset of adulthood, and highlight the importance of providing foster youth with developmental opportunities to engage in the social roles and tasks of late adolescence and/or early adulthood. Implications for further refining the concept of stepping down from a developmental perspective are discussed.

Experiences of young parents with foster care backgrounds during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has brought unique challenges to parents of young children, due to the closure of schools and childcare centers, and increased caregiver burden. These challenges may be especially pronounced for youth with foster care backgrounds, as they lack critical support and resources to rely on during emergency situations. OBJECTIVE: The purpose of the present study was to examine the experiences of these vulnerable young parents since the beginning of the pandemic. PARTICIPANTS AND SETTING: Our study included 17 young parents ages 18-26, who had recently aged out of foster care or were currently in extended care. Participants were predominantly female, and Black, Indigenous, or people of color (BIPOC). METHODS: Youth participated in virtual focus groups or individual interviews and described their experiences and challenges during the COVID-19 pandemic. A structured thematic analysis approach was employed to examine key themes in youths` accounts. RESULTS: Analysis resulted in five major themes: (a) employment disruptions and economic hardships, (b) educational challenges for parents and children, (c) parental and child mental health concerns, (d) insufficient resources and barriers to service receipt, and (e) "silver linings". CONCLUSIONS: Young parents with foster care backgrounds faced numerous challenges due to COVID-19 and struggled to access critical resources and supports. Implications for policy, practice, and research are discussed.

Do Independent Living Services Protect Youth Aging Out Foster Care From Adverse Outcomes? An Evaluation Using National Data.

OBJECTIVE: Youth aging out foster care are at high risk of experiencing adverse outcomes. Federal funded programs have provided independent living services (ILSs) to these youth. This study evaluated the effectiveness of the continuity of ILSs at ages 17-19 in protecting youth aging out foster care from homelessness and incarceration at ages 19-21. METHOD: This study used data on 4,853 foster youth from the National Youth in Transition Database and the Adoption and Foster Care Analysis and Reporting System. Logistic regression was used to regress two binary outcomes on seven ILS variables and covariates. RESULTS: The results suggest that remaining in foster care, continuous receipts of academic support, and financial assistance services at ages 17-19 protected foster youth from experiencing homelessness. Remaining in foster care and continuous receipt of financial assistance services at ages 17-19 protected foster youth from incarceration at ages 19-21. But, surprisingly, continuous receipt of housing education and home management training, and health education and risk prevention training at ages 17-19 were each associated with increased risk of homelessness at ages 19-21. The results also showed statistically significant effects of several covariates. CONCLUSION: Implications are provided based on the importance of financial assistance and academic support services.

"Just being there, like a shoulder to lean on": Resilience and Mental Health among Older Youth in and Aged out of Foster Care during COVID-19.

Disasters share a common potential for significant ecological and psychosocial disruption at the individual, community, and societal levels, and are especially harmful to members of social groups in vulnerable situations, including youth in foster care and those recently emancipated from care. These young people are susceptible to mental health challenges and understanding their resiliency is key to mitigating pandemic-related harms. This qualitative study aims to (1) understand how the COVID-19 pandemic affected the mental health of older youth between the ages of 18 and 23 (M = 20.5 years, S.D. = 1.7 years), currently in or aged out of foster care (M = 5.9 years in care, S.D. = 4.4 years), and experiencing mental health challenges, and (2) gain insight into the resiliency that supports young people in dealing with these challenges. Twenty-six young people (77% female-identifying, 38% White, 27% Hispanic) in the USA participated in in-depth interviews. Salient themes include: 1) supportive relationships, 2) adaptive coping skills and mindsets, and 3) environmental, institutional, and social supports. Results amplify the voices of these young people concerning the impact of COVID-19 on their mental health and foreground the dynamic strategies they are using to alleviate their distress. Supplementary Information: The online version contains supplementary material available at 10.1007/s40653-022-00498-7.

Nothing About Us Without Us: Using Participatory Action Research (PAR) and arts-based methods as empowerment and social justice tools in doing research with youth 'aging out' of care.

Child welfare practices and policies are often disconnected from youth in care's perspectives and lived realities. Youth 'aging out' of care should be empowered to define their own needs, goals and success based on the unique context they are transitioning from. In research, this can be supported by engaging them as co-researchers through emancipatory approaches. Participatory Action Research (PAR) requires collaboration with those who are affected by the issue being studied in all aspects of the research, with the aim to build advocacy capacity and affect transformative social change. Photovoice employs photography and group dialogue - the fusion of images and words - as an empowerment tool, through which individuals can work together to represent their own lived experiences rather than have their stories told and interpreted by others. This is a particularly powerful approach in engaging youth with care experience, as they are often systemically disenfranchised, isolated and in need of connections to the community. This article presents the Relationships Matter for Youth 'Aging Out' of Care project, a Participatory Action Research (PAR) photovoice research project with young people with lived experience, as a case study. The project aimed to take a closer look at the relationships that matter to youth from care and how they can be nurtured over time. Narratives about the experience of participating in the project are also featured, from the perspectives of three of the youth co-researchers. Some of the benefits, challenges and lessons learned are also explored, framed within the Relationships Matter project methodology and process. Recommendations for future social work research are also presented.

Connected After Care: Youth Characteristics, Policy, and Programs Associated With Postsecondary Education and Employment for Youth With Foster Care Histories.

Recent federal laws and state policies reflect the government's investment in improving education and employment outcomes for youth with foster care histories. However, little research has assessed the roles of these programs using national data. Drawing on data from the National Youth in Transitions Database (NYTD) (n = 7797), this study examines the roles that state-level policies and programs, youth-level participation in programs and services, and youth characteristics play in youths' connection to employment and education ("connectedness") at age 21. Results from multilevel regression analyses find that foster youth in states with widely available tuition waiver programs increases the odds of connectedness to school. The amount of time youth spend in extended foster care, as well as receipt of postsecondary education aid and services, also increases connectedness. Study findings underscore the importance of material and relational supports in supporting foster youths' connection to employment and education in early adulthood.