Review of the Literature



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Foster Care Youth: A Brief Review of the Literature

Foster youth are children who have been removed from the care and custody of the biological parent(s) by the Family Court or Juvenile Court system and placed in a temporary out-of-home living situation. Many foster youth are removed from their home because of abandonment, severe neglect or physical and/or sexual abuse, but the majority of children are removed for general neglect and emotional abuse.  Youth may also be placed in an out-of-home placement because of delinquency and the parent's inability to address the needs of their children’s delinquent and/or high risk behavior.  In some cases, parents may voluntarily arrange for their children to be placed in out-of-home care.  


There are a number of short- and long-term housing outcomes for children and adolescents under 18 when it is not longer safe or feasible to live at home. Foster youth may be placed in a licensed foster home ,with a relative (“kinship placement”) or a group home. Youth in the system who could be referred to as “foster youth” may also be placed in emergency care, a shelter, transitional living program, juvenile detention or a Community Treatment Facility. There is also a population of homeless youth that although they were placed in foster care, they have left placement and live on the streets because of factors such as abuse in abuse in care, substance abuse, emotional issues and/or other reasons
It is not uncommon for youth who enter the child welfare system to experience many placements in the course of their childhood. Most children are separated from siblings when placed into foster care. Depending on their situation, plans may be put in place to try to reunify the youth with their parents/caregivers. However, reunification plans involve agreements on the part of the caregiver(s) to address the reasons why children were placed out of the home through substance abuse treatment, parenting classes, family therapy, compliance with court orders, etc. If the reunification plan is not successful within a limited amount of time, parental ties can be permanently severed.

California-specific statistics:



  • California has approximately 131,000 children in its foster care system, comprising approximately 20% of the nation’s total.

  • 71% of California’s children in foster care are six years of age or older.

  • 60% of kids remain in foster care for 18 to 42 months or more.

  • 48% of kids placed in traditional foster homes or group homes are moved three or more times.1

National statistics:

  • Although system youth have greater access to psychiatric care than non-system youth, studies show that less than one-third of youth in foster care receive mental health services, partly due to the lack of mental health professionals available to this population.

    • Approximately four times the number of foster care residents versus non residents attempted suicide.

    • Approximately five times more system residents were diagnosed as drug dependent compared to non-system residents.

In California and throughout the nation, African-American children are over four times more likely than Caucasian children to be placed in out-of-home care. Children of two or more races are twice as likely to be place in out-of-home care. American Indian and Alaska Native children are about three times more likely than Caucasian children to be placed in out-of-home care.2 Children with these racial backgrounds also stay in foster care longer and the rates of permanency/ reunification are much lower on average. Racial minorities are greatly over-represented in the foster care system, far exceeding their proportion in the general population. This disproportionality is linked to poverty, violence and substance abuse risk.

California's foster care system is struggling to provide children with the basics – food, shelter and medical care. Three out of four kids wait 2-3 months to receive basic medical care and half of the youth in foster care are not receiving dental care or mental health services. Services to assist youth transition to adulthood once foster care placement services end at age eighteen are no available in many communities and cannot serve more than a very small percentage of transitional youth in communities where services do exist. Approximately one-third of young people that age out of California’s system at 18 fail to complete high school. Nearly 25% of transitional youth become homeless, and unemployment rates hover near 50%. Almost 25% are arrested and spend time incarcerated. 3

While it is impossible to precisely determine the number of lesbian, gay, bisexual, transgender, or questioning (LGBTQ) youth in this system, recent studies suggest that these youth make up between 5 and 10 percent of the total foster youth population. The actual percentage may be higher since LGBTQ youth are over-represented in the foster care pool because of discrimination and abuse many of these youth face in their families of origin and in their schools. In a terrible irony, many of these youth - as many as 78% as indicated in a recent study - endure further harassment or abuse after being placed in out-of-home care. As a result, some LGBTQ youth runaway from their placements, preferring to live on the street rather than in homophobic or transphobic settings where they are in danger of harassment or violence.4 Twenty-five percent of homeless youth are LGBTQ.5
Due to the circumstances that brought these youth into the system and challenges with the system itself, young people that experience foster care are at greater risk than their non-system counterparts for a wide range of problems. As indicated by the statistics above, these problems include substance abuse, criminal involvement, early parenting, unemployment, homelessness, mental health problems that are often exacerbated by the use and abuse of alcohol and other drugs.
The trauma of being abused or neglected at the most vulnerable time in one’s life by one’s primary caretakers cannot be understated. The response to being victimized is often to develop mental health problems that then require attention; if appropriate attention through therapy and potentially medication are not accessed, many individuals will turn to coping mechanisms that offer short-term relief but hinder development over the long term. Perhaps the most common way to cope is to self-medicate through alcohol and other drugs. This behavior sets the stage for the individuals to find themselves in situations where they can once again be taken advantage of, where their safety is compromised, and the cycle of victimization, mental health problems, substance abuse and lack of self-care repeats itself. The post-traumatic symptoms and lack of psychological and physical boundaries perpetuate this destructive cycle.
Youth that fall out of the system – those that age-out, and/or become homeless because they may have run from placement – or are “hard to place” (older youth, racial minorities, sexual minorities, and youth with mental health problems) are at higher risk for substance abuse than those who are in stable foster care placement.

According to the World Health Organization, nearly 20% of all children and adolescents suffer from some type of emotional or behavioral problem. In contrast, about 35-85% of youth entering foster care have significant mental health problems. The incidence of emotional, behavioral and developmental problems among foster children is three to six times greater than among non-foster children. Despite having poor access to services due to limited or no available service and incorrect diagnoses, foster children use mental health services more often and at higher cost than other children.1

Adolescents in out-of-home care are at greater risk of mental health problems than children in the general population because of past histories of child abuse and neglect, separation from biological parents, and placement instability. The majority of children in foster care are struggling to cope with the traumatic events that brought them into care, events that have left them in a quandary of emotions feeling unprotected, hopeless and suffering from a psychopathology based in shame. Foster youth are more likely to experience depression, anxiety, loss of behavioral and/or emotional control, and poor psychological well-being than adolescents in the general population. Thus, these children are more susceptible to substance abuse. Substance abuse for many adolescents replaces healthy coping mechanisms, leaving them with little or no methods of escaping the pain caused by the emotional and mental strain when they are placed in foster care.

This literature review provides a look at key trends and findings on foster youth risk and protective factors, including best practices to prevent and/or minimize substance abuse in this population. The data in this review was drawn from six individual studies on various aspects of substance abuse among adolescents in foster care.




Key Trends and Findings

It may seem that youth in the foster care system, particularly those in residential institutions or “group homes”, do not have access to alcohol, tobacco or other drugs because of strict institutional oversight and around-the-clock supervision. This is not the case. Access to substances and exposure and participation in violence (including gang-related activity) occurs via home visits, friends and family visiting residential facilities, facility staff, poorly supervised facilities and, with authorized and unauthorized trips off-site. The latter instance includes runaway incidents, cutting class or skipping an activity and briefly leaving the facility, and authorized off-site employment or excursions (Morehouse & Tobler, 2000). Opportunity for exposure to and engagement in ATOD and/or violence among youth placed in foster family settings is comparable to that of non-foster youth counterparts.


Vaughn et al. (in press) found that older foster care youth were particularly at risk for high rates of use and substance use disorders when they were living in independent living situations and had diagnoses of Post-Traumatic Stress Disorder or Conduct Disorder.


  • Adolescents within foster care are more prone than non-system residents to engage in various types of substance use at least once in their lives.




  • Factors that put system residents at higher risk include:

  • Their birth parents’ substance abuse

  • Their own age at first use

  • Transitions and mobility

  • Early occurrences of antisocial behavior, and

  • Personal attitudes favorable to drug use




  • Youth exposed to birth parent’s substance abuse are more likely to become abusers.




  • Youth with post-traumatic stress syndrome (PTSD) and conduct disorder (CD) were found to have higher rates of substance use and disorder, with strong relationships found between being diagnosed with CD and all types of substance use and disorder, current and lifetime.




  • Studies indicate that youth in foster care have significantly higher rates of substance abuse than their peers living at home. One study (Urada, 2007) documented 42% of foster youth reporting frequent, regular alcohol and marijuana use.




  • The five most prevalent diagnoses of behavioral disorders among foster care youth are:

    • Mood Disorder and Depression

    • Oppositional Defiance Disorder

    • Post-Traumatic Stress Disorder (PTSD)

    • Adjustment Disorder

    • Conduct Disorder




  • Many mental health problems go undiagnosed because symptoms are overshadowed by other disruptive behaviors such as substance abuse, anger and opposition.




  • System youth reported more use of prescription medications for psychological problems than did non-system youth.




  • Compared to their male counterparts, female youth reported more conflictual problem-resolution tactics. They also reported a higher instance of sexual abuse.




  • Foster care adds yet another stressful experience in addition to those they have already experienced (e.g., parental neglect, addiction, or abuse).




  • Foster care is a marker of adversity rather than a cause of psychopathology.




  • New experimental techniques that illuminate the thoughts of adolescents have indicated that the brains of teenagers are changing more than was previously thought. Neural systems that respond to thrills, novelty, and rewards develop well before the regulatory systems that would normally provide balance by reigning in questionable actions.




  • Under everyday (normal) circumstances, adolescents often have difficulty navigating through the environment and emotional demands with which they are faced.




  • The inability for teens to regulate their behavior like adults places them at greater risk for substance abuse when placed in foster care.




  • Reports indicate that the longer an adolescent is housed in foster care, the more susceptible s/he is to the negative influences and consequences of substance abuse.




    • The absence of targeted intervention methods leaves foster care adolescents in danger of related issues in adulthood, including the possibility of criminal activity.



Additional Considerations for Substance Abuse Prevention

for Youth in Foster Care
Service design needs to be aligned with the realities that foster youth are facing. This includes every facet from marketing and outreach to implementation and evaluation.
Most foster youth are by definition experiencing a high degree of mobility and uncertainty, potentially seeking to reunify with their birth parents or transfer their foster placement. For this reason, fewer sessions and activities that can be accessed from multiple locations (e.g., several cities or towns within a county) may be less likely to suffer attrition. Evaluation should also be planned with the expectation that the youth could be transferred without notice; not only should relationships and agreements be in place to maintain contact with the youth, but outcome measures should also be based on what can realistically be captured under these circumstances, potentially without long-term follow-up.
Foster youth are often raised in non-traditional families – with grandparents or other extended family or single individuals (23 percent of youth in foster care are placed with licensed foster parents who are also kin). Among such a diversity of family configurations, the outreach and service activities must be welcoming and respectful.
Many foster youth are also a part of a larger sibling group that has been threatened with separation or has in fact been separated. (In October 2005, 68 percent of children in the California child welfare system had at least one sibling in out-of-home care.)
Given the overwhelming neglect and abuse suffered by foster youth prior to their entrance into the system and system delays that often prevent consistent access to health care, we must consider the issues associated with dental, physical and mental health problems. Foster youth are often on multiple medications with unpleasant side effects and require flexibility in their schedules to accommodate appointments with physicians, psychiatrists, and social workers.
Coping mechanisms that have aided foster youth’s survival may now be hindering their ability to fully participate, such as reluctance to discuss feelings, become attached, rely on others and let down their guard. The staff and volunteers working with these youth must be well trained, supervised and supported so that they learn to work with youth from a strengths-based approach and follow through on their commitments so that they do not potentially cause further harm (e.g., missing appointments).
The circumstances that led to the removal of many foster children from their homes also contributed to their birth parents requiring treatment and/or imprisonment. Services are usually extended, if not required of their parents to increase the likelihood of healthy family functioning, and potentially reunification, over time. Additionally, we can expect the youth to have strong feelings, including fear, shame, guilt, anger and confusion over their parents’ circumstances. Services must provided to youth to create a safe place for these feelings to be expressed.
Services will be most effective when coordinated across multiple sectors and among the various individuals responsible for the care of the youth in the system, including but not limited to the departments of child welfare, juvenile justice, mental health, and substance abuse, the school district and county office of education, and the social and/or case worker(s), independent living program (ILP) coordinator, school administrator, and guardians.
Additionally:


  • Parents or foster parents should be required to attend behavior management training.




  • Parent skills training combined with family strengthening activities should be an integral part of prevention in light of the overwhelming evidence for the positive effects of family involvement.




  • Therapeutic foster care models with intensive case management and individualized services.




  • Early and intensive response by parents, teachers, and other authorities to a youth’s delinquent behavior.




  • Prevention and treatment may be more successful if they are individualized, family-based, and delivered in the community.




    • Interventions should be guided by policies that emphasize positive interventions over punitive ones (integrating punitive measures on an individual case basis).




    • Prevention and treatment should be sensitive to cultural diversity. Building cultural pride, self-respect, and a strong sense of identity are key components in cultivating character, feelings of worth and self-esteem.




    • Programs that provide understanding and coping strategies for parents, foster parents, teachers and other caregivers providing care and support to those within this population.




    • Approaches that include resistance skills training in which students learn about the social influences that can lead to AOD use, as well as specific skills for resisting these pressures, have been shown to prevent substance use in the short-term.

Ideally, a community is able to garner resources to provide multiple, coordinated, intensive services for each foster youth and their families. The Office of Juvenile Justice and Delinquency refers to Wraparound as a complex, multifaceted prevention and/or intervention strategy designed to keep delinquent youth at home and out of institutions whenever possible. As the name suggests, this strategy involves “wrapping” a comprehensive array of individualized services and support networks “around” young people, rather than forcing them to enroll in pre-determined, inflexible treatment programs (Portland State University Research and Training Center, 2003). Wraparound programs feature several basic elements, including:




  • A collaborative, community-based interagency team that is responsible for designing, implementing, and overseeing the wraparound initiative in a given jurisdiction. This team usually consists of representatives from the juvenile justice system, the public education system, and local mental health and social service agencies. In most cases, one specific agency is designated the lead agency in coordinating the wraparound effort.




  • A formal interagency agreement that records the proposed design of the wraparound initiative and spells out exactly how the wraparound effort will work. At a minimum, this agreement should specify who the target population for the initiative is; how they will be enrolled in the program; how services will be delivered and paid for; what roles different agencies and individuals will play; and what resources will be committed by various groups. The comprehensive integrated service delivery system that emerges from these agreements is often referred to as “a system of care.”




  • Care coordinators who are responsible for helping participants create a customized treatment program and for guiding youth and their families through the system of care. In most wraparound programs, these care coordinators are employees of the designated lead agency, which may be a public program or a private nonprofit agency.




  • Collaborative teams consisting of service providers, and community members (such as teachers and mentors), who know the youth and are familiar with his or her changing needs. Assembled and led by a coordinator, these teams work together to ensure that the individual child’s prevention needs are being met across all domains—in the home, the educational sphere, and the broader community at large.




  • A unified plan of care developed and updated collectively by all the members of the child and family team. This plan of care identifies the child’s specific strengths and weaknesses in different areas, targets specific goals for them, and outlines the steps necessary to achieve those goals. It also spells out the role each team member (including the child and family) will have in carrying out the plan. Ideally, the plan is updated constantly to reflect the child’s changing needs and progress.




  • Systematic, outcomes-based services. Almost all wraparound programs require clearly defined performance measures, which are used to track the progress of the wraparound initiative and guide its evolution over time.

Recent literature on wraparound also emphasizes the importance of recruiting committed and persistent staff and creating programs that are culturally competent and strengths-based (Franz, 2003; Bruns et al., 2004).




Conclusion

Throughout the examination of the various studies for this project it became apparent that children, adolescents, youth or teens removed from their birth parents are traumatized. In most cases, foster care parents are not professional or even lay counselors. What this means is that although the new foster care resident is in a “safe place”, their emotions (e.g., fear, shame, anger, issues of abandonment and betrayal) are not necessarily addressed. When these emotions are not addressed, there exist greater tendencies for these adolescents to turn to other measures to relieve their suffering.


There are a number of issues that must be addressed to turn the tide in favor of foster care youth. While this research snapshot is not designed to cover them all, there is one additional issue that needs to be highlighted: school success. Literacy, maintaining an appropriate grade level, and graduating from high school surface repeatedly in studies of youth that develop the resiliency to resist substance abuse. Falling behind in school, on the other hand, creates a downward spiral that includes alienation from teachers and peers that are doing well; a loss of self-efficacy, or the feeling of success or mastery; detachment from school; and the acquisition of friends who likewise are detached from school.
The reason that this is important to discuss in the context of youth in foster care is that these youth face tremendous odds in their educational attainment. They often experience multiple changes in placements and in school attendance. According to the California Foster Youth Education Task Force, for every change in school, foster youth can be expected to fall three to six months further behind their classmates. Thus, every effort must be made to ensure seamless school transitions, boosted with support services like counseling and tutoring that will compensate for the change. We must stay abreast of and support policies and legislation that will create the environment in which school success for foster youth is developed (e.g., CA AB490, the Foster Youth Services Program administered by the CA Department of Education, and the Guardian Scholars Program).
If we are to make a difference in the life trajectories of youth placed in foster care, we must be vigilant in assuring that they have consistent access to quality mental health care and education. We must also address the issue of substance abuse head on: involving the birth parents and foster families in treatment as necessary, offering skills-based programming, shaping personal attitudes unfavorable to drug use, and assisting in friendship and social network development that will support those values.
As stated earlier, foster care is a marker of adversity that can be overcome, rather than a cause of psychopathology. As we utilize lessons learned from research and practice, we can limit the negative outcomes currently associated with this population. You are invited to learn more about the issues raised in this brief by reading the journal articles and reports and visiting the websites and in the References section.
Primary References

Alcohol and Substance Use among Adolescents in Foster Care in Washington State Report: Results from the 1998-1999 Adolescent Foster Care Survey. Published March 2002 by the U.S. Department of Health and Human Services (Report Number 438) and the Washington State Department of Social and Health Services.


Morehouse, E., & Tobler, N.S. (2000). Preventing and reducing substance use among institutionalized adolescents. Adolescence, 35 (137), 1-28.
Pilowsky, D.J., & Wu,L. (2006). Psychiatric symptoms and substance use disorder in a nationally representative sample of American adolescents involved with foster care. Journal of Adolescent Health, 38, 351–358.
Slesnick, N., & Meade, M. (2001) System youth: A subgroup of substance-abusing homeless adolescents. Journal of Substance Abuse, 13, 367–384.
Thompson, R.G., & Auslander, W.F. (2007). Risk factors for alcohol and marijuana use among adolescents in foster care. Journal of Substance Abuse Treatment, 32, 61– 69.

Urada, L. (2007). Pre-emancipated foster youth program outcomes: Family planning, HIV/AIDS, and drug abuse information.  Accepted for oral presentation, CSWE Conference, October, 2007.



 Vaughn, G., Ollie, M.T., McMillen, J.C., Scott, L. & Munson, M. (in press). Substance use and abuse among older youth in foster care. Addictive Behaviors.


1 Karpilow, K. & Reed, D. (2002) Understanding the Child Welfare System in California. California Center for Research on Children and Families.

2 Casey Family Programs www.casey.org

3 Wonder, Inc. http://www.wonderinc.org/program/foster_care_facts.html

4 The National Center for Lesbian Rights http://www.nclrights.org/publications/lgbtqfostercare.htm

5 The Safe Schools Coalition http://www.safeschoolscoalition.org/RG-homeless.html


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