Open access peer-reviewed chapter
Abstract
Children and youth in the foster care system face significant and continuing barriers to both physical and mental health, including lack of a medical home, disruptions in primary care providers, frequent moves to new homes, excessive caseloads for oversight providers, and at times continuing exposure to the risk factors that are considered Adverse Childhood Experiences (ACEs). The underdog DREAMS project sought to alter the course of the foster youth experience via a tri-part model that focused on clinical, research, and advocacy interventions for foster youth and the development of the workforce that supports them through training on the impacts of trauma and poverty.
Keywords
- Foster youth
- Health
- Physical
- Mental
- Adverse Childhood Experiences
1. Introduction
The purpose of the foster care system in the United States is to provide for the well-being of children and youth who have been removed from their family of origin due to abuse, neglect, and/or other reasons: exposures collectively referred to as Adverse Childhood Experiences (ACEs) [1]. Meeting the physical and mental health needs of this population is an acute challenge, as children and youth typically enter the system with an array of significant social and medical issues and factors within the system, such as lack of access to care, compound the problem. Roughly 40% of children (ages 3–9) and youth (ages 10–17) in foster care have a serious mental health disorder, including PTSD; alcohol, nicotine, and other drug abuse; depression and anxiety; eating disorders; and social phobia [2]. They are also more likely to require treatment for physical conditions such as asthma, obesity, chronic pain, and other problems that may interfere with physical activity [3, 4, 5]. Unfortunately, national long-term health outcomes associated with foster care include high rates of chronic mental (54%) and physical (30%) health disorders among young adults exiting the foster care system [6].
As of 2017, 443,000 children and youth live in foster care in the United States. The average age of entry is 7, and the average duration in care is 20.1 months [7]. According to 2014 data, Florida is fifth in the nation in the number of children investigated per 1,000 children in the general population (70.6%) [8]. Since October 2013, the number of children and youth in out-of-home care statewide in Florida has risen from just over 17,000 to now almost 24,000 [9].
By 2005, the state of Florida had transitioned to a privatized system. Recent reviews have found this system to be in disarray, and despite some positive signs [10, 11], the state is failing to implement many recommendations related to the physical and mental healthcare needs of children and youth in the foster care system [10, 11]. While the percentage of children and youth in foster care who received some medical care over the previous 12 months has risen from 80% in 2011 to over 95% in 2017, the level of care available continues to fall short of demand Figure 1 [12]. Shows that less than 75% of foster children and youth are getting their mental, behavioral, physical, and dental needs met.
Figure 1.
MyFLFamiles dashboard summary.
The information currently available indicates that children and youth with ACEs who remain untreated are at significant risk of suffering a 20-year difference in lifespan compared to their peers who are unaffected by ACEs, as well as increased risk for unemployment, poverty, homelessness, and more [13, 14]. Programs that provide these young people with skills and strategies to improve their health and well-being can mitigate the risk of chronic physical and mental illness [15].
2. Wicked Problem Impact Project (WPIP) description
Florida’s fractured and privatized child welfare system leads to significant deficits in foster child and youth education and physical and mental healthcare. These deficits directly translate to poor quality of life outcomes for Florida’s foster children and youth. The Wicked Problem Impact Project of underdog DREAMS was to identify strategies to improve the quality of life and well-being for Florida foster youth. Our work identified three key strategies essential for helping youth in foster care reach their potential:
Education
Mental and physical wellness
Access to innovative technology
3. Approach
The underdog Dreams team participating in the Clinical Scholars program consists of two clinical social workers (DS, SB), a family physician (AB), an adolescent psychiatrist (AD), and a clinical psychologist. The underdog DREAMS project engaged in a multi-faceted approach to support foster youth as well as the healthcare providers who play a role in the foster care system infrastructure. Thus, the team focused on clinical, research, and advocacy interventions for foster youth and on the development of the workforce that supports them through training on the impacts of trauma and poverty. The initial goals for the project were adjusted based on our research and investigative findings, particularly during phase one:
Phase two concentrated on
Figure 2 is a visual timeline representing the underdog DREAMS team’s approach and accomplishments and the next steps to be implemented.
Figure 2.
underdog DREAMS Timeline.
4. Activities and outcomes
4.1 Phase I: look, listen, and learn
Capitalizing on best practices in community-based engagement principles, our team partnered with foster youth so that their perspective served as a foundation for all later actions. Youth sources included foster youth enrolled in the First Star Central Florida Academy, the Job Readiness and Leadership Bootcamp, and other Central Florida area youth. Simultaneously the team conducted an in-depth literature review on this topic, including researching the current foster care environment in the State of Florida. The goal of this exercise was to figure out what had been or was being done in this arena and (more importantly) who seemed to be doing it effectively.
4.2 Phase II: engagement strategies
Team underdog DREAMS executed several engagement strategies which included:
An active partnership with foster care youth and other community partners;
A physical activity-based life skills intervention and collaboration entitled underdog DREAMS Foster Youth Physical Activity and Social Emotional Development Program with an organization called Move + Live + Learn;
Education to promote community awareness and advocacy;
Education directly tailored for foster youth and advocacy;
Foster youth mental and physical wellness; and
Technology solutions to support youth in foster care.
4.2.1 Active partnership with foster care youth and other community partners
Youth in foster care are the most critical community partners, and thus the team emphasized building trust and engaging with them to build a positive and trusting relationship and to identify their physical, social, and emotional needs.
4.2.2 underdog DREAMS foster youth physical activity and social emotional development program
Team underdog DREAMS collaborated with Move + Live + Learn to develop, deliver, monitor, and evaluate an 8-week physical activity-based life skills program. The ongoing collaboration helped underdog DREAMS develop our three strategic categories for maximum impact on the lives of foster youth in Florida: education, mental and physical wellness, and technology. This program was designed to increase:
Physical activity levels;
Understanding of healthy eating behaviors;
Proficiency in practical life skills;
Proficiency in social–emotional skills such as emotional regulation, communication, and decision making; and
Understanding of how to make choices that enhance wellness.
4.2.3 Education to promote community awareness and advocacy
Led or participated in outreach experiences including training and ongoing reflective supervision to professionals, facilitating simulations, and presenting at conferences
Represented youth voices at Florida Baker Act Task Force for Adolescents
Served on Florida Child Welfare Advisory Board as an advocate for foster youth
Hosted the underdog DREAMS Foster Care Month Celebration and Fundraiser Event held at Topgolf Orlando, highlighting underdog DREAMS’ $42,000 sponsorship of First Star Central Florida Academy
Submitted an opinion piece to the American Academy of Family Physicians that included a call to action to create a formal initiative for Family Medicine around the child welfare system
Created underdog DREAMS Child Welfare Standard of Care Protocol
4.2.4 Education directly tailored for foster youth and advocacy
First Star Central Florida Academy: underdog DREAMS participated in the academy’s onsite summer program and monthly at their Saturday sessions.
underdog DREAMS Job Readiness and Leadership Boot Camp: The team created and facilitated a preparatory program for 18 Central Florida foster youth ages 16–17.
Experiential Learning Experiences: The team sponsored trips to North Carolina; Washington, DC; and Puerto Rico.
Student-led video development: Participants created a video to pitch concepts on how the Microsoft HoloLens can innovate the child welfare system and improve long-term outcomes.
4.2.5 Foster youth mental and physical wellness
4.2.5.1 Clinical care
In an effort to deliver continuity of mental healthcare and address the frequent turnover of medical providers foster youth must endure, we implemented evidence-based treatment rooted in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), utilizing telepsychiatry to ensure continuity of care and access to child and adolescent psychiatry.
4.2.5.2 Research
We partnered with MOVE + LIVE + LEARN to create the underdog DREAMS Foster Youth Physical Activity and Social Emotional Development Program and evaluate a pilot intervention entitled underdog DREAMS: A physical activity program focused on life skills and social emotional health for deserving youth in foster care. Results of this mixed-methods research project are presented in the Notable Findings section of this chapter.
4.2.6 Telepsychiatry and other modalities
Telepsychiatry and our presence on-line and in social media contributed to the effectiveness of this project. We partnered with remote professionals to deliver innovative and engaging curriculum for youth in our underdog DREAMS Job Readiness and Leadership Boot Camp.
4.3 Phase III: implementation phase
Notable Findings.
4.3.1 underdog DREAMS Child Welfare Standard of Care Protocol
To support a more unifying approach to foster youth across the state, Team underdog DREAMS developed an evidence-based standard of care protocol outlining the necessary services that should be provided to every child entering the child welfare system. Ideally, this protocol would be legally mandated and utilized by the Community-Based Care (CBC) system to ensure all children and youth receive equal access and the highest caliber of treatment across the state.
There are 4 components to this protocol: Access, Assessment, Assistance, & Advocacy (see Figure 3).
Figure 3.
underdog DREAMS Child Welfare Standard of Care Protocol.
4.3.2 underdog DREAMS Job Readiness and Leadership Boot Camp
At the end of year 2, underdog DREAMS implemented the underdog DREAMS Job Readiness and Leadership Boot Camp, a preparatory program for CBC Central Florida foster youth ages 16–17 who were embarking on summer employment opportunities. There were 18 participants who attended the 4-day program that included psychosocial education, life skill training, and experiential learning.
On the final day of the camp, the participants completed a survey that asked for in-depth feedback on different aspects of the program. One set of questions focused on satisfaction, specifically with the presentations, the training facilities, and the overall quality of the workshop. The results of these questions are illustrated in Figure 4.
Figure 4.
underdog DREAMS Job Readiness and Leadership Boot Camp Program Results.
Feedback data was overwhelmingly positive, with 100% of participants being satisfied/very satisfied, stating the program met their expectations, and they would recommend it to others. Results were similar for participants’ views about instructional quality. Several youth attendees commented specifically on how much they liked learning with the use of video conference technology.
One theme that stood out among the positive comments from the foster youth was their enjoyment with interacting, hearing others’ thoughts, debating, group discussions, and “networking” with one another.
4.3.3 underdog DREAMS Foster Youth Physical Activity and Social Emotional Development Program
In the summer of 2019, Team underdog DREAMS launched an evidence-based youth physical and mental health program consisting of 24 sessions designed to increase physical activity levels and perceptions of physical activity; improve functional life skills (e.g., communication, nutrition education), and improve social emotional learning skills (e.g., coping strategies, decision making). Three group homes were partners in this project and transported youth to a central location for the twice weekly program throughout the summer. Trained coaches facilitated the lessons.
The underdog DREAMS team hypothesized that if the program proved to substantially improve the health (i.e., physical, mental, social, etc.) of youth in residential foster care, the successful elements of the program might be applicable in other residences. A mixed-methodology (quantitative and qualitative) evaluation occurred toward the end of and upon completion of the 8-week program. The quantitative assessments consisted of two previously validated instruments: the Survey (YES) 2.0 and the Life Skills Assessment (LSA) (Figures 5 and 6) [16, 17]. The qualitative analysis consisted of an opt-in participation focus group session so that participants’ voices could be heard. Program participants also completed an informational questionnaire (Google forms) in a guided opt-in focus group. All program participants completed “exit slips” that indicated the degree to which the learning objectives were met by the session.
Figure 5.
Life skills assessment (LSA) observation tool findings of program participants, post participation. Legend: 1 = does not yet do; 2 = does with a lot of help; 3 = does with some help; 4 = does with little help; 5 = does independently.
Figure 6.
Youth experience in sport (YES) 2.0 tool findings of program participants, post participation. Legend: 1 = not at all; 2 = a little; 3 = quite a bit; 4 = yes, definitely.
Challenges emerged related to consistency on the part of group home staff to transport youth to the programming. Thus, while underdog DREAMS planned for, recruited, and could accommodate approximately 60 youth for the program, a total of 13 youth attended all 24 sessions. While this reduced expected numbers, it allowed for the intervention to be piloted and points to the key role that transportation plays in intervention planning and design.
4.3.4 Quantitative findings: The Life Skills Assessment
The Life Skills Assessment (LSA) is an observation tool completed by facilitators of the program for each youth who participated in the program. This tool provides a sense of where coaches feel youth are in terms of applying the social–emotional skills they were taught in the program. Coaches observed high ratings in the LSA skill areas in youth who had participated in the program.
The YES 2.0 tool was completed by participants following their participation in the program, and specifically referred to the underdog DREAMS physical activity program. Participants of the program stated that overall they had gained helpful skills centered around topics such as goal setting, effort, problem solving, time management, emotional regulation, positive relationships, managing stress, etc. at rates between
A stepwise linear regression analysis revealed that positive relationships among youth significantly predicted the observer’s overall assessment of the overall life skills of each participant. In other words, the higher someone reported that the program had a positive impact on their relationship with others, the higher the coaches rated their overall use of life skills during the program.
Qualitative data was collected through focus groups with participants. Analysis indicated that youth in the foster care system may respond better in a focus group with one other youth or in a one-on-one setting. Youth had to be continuously directed to refocus and did not share their experiences as much as we anticipated. Four primary themes emerged from the focus groups (Figure 7).
Figure 7.
Focus group themes.
Overall, the data suggest that the time and resources designated to teach social emotional skills and functional life skills had a positive impact on those youth in foster care who were able to attend regularly. Participants indicated that the program primarily helped them with self-management and emotional regulation skills (e.g., dealing with conflict, knowing when to step back and walk away).
5. Discussion
Youth in foster care rarely participate in studies on well-being related topics such as physical activity and social emotional skills. There are many reasons for this as highlighted by Quarmby and Pickering, who conducted a scoping review of barriers and policy related to physical activity behaviors of youth in foster care [18]. To illustrate the minimal literature on this topic, only seven research articles qualified for their 2016 review from an original pool of 576 potential articles. The criteria for the authors’ broad review included: published in English, published in a peer-reviewed article, published between 1989 and 2014, related to children and youth living in or leaving foster care (including residential homes), and referenced physical activity participation [19]. Thus, drawing comparisons from previous research on physical activity and social emotional learning programs for youth in foster care is difficult; this fact emphasizes the need for work such as our project to determine what types of programming best supports the well-being of youth in the foster care system.
5.1 underdog DREAMS Foster Youth Physical Activity and Social Emotional Development Program
The majority (n = 12) of total participants (n = 13) who participated in all 24 sessions of the physical activity life skills and social emotional program were adolescent girls. According to the 2018 US Report Card on Physical Activity for Children and Youth, only 18% of adolescent girls receive the recommended 60 minutes of moderate to vigorous physical activity daily, compared to 36% of adolescent boys [20]. Given that fact, it was promising to the underdog DREAMS team that something about this particular program kept 12 girls returning to the program. Perhaps it was the social component, the inclusive nature of the evidence-based physical activities provided, and/or the positive relationships established among participants and between participants and facilitators of the program. Choice is highlighted here as a potential motivating factor because previous researchers determined choice in physical activity is a predictor of self-determination [21]. Facilitators of the underdog DREAMS program reported that when participants informally communicated joy from particular activities, they were sure to revisit those activities in future settings, which may have contributed to the girls’ continued participation.
While the underdog DREAMS team celebrates that adolescent girl participants increased their physical activity levels and reported learning life skills, one should not assume that local boys in residential homes did not want to participate or that the program is not ideal for adolescent boys in foster care. In this program, two of the three sites with whom we formed partnerships failed to transport youth to the programming location. Decision makers of these group homes were on board for this programming, but group home staff lacked either the capacity or the motivation to transport youth on a consistent basis. Consistent transportation to an off-site venue may have yielded more male participants.
After several weeks of delivering the program to participants from one group home, we changed our program location to their group home property. We did this to reduce transportation needs for that group home and to increase the number of youth from that program participating. This increased participation in the second half of the program implementation.
Youth in this program completed exit slips after some of the sessions as a form of formal, formative assessment. Facilitators analyzed their responses and used them to guide future instruction accordingly. Applying best pedagogical practices to this program was important to the collaborative because this program was not just focused on increasing physical activity behaviors; it was also focused on equipping participants with the necessary social and emotional skills that are often learned from parents. Analyzing these exit slips was extremely promising for the collaborative because participants were able to demonstrate an understanding of the social emotional and life skills taught.
5.2 Methodological Issues in Data Collection on Youth in Foster Care
One particular methodological issue that presented itself during data collection was that participants did not share their experiences in detail during the qualitative focus groups program evaluation portion of the project. Even with qualitative research interview strategies such as probing and prompting, youth seemed reluctant to share information about their experiences in any detail. Fortunately, this evaluation was a mixed-methodology study and included a monitoring phase where participants were welcome to give informal feedback at any time. This informal feedback was critical and contributed to the program’s success.
5.3 Replicating underdog DREAMS Foster Youth Physical Activity and Social Emotional Development Program in Other Communities
Our results show a great deal of promise for the underdog DREAMS physical activity program, and communities are encouraged to replicate this program. Key successes of program planning and implementation include the following:
A
detailed training is important to make sure all facilitators are on the same page and are prepared to collaborate and help each other work through any issues that may arise. Underdog DREAMS created a day-long training to prepare facilitators on how to deliver the program optimally.Program facilitators display
reflective practice and flexibility throughout the implementation.Informal formative feedback is gathered from the youth throughout the program.
5.4 Future programming
Future sites that implement this program can learn from our implementation and make every effort to increase participation by minimizing challenges to transportation. While we invested in partnerships with organizations and key decision makers, perhaps more time could have been spent with group home staff (i.e., those directly responsible for transporting the youth).
Future implementation of this program should consider giving youth a choice to record their answers individually rather than in a focus group and/or allowing youth to choose how many and which peers they feel most comfortable sharing their thoughts and experiences within a focus group setting. Youth may also be encouraged to write their responses rather than sharing them verbally.
Future sites should collaborate with the underdog DREAMS team to benefit from the body of research in this area. As the program is replicated it can continuously be monitored to measure the impact. It is critical to contribute to the literature as so few studies examine the influence of physical activity programming for youth in foster care [22].
6. Leader learning
Below are remarks from our team on our crucial leadership insights gained through the experience of serving as a Clinical Scholar.
6.1 Health equity
As defined by the Robert Wood Johnson Foundation, “Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care” [23]. Belief in this value should be the “north star” for your project and the foundation upon which to build a vision and culture and guide your efforts. In all that our underdog DREAMS team did, we asked ourselves, “does this advance health equity for foster youth?” For example, the underdog DREAMS Child Welfare Standard of Care Protocol is designed to require that
6.2 Social determinants of health
Social determinants of health (SDoH) are the conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes [24]. We recommend spending time understanding the SDoH affecting your target population and creating interventions to address them specifically. Foster youth living in group homes have limited accessibility to healthy food choices, are often responsible for making their own meals, and are unable to participate in sports or fitness activities due to lack of transportation. These were the SDoH identified and addressed in our project; other projects and work might address others.
6.3 Visioning
The underdog DREAMS team initially created and were subsequently guided by our vision: Utilizing the value of health equity, create and project a compelling and engaging vision. Our team recommends that others engaging in this work ground their own approach in a strong overarching vision, as indicated in the (Figure 8) below.
Figure 8.
underdog DREAMS Vision Statement.
6.4 Creating effective organizational culture
6.5 Collaboration/creative partnerships
One of our greatest successes was the development of relationships with key stakeholders. Our relationship with the youth in foster care was most pivotal. By spending quality time engaging in conversation both formally in the classroom and informally through fun activities, we learned from the experts how best to make an impact in their lives. By consistently demonstrating our values of transparency and accountability along with hard work and dedication to this project, underdog DREAMS developed a reputation as trustworthy, knowledgeable team-players, thus allowing for these partnerships to form and grow.
7. Toolkit
7.1 underdog DREAMS Websites
Forms, additional charts and data can be accessed at the underdog DREAMS website.
7.2 Relevant websites
U.S. Department of Health and Human Services Children’s Bureau
U.S. Department of Health and Human Services Child Welfare Information Gateway
Florida Department of Children and Families
Florida’s Child Welfare Statistics
Casey Family Programs
Center for Youth Wellness
American Academy of Pediatrics Health Foster Care America
National Youth in Transition Database (NYTD)
Tracking the United States Congress
7.3 Partnership websites
Community-based Care Central Florida
Move Live Learn
University of Central Florida Foundation
First Start Central Florida Academy
UCF College of Community Innovation and Education
Orange County Parks and Recreation
Friends of Puerto Rico
Lo Cal Guest
Cavarocchi Ruscio Dennis Associates
A more comprehensive toolkit can be found at https://clinicalscholarsnli.org/community-impact.
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