The Well-Being and Risk Behaviors of Young Adults from Foster Care

1. The Well-Being and Risk Behaviors of Young Adults from Foster Care Dissertation Defense April 24, 2009 Tonia Stott Committee: Dr. Karen Gerdes Dr. Mary Gillmore Dr. Nora Gustavsson

2. The worst thing about moving from one place to another • Not ever being able to attach to a person one hundred percent. The hardest thing that effects me now… I just signed a year lease, but I’ve never lived somewhere that long….. • If you actually make friends, though I didn’t get to know a lot of people, then you don’t ever get to see them again. • Moving, having to leave friends, leave brothers and sisters and not knowing what was going to happen to them. Getting used to new people, getting used to a new routine and having to figure out who was going to steal your stuff.

3. Introduction • Young adults aging out of foster care are at great risk of faring poorly in young adulthood, yet, little is known about how to affect these outcomes. • Relational-cultural theory posits that people, especially people in marginalized groups, develop in and through connected relationships. • Placement instability may be effecting youths’ access to and ability to engage in connected relationships. • Due to a lack of connected relationships, young adults from foster care may lack the emotional and social competencies necessary to fare well in young adulthood.

4. Background Literature • Former foster care young adults • Placement instability • Substance use in young adulthood • Sexual behaviors in young adulthood • Relational-Cultural Theory

5. Former Foster Care Young Adults • 50% leave care without a High School Diploma • 25 - 50% are unemployed at any given time • 10% - 33% experience homelessness • 30% have been arrested and/or incarcerated • 40% - 60% experience mental health problems • 40 - 55% do not have health insurance • 25% are using substances • 15% have a substance dependence disorder • 40% - 60% have expected a child • 30% - 50% are parenting children

6. Former Foster Care Young Adults • Are expected to be self-sufficient at an age when other young adults are not socially expected to do the same. • Have no safety nets • While the Chafee Foster Care Independence Act of 1999 doubled the federal funding for youth transitioning from foster care, the resources and funding available to this population are still far from adequate.

7. Placement Instability • Youth who age out of foster care moved, on average, every six months while in care. • Movement is usually due to • Systemic needs (moving up or down in level of care, placement with relatives, licensing issues) • Foster parent inability or unwillingness to tolerate the child/youth’s behaviors often exacerbated by a lack of services to the foster family

8. Placement instability Each time a youth is moved, it typically causes changes in: • School • House rules • House/familial norms, culture (including attitudes toward substance use and premarital sex) • Access to family, siblings, extended family, friends, boy/girlfriends • Ability to work, belong to clubs, or participate in organizations/sports Each move is also associated with loss • Relationships with care providers & service providers • Friendships • Boy/girlfriends • Natural mentors • Important possessions

9. Consequences of Placement Instability • Educational deficiencies • Poor self-esteem • Problem behavior • A distrusting stance toward relationships • Hopelessness • Lack of motivation to plan for the future • More instability • The greatest predictor of future instability is past instability

10. Substance Use in Young Adulthood • Can be somewhat normative for college-attending young adults who generally have multiple protections and safety nets. • Is more risky for non-college attending young adults and is more likely to lead to a trajectory of substance abuse.

11. Factors Associated with Poor Substance Use Trajectories • Low educational attainment • Mental/behavioral health problems (esp. depression and anxiety) • Disorganized social environments • Low socio-economic status • Social networks comprised of other users or others with problem behaviors • Familial histories of substance abuse • Childhood adversity

12. Substance Use and YAFC • These conditions characterize most youth who age out of foster care. • They are less likely than their peers to: • Graduate from high school • Go to college • They are more likely than their peers to: • Have mental/behavioral health conditions • Be in poverty in young adulthood and to have been raised in poverty • To have diffused social networks while in foster care or have social networks consisting only of other foster youth • Have pervasive substance abuse in their families • Have experienced extensive childhood adversity

13. Risky Sexual Behaviors in Young Adulthood • Can have lifelong consequences • Unplanned pregnancies • Infertility from PID resulting from untreated Chlamydia and Gonorrhea • Viral outbreaks from herpes • Cervical Cancer from HPV • Death from Hepatitis B & C and AIDS

14. Factors Associated with Young Adult Risky Sexual Behaviors Adolescent Pregnancy • Low socio-economic status • Living in oppressed communities • Racial/ethnic minority status • History of sexual abuse • Child maltreatment • Difficulties in school • Poor familial communication • Substance use • Lack of sense of opportunity • Stressed/Distressed feelings • Poor sense of self-efficacy • Low self-esteem • Depression • Ambivalent attitudes toward childbearing

15. Factors Associated with Young Adult Risky Sexual Behaviors Adult Sexual Risk Behaviors • Current substance use • Early initiation of substance use • Child maltreatment • History of sexual abuse/rape • Early age of first intercourse • First intercourse with older partner • Lack of self-efficacious decision-making style • Homelessness • Living in disadvantaged neighborhoods • Racial/ethnic minority • Attitudinal adherence to traditional gender roles • Depression • Experiencing social oppression • Low educational attainment • Low self-regulation • Attraction to risk-taking

16. Risky Sexual Behaviors & YAFC • Many of these conditions disproportionately effect youth who enter and remain in foster care • About half of females who age out of care have a history of being sexually abused • Foster care youth came from disadvantaged neighborhoods and the majority of families served by the child welfare system are in poverty • Racial and ethnic minorities are over-represented among foster youth • Foster youths’ primary social networks are comprised of other foster youth with high risk behavior, and inconsistent messages about sex • Foster youth are more likely than their peers to • fall behind in school, to be suspended, and have IEPs. • to have used substances in adolescence • to have had a younger sexual debut

17. Relational-Cultural Theory (RCT) • Posits that individuals, especially those from non-dominant groups, primarily develop in and through relationships. • Healthy, “connected” relationships, characterized by mutual empathy and authenticity, lead to the “5 good things” which are consistent with emotional and social well-being.

18. Relational-Cultural Theory(RCT) The “5 Good Things” • zest (absence of depression) • empowerment (self-competence/ self-efficacy) • sense of worth (self-esteem) • relational clarity (ability to differentiate healthy from unhealthy relationships) • desire for more relationships (positive social orientation)

19. Transformative Connection relational resilience Disconnection shame/fear isolation Desire for Connection empathy authenticity Connection Chronic Disconnection relational competence lack of energy learned helplessness/immobility diminished self-worth relational confusion separation from relationships Differentiated Connections zest/energy empowerment/motivation for action sense of worth relational awareness desire for more relationships

20. RCT & Placement Instability • Youth in foster care experienced disconnection in their primary relationships • abuse, neglect, abandonment • removed from their homes, siblings, schools, friends, neighborhoods, communities • They need access to transformative connections • relative care-givers, foster parents, group home staff, helping professionals • friends, relationships with significant others, natural mentors, concerned adults (parents of friends or boy/girlfriends), teachers

21. RCT & Placement Instability • Placement instability interferes with relationships, and can cause multiple disconnections from any transformative relationships which were developing. This can leave youth feeling in a state of condemned isolation. • Placement instability is associated with significant relational losses. Many youth utilize self-protection mechanisms to guard against engaging in future relationships.

22. Hypotheses • Foster care placement instability is positively associated with substance use and risky sexual behaviors and negatively associated with emotional and social well-being in young adulthood. • Emotional and social well-being is negatively associated with substance use and risky sexual behaviors in young adulthood. • Emotional and social well-being mediate the effect of placement instability on substance use and risky sexual behaviors.

23. Methodology • Participant Protections • Sampling Frame • Recruitment • Sample • Data Collection • Interview Schedule • Data Analysis

24. Participant Protections • Arizona State University’s IRB approval • Certificate of Confidentiality from the National Institutes of Health • Approval from the Division of Children, Youth, and Families (DCYF) Research Committee • Data Sharing Agreement between DCYF and the researcher • All student researchers and other associates signed confidentiality agreements

25. Sampling Frame • DCYF provided the researcher with the names and placement histories of young adults who turned 18 while in their custody between July 1, 2004 and June 30, 2008. • A total of 2045 young adults were identified

26. Primary Recruitment • Young adults with a valid address were mailed a recruitment packet consisting of • Flyer • Recruitment Letter • Enrollment (Informed Consent) Form • Decline Form • Resource Directory • Addressed, postage paid envelope

27. Secondary Recruitment • Flyers posted at agencies serving young adult populations • Communication with Independent Living Skills providers and CPS District Young Adult liaisons concerning updated addresses for young adults with no address. • Snow-ball sampling question within the interview schedule • Distribution of informational flyers at community meetings with providers for this population and at community events. • Follow-up letters with young adults who enrolled but could not be contacted via phone.

28. Sample • 183 young adults enrolled • 2 withdrew • communication was lost with 48 • 123 young adults were interviewed • 114 young adults are included in the analysis • 5 were removed because it was unknown if they could understand the informed consent or they did not fit the sampling parameters • 4 were removed because they had no placement history on the files from DCYF

29. Data Collection • Interviews were conducted between July 2007 and November 2008. • Participants were interviewed following an interview schedule which was administered using Survey Monkey. • When participants consented, interviews were audio-taped. • Their placement histories were extracted from the DCYF administrative data. • Students in Child Welfare Training Units who chose to participate in this project were trained in conducting the interviews. They conducted 26 of the 123 interviews.

30. Interview Schedule • The interviews lasted between 45 minutes and 1 and a half hours. • The domains covered in the interview were: • Self-sufficiency well-being • Substance use • Sexual behaviors • Foster care experiences • Lifetime exposures to trauma

31. Interview Schedule • Three standardized instruments were also administered through the interview • Center for Epidemiological Studies –Depressed Mood Scale (CES-D) • Self-Esteem Rating Scale-A (SERS-A) • Network Orientation Scale (NOS) • One instrument of the author’s creation was administered • Connectedness in Last Placement (CiLP): assessed their feelings in their last placement before turning 18 concerning, the degree to which they felt like they belonged, were cared about, had influence over their own life, and had at least one person in their life who understood them and at least one person who they could trust.

32. Data Analysis • Cleaning and coding of the interview data • Placement histories of the participants extracted and reviewed • Variables identified and operationalized

33. Data Analysis Variables • Independent Variable: Placement Stability • Number of Placements • Mediating Variables: Emotional & Social Well-Being • CES-D Sum Score • SERS-A Sum Score • NOS Sum Score • CiLP Sum Score • Dependent Variables: Young Adult Risk Behaviors • Substance Use • Risky Sexual Behaviors • Control Variables: Exposure to childhood traumas • Parental/home characteristics • Child maltreatment • Intimate partner violence

34. Number of Placements Operationalized • The total number of lifetime locations/placements for each participant. • Placements which began at or over the age of 18 were removed from the total number.

35. Emotional & Social Well-BeingOperationalized • CES-D (20 items on a 4 point scale) • Sum of numerical responses • positive items reverse coded • scale placed on a zero order • possible range of 0 to 54 (the last two items were inadvertently omitted) • As the number increases, depression increases • SERS-A (23 items on a 7 point scale) • Sum of numerical responses • negative items assigned a negative value • possible range of -65 to 73 • As the number increases, self-esteem increases

36. Emotional & Social Well-BeingOperationalized • NOS (20 items on a 4 point scale) • Sum of numerical responses • items were reverse scored to be consistent with the literature • the scores of negatively worded items which would have been reverse scored were retained • has a possible range of 20 to 80 • As the score increases, negative attitudes about engaging in social networks increase • CiLP (15 items on a 5 point scale) • Sum of numerical responses • possible range of 15 to 75 • As the score increases feelings of connectedness in their last placement increases

37. Substance Use Operationalized • Frequency for each drug used and frequency of intoxication over the past five months summed • Substance Use Scale: 0 = no use 1 = used once a month 2 = used 2-3 times a month 3 = used once a week 4 = used 2-4 times a week 5 = used daily • All scores over 5 converted to 5 due to extreme variance

38. Risky Sexual Behaviors Operationalized • All those who were not sexually active in the past three months were coded with a 0. • All those who had 1 partner in the past three months and always used condoms were coded with a 1. • For the remaining participants: • condom and other contraceptive use scores (for those who had vaginal intercourse) were averaged • number of partners they had in the past 3 months was multiplied by the average of condom/birth control use • condom use frequency only was used to determine the score of those who did not have vaginal intercourse • the young women who were currently pregnant were coded with a 5 (most scored that number, anyway) • All scores over 5 converted to 5 (most risky)

39. Risky Sexual Behaviors Operationalized • Risky Sexual Behaviors Scale 0 = no sexual activity 1 = one partner and always used condoms 2 = one partner and used condoms and/or birth control more than half the time, OR two partners and always used condoms 3 = one partner and used condoms and/or birth control about half the time, OR three partners and always used condoms 4 = one partner and used condoms and/or birth control less than half the time, OR two partners and used condoms and/or birth control more than half the time, OR four partners and used condoms all the time 5 = one partner and never used condoms and/or birth control, OR three or more partners and used condoms more than half the time or less, OR five partners and used condoms all the time

40. Childhood Traumas Operationalized No = 0, Yes = 1 • Parental substance abuse • Parental domestic violence • Parental poverty • Parental incarceration • Neglected • Physically abused (at home or in care) • Sexually abused/raped (by anyone) • Experienced intimate partner violence

41. Results • Demographics • Variable descriptives • Regression analyses • Path Model

42. Demographics

43. Demographics

44. Placement Descriptives

45. Emotional & Social Well-Being Descriptives

46. Substance Use Descriptives

47. Risky Sexual Behaviors Descriptives

48. Childhood Traumas Decriptives

49. Regression Analyses • To test the direct effects of placement instability on substance use and risky sexual behaviors, each of those variables was regressed on placement number with the control variables entered as covariates. • To test the direct effects of placement instability on emotional and social well-being, each of those variables was regressed on placement number with the control variables entered as covariates. • To test the mediating effects of emotional and social well-being on substance use and risky sexual behaviors each of those variables was regressed on each of the emotional and social well-being variables with the control variables entered as covariates.

50. Significant Results When controlling for childhood traumas: • Substance use scores increase by .06, on a five point scale, with each increase in placement number (p<.05). • Risky sexual behaviors scores increase by .06, on a five point scale, with each increase in placement number (p<.1).