Stepping Down and Stepping In: Youth’s Perspectives on Making the Transition from Residential Treatment to Treatment Foster Care

Abstract

Older youth preparing to emancipate from the foster care system are often served in residential treatment settings where they have limited opportunities to practice skills for independent living in a community setting. Stepping these youth down to less restrictive environments such as treatment foster care is a growing trend, especially for youth with mental health issues. Yet, few studies have explored the youth’s perspective on making this transition. This study utilized qualitative interviews with youths who were participating in a treatment foster care intervention study (n=8) to gain their perspectives on the process of transitioning from residential care. Youths were interviewed right before they exited residential care and two months after placement in the new foster home. Youths reported hopes for gaining family in the new home as well as fears of placement disruption. Findings point to the need to enlist youths in discussion and problem solving about difficulties they anticipate in the new home and expectations for their relationship with the new foster parents. In addition, the struggles described after two months in the home point to the need for youths to build specific skills to better manage ongoing relationships with foster parents and for foster parent training on how to help build these skills.

1. Introduction

Preparing older youth to successfully transition to adult roles is a critical task for child welfare systems. Independent living preparation for those emancipating from foster care has been a national priority for several decades, yet the young adult outcomes for these youth remain poor (Courtney, Dworsky, Lee & Raap, 2010). Absent a permanent home, family foster homes may provide the ideal setting for preparing older youth for adulthood. However, many youth continue to reside in restrictive congregate care settings. Stepping youth down from congregate care to family-based settings can provide them with more normative life experiences such as employment and increased opportunities to learn social skills necessary for adult relationships. Few studies have focused on this potentially important step-down transition and the elements that contribute to a successful move to community living. This study uses qualitative methods to explore the perspectives of older youths in the midst of a step-down from residential programs to treatment foster care homes.

2. Background

Young people who age out of the foster care system have significantly worse outcomes in young adulthood than their peers in the general population with low rates of educational attainment and employment and high rates of criminal involvement and homelessness (Courtney et al, 2010). Numbers in the domains of employment and income are especially low. At age 23–24, only 48% of youth who aged out of foster care were working and their earnings, at median, were only $8,000 dollars per year, an average of $10,000 less than their peers in the general population (Courtney et al, 2010). The years prior to system exit present an opportunity to provide these youth with the skills and supports they need to improve these outcomes. Unfortunately, large numbers of young people in foster care continue to reside in residential treatment programs, the most restrictive level of care on the child welfare placement continuum (Bates, English & Kouidou-Giles, 1997). About 10% of youth served in the foster care system nationwide are served in institutional settings (USDHHS, 2010) and for older youth, this number is even higher. One study of 17-year old foster youths found that 38% were residing in a residential or group home setting (McMillen et al, 2004). Moving to adulthood from these restrictive settings represents an especially steep transition with youth struggling to adjust to community living at the same time they are taking on the responsibilities of life on their own. In a qualitative study of professionals and youths who transitioned to independence from congregate care, many youths expressed that they had not been ready to be on their own. (Freundlich, Avery & Padgett, 2006).

Efforts to step youth down from residential treatment to less restrictive settings are complicated by the fact that many youth served in these settings are also managing mental health problems. Past research has found that older youth in foster care experience high rates of mental disorders (Keller, Salazar & Courtney, 2010; McMillen et al, 2005), with lifetime prevalence of any disorder as high as 61% (McMillen et al, 2005). Youth with mental disorders are more likely to receive services in restrictive settings such as residential treatment facilities (Keller et al, 2010; McMillen et al, 2004). Recent evidence suggests, however, that youth with high mental health needs can be successfully treated and stepped down from residential treatment to less restrictive environments within six months of admission if acceptable community alternative are available (Lyons, Woltman, Martinovich, & Hancock, 2009). Prior research has found that the aftercare setting to which youth transition and the discharge planning they receive as they leave, are key determinants of long term success after leaving residential treatment (Epstein, 2004; Curry, 1991). This highlights the need to ensure that these transitions are carefully managed in order to promote successful outcomes.

Treatment foster care is one alternative to residential services that has increasingly become part of the system of care (Farmer, Wagner, Burns & Richards, 2003; Hussey & Guo, 2005). One study found that many youth served in treatment foster care settings are stepping down to these placements from more intensive levels of care (Farmer et al, 2003). While these placements are often successful in maintaining youth in the community, older youth have greater risk for disruptions in placement due to adverse incidents than their younger peers (Farmer et al, 2003). Some qualitative studies conducted with youths and foster parents have found that preparation for making placement changes is important for ensuring success. Both youths and foster parents identified the importance of pre-placement visits to ensure a good fit between the youth and foster parent (Hyde & Kammerer, 2009, Castellano-Brown & Lee, 2010). Even with pre-placement visits, however, many placements disrupt (Castellano-Brown & Lee, 2010). Additional attention to the process of transition from residential treatment specifically for older youths is warranted in order to identify strategies to promote successful moves to the community prior to exit from state care.

Currently, there is limited research to assist in understanding exactly how best to manage placement transitions, especially for youth with psychiatric problems (Castellano-Brown & Lee, 2010). One key source of information that has been largely missing from the literature on placement transitions is the perspective of the youths themselves (Unrau, 2007). It is widely acknowledged that inclusion of youth voices to guide treatment and planning is critical to providing effective services to older youth (Deschenes & Clark, 1998), yet we currently know little about how youth experience the step down from a residential placement to treatment foster care. Previous qualitative work has solicited youth’s advice about placement transitions but has not captured the actual experiences of youths as they made the transition (Hyde & Kammerer, 2009). A better understanding of youth’s expectations and experiences in making the move from residential to treatment foster care can provide valuable information about how to manage changes in restrictiveness to both ease these transitions and promote stability in the foster care placements.

The current study begins to address this gap by providing youth perspectives on this step-down transition. As part of a program to develop a treatment foster care program specifically for older youth, we interviewed young people immediately before they left residential placements, then followed up in their foster homes two months later. Our study focused on answering three research questions: What were youth’s concerns and fears prior to the step down from residential to a new foster home? What were youth’s hopes and expectations for community living? How had these concerns and expectations unfolded two months later? Answers to these questions can inform practices to prepare youth for transition to treatment foster care and prepare foster parents to meet their needs.

3. Methods

Participants in this study were involved in a project designed to develop and pilot a step-down intervention for older youth. As part of an effort to further refine the intervention, youths were interviewed prior to and after stepping-down from a residential program into a treatment foster care home. Interviews were conducted between January 2009 and December 2010. All portions of the study were approved by the University’s Institutional Review Board.

3.1 Participants

Youths were referred for inclusion in the study from a private foster care agency contracted to handle both routine and high needs foster care cases. Youths were eligible to participate if they were 16 to 18 years old at initial contact and: 1) were in state child welfare custody, 2) had been hospitalized for a psychiatric illness in the past year or were receiving psychotropic medications 3) were residing in a licensed residential treatment facility, 4) had been in the foster care system for at least 9 months and 5) had a documented full scale IQ of 70 or more. IQ was restricted in order to recruit participants who could successfully participate in structured and semi-structured interviews and provide informed assent.

Administrators at the referring agency used administrative databases to identify potentially eligible young people based on age and placement history. They provided a list of 96 young people and the names of their care managers to the study team. Care managers were approached to further determine if youth met criteria for the study. Of the 96 youths referred, 46 were determined to meet our eligibility criteria (48%). Of these youths, 27 were excluded from further consideration based on care manager discretion for reasons such as being actively suicidal or homicidal, medically fragile, undergoing sex offender treatment, or having already had plans for reunification with family members. Informed consent to participate in the study was provided by the youth’s care manager and the youths provided written assent.

Once youths were determined to be eligible for the study, an initial structured research interview was conducted. This interview included portions of the Diagnostic Interview Schedule Version IV (Robins, Cottler, Bucholz, & Compton, 1995) that assessed criteria for lifetime and past year psychiatric diagnoses of post-traumatic stress disorder (PTSD), attention deficit hyperactivity disorder (ADHD), depression and mania, oppositional defiant disorder (ODD), and conduct disorder (CD). The interview assessed for maltreatment history using the child trauma questionnaire (Bernstein & Fink, 1998) and 3 items on sexual abuse adapted from Russell (1986). Youth were also asked to report when they had last entered the child welfare system and the number of previous placements they had experienced. After the baseline interview, youths were matched into pairs based on their interview-derived or “official” mental health diagnoses in the agency database and then randomized into the TFC-OY or usual care conditions using a random numbers table. Eight youths were matched and randomized to receive the intervention. Seven of these eight youths enrolled into the intervention. One youth who had been randomized into the intervention decided not to participate in the program prior to placement in a foster home. Youths who were randomized into the intervention were placed in specially trained foster homes with individualized support from a team of professionals. The program provided supportive services for foster parents, families, and youths through a new manualized intervention developed specifically for older youths.

The eight youths randomized into the intervention comprise the sample for the current study. Two of the youths were age 16, five youths were age 17 and one youth was 18. Three of the youths were male and five were female. The majority of youths identified as African-American (n=6) with one youth identifying as Bi-racial and another as Caucasian. They had long histories of placement disruption, with an average of 13 previous placements (range= 6–32). and had been at their current residential placements for an average of 9 months (range 1–18 months). Three youths had been at their current placements for less than 6 months, but had come to these placements from other residential settings and had spent the majority of the last six months in a residential treatment setting.

Using cut scores from the child trauma questionnaire, four youths met criteria for physical abuse and two met criteria for physical neglect. Six of the eight youths met criteria for sexual abuse by answering yes to any of three questions about unwanted sexual contact. Based on past year interviewer-derived DIS diagnosis, two youths met criteria for PTSD, two met criteria for a mood disorder (either depression, mania or both), three met criteria for ODD, one met criteria for CD and one met criteria for ADHD. Three of the youths did not meet criteria for any of these diagnoses based on their reporting of past year symptoms. Six of the eight youths had been in a psychiatric hospital within the past year and all were on at least one psychotropic medication. Three youths took only one medication and the other five took four or more medications. The most commonly prescribed medications were anti-psychotics (n=6), anti-convulsants (n=4), and anti-depressants (n=3).

3.2 Interviews

The first semi-structured interviews were conducted just before youths transitioned from their residential program to the treatment foster home. Youths had all met their new foster parents prior to the interview and had visited the homes they were moving to. The goal of the interview was to obtain youths’ perspectives on their experiences in the residential treatment programs they were leaving, perceived plans for the future, perceptions of the program they were entering, and their hopes and fears about the upcoming placement. An interview guide was used that contained questions such as “What do you think you will miss when you leave here (residential facility)?” “What was your first impression when you met [name of foster parents]?” “What is your biggest hope about moving into a new foster home?” and “What is your biggest fear?” The one youth who was randomized into the intervention but chose not to participate was also interviewed in order to understand his decision to remain in the residential facility.

A second semi-structured interview was conducted two to three months after placement in the foster home with the seven youths who entered the program. This interview focused on understanding the youths’ experiences thus far and the challenges and triumphs in the new foster home. The interview guide contained questions such as “What was the transition like for you when you moved from the residential home to your foster family home?” “Talk about your experience of getting to know this family” and “How has been living here been different than what you expected?”. Youths reflected on the transition from residential care to community living and talked about their daily lives in the foster home. Interviews were conducted by an expert consultant in qualitative research and by doctoral level research assistants who received training on qualitative interviewing from this consultant. Interviewers were trained to elicit stories and detail from the youth on their experiences. Interviews typically lasted 30–45 minutes and were audio recorded and transcribed. Youths received $15 for each of these semi-structured interviews. Information provided by the youths in these interviews was summarized and made available to members of the intervention team to provide additional information for facilitating the transition to the new home.

3.3 Data Analysis

Our analytic strategy employed a team-based open coding approach. We began codebook development by coding data from the first set of interviews conducted just prior to placement. Three members of the research team read the same three transcripts, identified themes, and formulated an initial template of codes with examples of situations in which to apply them. After discussion to come to consensus, this initial codebook was tested by using it to code two additional interviews. The investigators compared coded text and discussed discrepancies until agreement was reached. Once the codebook had been established, one investigator coded the final interviews. A second round of codebook development was used to expand the initial codebook and code the interviews conducted two months into the placement. The team further developed and refined the codebook and applied it to these interviews. In order to facilitate cross-case comparison, a conceptual cluster matrix was also used in the analysis (Miles & Huberman, 1994). The matrix contained reduced data such as phrases and quotations organized by themes and by case. This matrix was utilized along with the coded transcripts in team discussions about the results. All authors read these documents individually which facilitated discussion and eventual consensus about the meaning of the identified themes.

4. Results

Our results present the views of youths as they anticipated moving to a new foster home and then follows up with them two months later. During the first interviews as youths contemplated “stepping down” from residential treatment to a treatment foster home, they talked about their hopes for their new placements and their feelings of loss and relief at leaving the restrictiveness of residential care. Two months later, after these youths had “stepped in” to their new settings, they talked about their successes and substantial challenges in adjusting to community living.

4.1 Stepping Down: Youth thoughts on making the transition

Interviews conducted with youths as they prepared to move to their new foster home revealed substantial hopes and potentially critical losses. Youths also expressed fears about not being able to maintain themselves in community life and an eagerness to cope to the best of their abilities with upcoming challenges.

4.1.1 Idealized Hopes: Freedom and Love

Youths talked about how leaving residential care would provide opportunities for increased happiness, freedom and the chance to be “normal”. These older youths were eager to be freed from the rigorous demands and rules of congregate living, experience increased autonomy, and fully engage in the activities that they associated with being a normal adolescent. Things such as attending a regular school, getting a job, hanging out with friends and going places without adult supervision were particularly valued. This was presented in stark contrast to the high level of restrictiveness they experienced in their residential placements. One youth stated,

But, I’m really happy that I’m leaving, because then I won’t have to be in so much strict things, like saying you gotta ask to go to the bathroom, ask to come out of your room, knock on your door before you come out. I don’t like that. I feel like I’m not free. But when I come in this house, when I’ll be visiting, I feel like I can be just me.

Another youth reflected after her first weekend visit with the new family that “I won’t have to ask to open the refrigerator or ask to open the door to go outside.”

Youths’ desires seemed to fall into two distinct groups. For half of the youths, the hopes about community living were articulated primarily around a desire to be accepted by a family and their wish for positive relationships with these new family members. At the first interview, several of these youths were already calling their future foster parents “mom” and “dad” and referring to foster siblings as their brothers or sisters. A seventeen year old girl described her first meeting with her foster placement by saying, “When they told me they were my foster family, it shocked me. I’m just really happy that I got a family now.” These youths also were eager to contribute to their new household. They talked about helping with child care and cleaning. A 16 year old girl described how she saw her role in the new household:

Like, for me to be like a person that’s going to help her, and will for her to help me, and me willing to help her with anything she needs help with. And, like if she needs extra stuff done, I’ll do that. Of, if she needs me to do this, I’ll do it. Walk around to the corner store, or go grocery shopping…just do extracurricular activities that will help.

For the other subset of youths (n=4), hopes for community living were focused more on the desire to attain specific goals. Positive relationships with their new “family” were more a means to accomplish individual aspirations. While youths talked in general terms about how their goals would be accomplished, they appeared to have a general sense of self-efficacy. They were hopeful about finishing high school, going to community college and obtaining employment. These youths were much more specific about their goals for the future. One youth described his aspirations: “I want to cut hair, and have my own barbershop. And then, my second goal is I want to become part of a law enforcement program which goes out to talk to kids that are in gangs…” His hopes for success in the foster care placement were tied in with his desire to achieve these goals. Another youth who spoke about her desire to get a good education stated: “I used to have a problem in school with my behavior. But I think if I have like a stable home, then I’d probably be able to learn something from my foster parents and that would probably carry on into school.”

Focus on goals for the future also led one youth to decide not to participate in the treatment foster care program. Though he had visited a foster home, he chose to stay at his placement and keep working at a job in order to move to a transitional living program where he could “progress from that to my own apartment.” Rather than wanting the support of a family, he described the advantages of the transitional living program for reaching his goals.

It’s just like, basically you go to school, or you work, and this teaches you, I guess, how to be on your own more. And … You don’t have people telling you what to do. Well, you still got people telling you what to do, but it’s not like they’re on your back more. And, like it’s basically up to you to do what you’re supposed to do.

4.1.2 Potentially Pointed Losses: “I really, really, really like my therapist”

While youths eagerly anticipated the freedoms that would accompany community living, they also expressed some feelings of sadness and loss about leaving their residential placements. Relationships with staff members emerged as a central component of their lives in residential treatment. Most youth participants mentioned that they would miss some of the staff members once they left. They described strong, supportive, and influential relationships with school, mental health, and direct-care staff members. Youths talked about how staff members would help them to stay out of trouble and would also fill important roles in their lives, serving as surrogate parents in some cases. One youth stated “I became attached to the staff really bad. I’m scared to leave, cause I’m afraid that I’ll never see these people again.” Another youth talked about leaving his therapist at the residential facility: “I have a therapist, and I really, really, really like my therapist. You know I really, really so respect my therapist, because my therapist helps me get things off my mind.” Youth participants also talked about their relationships with other residents and the friendships they had made.

In addition to missing people, changing from a highly structured to less structured environment emerged as something participants talked about with mixed feelings of regret and relief. “Routine, changing my routine is really going to mess me up.” one youth remarked. Another youth commented on the familiarity of residential life: “I mean, I’ve been here for two years and I know this place by heart.” This youth presented the advantages of structured recreation and time with friends but eventually concluded that “it’s kind of like, you know, boring, cause you know everything and you know what’s gonna happen, like as if you live your day, the same day over and over and over and over.” The highly structured nature of their lives in residential appeared to be simultaneously comforting and confining and youths were not sure how they would react to a new, less structured routine.

4.1.3 Fears: They’ll Put Me Out the Next Day

At the initial interview, youth participants were asked to describe their fears related to the move. For many youths (n=4), their first response was concern about the placement not working out. Youths talked about previous foster care experiences as they described fears that foster parents wouldn’t be able to stick with them. As one youth put it,

My biggest fear is for me to get put out, basically. Because I want to be able to get there, get used to her (foster mom) and get successful and not being able to just get in there and then be put out the next day or something…

Another youth described her fear that “they won’t lose interest and not want me. Meaning, like, I hope that this never happens, it won’t happen like it did in the foster homes that I’ve been in, like they just give up on me.” These youths had long placement histories that appeared to shape their thinking about the move to treatment foster care.

These youths recognized that they had behavioral and mental health problems and their fears of disruption often centered around identified problems with anger and mood swings. One youth said,

I’m just a little, right now I’m just like a little frightened of she’s (foster mom) not seen my, um, mood swings…because whenever people see my mood swings, they don’t know what to do, so I end up leaving.

Other youths articulated fears that “my anger might come back up” or “Me getting into a lot of trouble. My anger.” Another youth stated “And if one day, if I don’t listen or something, they yell at me, I don't know what I’ll do. I know I wouldn’t hurt them or do anything physical, I would just like probably yell back…” These comments revealed a remarkable level of insight about the youth’s problems and potential pitfalls of the upcoming foster placements.

4.1.4 Coping Skills: Ready for Deployment?

When talking about how they would handle difficulties they might encounter in the new placement, participants could easily describe coping strategies they could use to defuse difficult situations. Strategies ranged from walking away to talking things out with someone to writing poetry. This description from a young woman was typical: “So, when I get angry I either go in my room, or I count to ten, and take a deep breath, or I listen to music.” Another youth stated,

Coping skills I have…I know basically I have to be away from people. Just when I’m away from everybody, um, by myself, I have more better time to just reflect on what happened and just think and stuff. And then when I’m done calming down, I can go to you and tell you.

While youths could confidently identify coping skills, they were sometimes unable to provide details about how they would implement these skills in the foster home. When youths talked about how they would handle problems in the new home, their comments were very general with few details about how this would actually work. This comment from a young woman was typical “I’m just going to have to work through whatever it is and just take one by one, just work on what I say or do or look around whatever.”

4.2 Stepping In: Youth’s Experiences Two Months Later

When youths were interviewed two months later, the content of their expressions had changed considerably. There was no more talk of residential care and the people and losses from that experience. There was substantially less talk of hope, especially for enduring relationships with their foster family. There was some talk of living a more normal life. But all of the domains of life that youth talked about reflected the considerable challenges involved in transitioning from a residential setting to community living with a foster family.

4.2.1 Living a Normal Life

Living in a community setting did provide some of the opportunities that youth had anticipated. Two months into their placements, some youth presented the positive side of being part of a family and living more “normal” lives. One youth described her experience in learning to cook in the new foster home: “I didn’t know how to cook anything until I came here. …I watch mom do it. I remember some things…She taught me how to use the oven and how to grease the pan…” Another youth described having fun with the foster parent. “We have watched movies together …we went shopping. She gave all of us forty bucks…” These positives, however, were accompanied by descriptions of the struggles youth felt in these relationships. One youth who had anticipated the increased freedom that would come with community living complained that she was not allowed to go walking by herself. “I have to have a point sheet, I can’t go on walks.” Instead of the freedom she had anticipated, she actually found aspects of the foster home more restrictive.

While some youth had anticipated attending regular school prior to the transition to a foster home, their actual experiences once they entered these schools depicted challenges not typical for “normal” youth. One youth talked about her struggles to maintain in school: “I’m always at school, I just don’t really finish the days, like I don’t actually finish a week because I either get sick, or something bad happens.” Another youth described being suspended from school for hitting the principal. One youth was unable to even attend school after being court ordered to attend drug rehabilitation: “I’m in this drug program, so I have to kind of give up school.”

4.2.2 Negotiating Relationships: I Adore Her, Kind of a Little

At the same time, the reality of managing relationships with their new treatment foster parents presented incredible challenges. Youth displayed sharply mixed feelings about their foster parents. As one youth stated: “I love her. I adore her. Well, I don’t love her. I like her, kind of, a little…a little of a little.” While youths clearly wanted to engage with foster parents, they appeared to have trouble negotiating these relationships. Many youths spoke about frustrated attempts to communicate with their foster parent. The dynamic presented by the youth in the following scenario was typical:

Youth: She (foster mom) like, run and tell everybody everything when she could come to me and tell me herself, but she don’t. If nothing at all she should come to me herself if she’s got a problem… Yeah, because it makes me mad when she don’t.

Interviewer: Yeah. Have you been able to tell her that you don’t like it when she goes behind your back?

Youth: Yes… But, she got mad so I didn’t tell her no more.

Interviewer: So, how do you deal with that?

Youth: I get mad.

Youth seemed to have limited relational skills to work through problems they experienced with their foster parents and found themselves frustrated by this. They seemed particularly lacking in their abilities to express their needs, desires and emotions to their foster parents. Several youths reported that they felt the foster parent should know how they were feeling and react accordingly. As one youth commented: “It’s better for them to find out on their own. If they notice. Then they can see it, instead of me telling them. I think they should look for it first.” Another youth described a situation where she became upset and her foster parent had not understood “Because she’s had me for two months, she says she knows basically everything about me, so she should have known.”

Unable to successfully work through problems with foster parents, situations escalated into conflicts. Many of the youths recounted a very recent conflict with their foster parent or foster siblings and it was clear that many of the youths were struggling to maintain their new living situations. One youth described her overall experience in the foster home:

Most of the time it’s a mixture of power struggles, because I can relate to her at some points, but most of the times I can’t. Because, like she’ll be okay at one point time and time, but most of the time she’s not, and most of the time we can’t relate. She’s either blocking me out, or I’m blocking her out, or we’re not communicating, or she’s not communicating. Or, we’re just not of that same level.

In response to this frustration, some youths shifted to focus on themselves. Rather than investing their energy into improving the relationships with the foster parents, they talked more about taking care of themselves. Youths that had talked extensively about connecting with foster families in the prior interview appeared to have recalculated their hopes and now talked about taking care of themselves. One youth described this change:

I’ve asked her what can I do to make things better, and basically that’s it, for real. And, then she doesn’t answer me, so I really can’t do… I can’t change nobody else. I can only change myself. So, that’s really it, for real.

5. Discussion/Recommendations

This study provides important new information about how older youths with psychiatric difficulties anticipated and experienced a step down from residential treatment to treatment foster care. The findings point to potential areas for improvement in preparing and supporting youth through these transitions. Several findings deserve further discussion as potential leverage points for ensuring smoother transitions through intervention with both youths and foster parents.

The sample in this study was a particularly challenging group of youths who had long histories of involvement with the child welfare system, including previous experiences in transitioning to new foster homes. These prior experiences provided them with important information about what might go wrong in a new placement setting. Given their long histories of placement disruptions and mental health problems, these youths were justifiably concerned that the new foster parents would not be able to handle their problems. Many youths had a lot of insight into their own problems, insight that might have been used more effectively to inform planning as they moved to new homes. Concerns such as those expressed in these interviews could be used to specifically facilitate conversations among the youth and the treatment team about how to handle these difficult behaviors in the new foster home. In the present intervention, the concerns were noted and conveyed to staff but were not explicitly used for planning. Enlisting the youth as the expert in these conversations could serve as both a way to validate and normalize fears of placement disruption and to anticipate and plan for problems that are likely to occur as the youth settles into the home.

Given these difficult histories, it is remarkable to note that many youths had very high hopes for their new home. These hopes reflected both the developmentally appropriate desire for independence and a desire for connection. Some youths moved quickly to seeing their new foster family as their own family, identifying ways that they could become part of this family. Other youths focused on how the foster family could help them meet their goals. While all older foster youths can benefit from support in both building independent living skills and in forming connections, understanding each youth’s hopes and desires in the new home can help foster parents to individualize their approach. Some youths may want to focus on independent living skills immediately, while others may want time to connect with a family before they are ready to think about being on their own. For youths that are hoping for inclusion in the family, foster parents could address these desires through open conversation and plans to include the youths in more structured family activities. Youths that are seeking more independence and help with goals will require different conversations focused around how the foster parent can facilitate getting to these goals. In both cases, open discussions as part of the transition to the home will help to identify and address youth’s expectations for their new situation.

The comments of these youths also highlight the importance of providing opportunities for them to contribute to their new family and community. The desires of the youths to be helpful in their new families mirrors other qualitative research in which older adolescents with mental disorders have talked about the importance of volunteering or giving back to the community (Leavey, 2005; Jivanjee, 2008). The ability to contribute has also been identified as a source of resiliency among successful foster youth (Hass, 2009).

Interviews two months into their placements highlighted the struggles youths faced in negotiating relationships in foster home settings. The coping skills youths had learned in residential treatment simply had not prepared them for the stress of managing ongoing relationships with foster parents. This makes sense when considering the nature and requirements for managing relationships in the two settings. While living in residential treatment, youths build relationships with a variety of staff who work shifts. Negotiating conflicts in these settings is focused on learning to control behaviors, often through consequences such as a point or level system. These environments have a team of workers who assist in managing the youth’s behaviors and those responding to behaviors are often encouraged to be professional and not take youth’s behaviors personally. In a foster home, however, the youth has one or two individuals with whom they interact constantly. Dealing with the conflicts and problematic behaviors in the context of ongoing relationships was not a skill youth had learned. In preparing youths to leave residential care it will be important for them to learn and practice relationship skills such as expressing frustration with a particular provider and repairing relationships with specific individuals when they have offended or hurt someone. As youths transition to treatment foster care, they need ongoing support for learning and practicing these skills.

In addition, youths expressed concerns with how foster parents communicated with them. Foster parents need to be prepared to model effective communication and to help youth learn these skills. The training provided to foster parents in our intervention did not emphasize the need to teach and foster relationship skills but was focused more around strategies to handle challenging behaviors. The experiences of the youths in this study highlight the need for training that helps foster parents take an affirming and validating stance and equips them to teach youth skills for managing relationships.

The findings of our study should also be viewed from a developmental perspective within the context of the challenges in negotiating the transition to young adulthood for foster youths. The youths in the study were approaching young adulthood and the period that has been termed “emerging adulthood” where youths are increasingly independent but not yet cemented in adult roles (Arnett, 2004). Recent research has highlighted the fact that youths who have been involved with public systems have some unique characteristics that diverge from the notion of emerging adulthood as it was initially defined based on research with college students (Goodkind, Schelbe & Shook, 2011; Munson et al, 2011). Youths in public systems frequently have limited support systems and do not have the leisure in which to spend time focusing on exploring possibilities and identifies. Youths in the foster care system often express the desire to exercise control over their own lives and be free of the constraints of the system at the expense of connections that can provide critical support and assistance as they transition to adulthood (Goodkind, Schelbe, & Shook, 2011). The child welfare system has traditionally promoted independent living more than connection, however, recent work has stressed the importance of helping youths to make lifelong connections not just gain skills for independence (Courtney, 2009). Treatment foster care programs that assist older youths to move to the community should be prepared to both support youths in learning skills for independence and in learning skills to build connections. As was evident for the youths in our study, building and negotiating relationships is an area that is especially challenging for youths in the foster care system with histories of complex trauma and disrupted attachments.

6. Limitations

While the study provides important new information about youths’ perspectives, it included a relatively small number of youths (n=8). This concern is mitigated by the fact that clear themes did emerge in the data. This is consistent with previous research findings on the number of participants needed to reach saturation in qualitative studies in which over 90% of findings were uncovered in the first six interviews (Guest, Bunce and Johnson, 2006). The small number did not allow, however, for identification of clear subgroups. Future studies with larger numbers should further investigate whether subgroups of youth with different expectations for the step down transition exist. Another limitation is that this study included only the youth perspective on the transition. Interviews with foster parents may have presented a very different picture of the youth’s progress in the foster home. More in depth exploration of the views of foster parents, service providers, and caseworkers would assist in contextualizing the views presented by youths.

7. Conclusion

Youth’s perspectives should be actively solicited and incorporated into planning as youth step down from residential to foster care settings. Open conversations about youth’s fears and expectations may assist in smoothing the transition process. In addition, this study highlights the need to teach not just coping but relationship skills prior to step down in order to prepare these youth to handle the different demands of the foster care setting.

Highlights.

• Youths had high hopes for becoming part of their new foster families and for how the foster care setting could help them meet their goals.

• Youths looked forward to leaving restrictive environment but would miss relationships with staff from residential treatment.

• Youths with long placement histories had insight into potential problems they might experience in their new foster home.

• Youths struggled with maintaining relationships and resolving frustrations after they entered their new foster homes and lacked skills for managing these challenges.