Rationale for a New Direction in Foster Youth Substance Use Disorder Prevention

Abstract

Background

Of the 463,000 children residing in United States foster care, 29,000 annually exit the system because they have “aged out,” are thus dropped from supportive services, and become responsible for their own housing, finances, and health needs. Given histories of maltreatment, housing instability, and parental substance use, youth preparing to exit care are at substantial risk of developing substance use disorders. Unfortunately, access to services is often limited, both before and after exit from care.

Methods

With the goal of developing a relevant substance use intervention for these youth, focus groups were conducted with foster care staff, administrators, and parents to assess the feasibility of potential approaches.

Results

Participants identified several population-specific barriers to delivering adapted intervention models developed for normative populations. They expressed concerns about foster youth developing, then quickly ending, relationships with interventionists, as well as admitting to substance use, given foster care program sanctions for such behavior. Group members stressed the importance of tailoring interventions, using creative, motivational procedures.

Conclusions

Foster youth seem to encounter unique barriers to receiving adequate care. In light of these results, a novel, engaging approach to overcoming these barriers is also presented.

Introduction

Each year, approximately 29,000 youth exit the United States foster care system due to “aging out” (US Department of Health and Human Services [USDHHS], 2010); i.e., they reach the legal age of majority (generally, 18) or a similar age-related criterion. Considered adults, aged-out youth are dropped from most state-supported services, becoming responsible for their own housing, health care, and financial resources. Although many young adults find transitioning to adulthood difficult, the path for those leaving foster care presents additional challenges, often resulting in high rates of substance use, unemployment, unstable housing, and both psychiatric and physical health issues (Courtney, Dworsky, Ruth, Keller, Havlicek, & Bost, 2005; Fowler, Toro, & Miles, 2009; Pecora et al., 2006). Additionally, these individuals have little access to support services and family resources (Geenen & Powers, 2007; McCoy, McMillen, & Spitznagel, 2008). Consequently, youth aging out of care have numerous health care needs and approach the transition to independence with limited resources to function well.

Foster Youth Substance Use

Comparisons with normed groups on diagnoses are discouraging, as alcohol and substance use disorders occur up to four times more often in foster youth (Pilowsky & Wu, 2006; White, Havalchak, Jackson, O’Brien, & Pecora, 2007). Among foster care alumni, frequent alcohol and substance use is common, with over 11% meeting criteria for alcohol dependence (White, O’Brien, White, Pecora, & Phillips, 2008). Incidence following exit from foster care is high, with an increase of alcohol and substance abuse diagnoses in 11% and 13% of alumni, respectively, within one year of aging out (Courtney et al., 2005), compared to a 1–2% increase in normative emerging adults (SAMHSA, 2009). These rates clearly indicate that the transition out of foster care is a critical time for these new adults.

Substance Use Services for Foster Youth

Availability and utilization of treatment and support services can be critical for young adults struggling with substance use problems. Despite the need, such youth rarely receive corresponding services, especially in traditional forms (SAMHSA, 2010). For alumni of foster care, this gap could become even wider as youth exit the system (Casanueva, Stambaugh, Urato, Goldman Fraser, & Williams, 2011; Ringeisen, Casanueva, Urato, & Stambaugh, 2009), particularly as youth have less contact with service providers (Casanueva et al., 2011). Significant barriers also exist within the system, including mistrust of institutions (Davis, 2003) and lack of delivery, coordination, or continuity of care, given housing instability (Horwitz, Owens, & Simms, 2000; Kelleher & Scholle, 1995; Simms, Dubowitz, & Szilagyi, 2000) or overburdened case managers (Schneiderman, 2004). In light of these bleak trends, substance use services should be prioritized for youth aging out of foster care. Moreover, such services need to address the population-specific needs and barriers to adequate care. It is currently unknown, however, whether a more traditional approach to alcohol and drug prevention is feasible with this unique group of young people. Indeed, understanding the values and context of such a vulnerable population is essential to intervention acceptability and overall success (Jason, Keys, Suarez-Balcazar, Taylor, & Davis, 2004). The current study begins a program of research to develop and test innovative substance use interventions for a vulnerable population with many barriers to care. Specifically, we examined the perceived acceptability of empirically-supported substance use interventions currently used outside of the foster care population.

Methods

Procedures

Individual focus groups were conducted with each of three subpopulations: (1) foster care staff, (2) administrators, and (3) parents, all at an agency serving foster youth in a Northeast United States metropolitan area. All staff and administrators at the agency were invited to participate. Administrators assisted with the recruitment of parents, for whom the only inclusion criterion was being a current foster parent. All three focus groups were conducted at the agency in a private room. Participants were given an overview of the study, a written consent form, and the opportunity to ask questions before they gave informed consent. None of the potential participants refused informed consent.

A semi-structured focus group script asked participants to provide feedback on the feasibility and acceptability of two potential interventions adapted from those commonly used in non-foster care populations: (1) Brief Motivational Interviewing (MI) to be conducted by trained alumni of foster care and (2) Screening, Brief Intervention, and Referral to Treatment conducted by trained case managers or health care workers (e.g., physicians or nurses). Although many staff and administrators were acquainted with MI, a thorough description of MI theory and the empirical rationale for inclusion of the two interventions was provided to all participants. Group members were also asked to design a hypothetical intervention using their own experiences of foster youth need and culture, knowledge of general clinical practice and research evidence, and ideas generated from the description and subsequent discussion of the previous two interventions. Participants were compensated $25 for their time. All procedures were approved by the Pacific Institute for Research and Evaluation Institutional Review Board.

Participants

Participants (N = 23) were all female, 87% Caucasian, 9% African American, and 4% Hispanic/Latina. Administrators and staff reported firsthand experience with foster youth populations ranging from 1 to 23 years (M = 6.0, SD = 6.7).

Data Analysis

Focus group sessions were audio recorded and lasted approximately 60 minutes. The session recordings were then transcribed and analyzed for thematic content using a grounded theory approach (Glaser & Strauss, 1967).

Results

Several major themes emerged, each of which are described below, with illustrative quotations selected to help explicate the identified recurring themes.

Trust and Connections

Each of the groups voiced concern about the brevity of the proposed interventions, as the approaches required clients to connect with a human interventionist. First, they believed that developing such a relationship in a short amount of time was unlikely. One group member stated that:

“…they’re not going to trust who’s ever talking to them, and I mean even like with professionals it takes a long time for a lot of these kids to really open up and really verbalize what they’re going through.”

Although developing an alliance with an adolescent from the general population can also present challenges, group members expressed that abruptly ending this connection could be damaging for foster youth. Specifically, they indicated that significant attachments are often made between foster youth and mentor-type figures, only for that person soon to exit their lives. A current foster parent noted:

“I get the feeling that for the kid who’s had lots of people come and go, they’re going to say, ‘oh they just came and went’.”

A similar comment was made by another group member:

“…the one thing, for certain, that they don’t have, at this moment, is a grounded, permanent, adult connection. The idea of introducing them to somebody… And we know that … we’re going to terminate that connection? That’s … not where we want to go. We’re thinking about kids who already have attachment issues… So, if our best case scenario is a connection will be made and we’re going into it knowing that that connection will not be sustained, I guess that gives me pause to have concern about that … for this population of kids.”

Disclosure: Empathy and Consequences

A second major theme supported by all three groups was the high likelihood that youth would be unwilling to disclose alcohol or drug use, especially to a service provider or case manager. One reason, they noted, is that they might suspect the interventionists would lack understanding or empathy for the foster youth’s history:

“They’re not going to say [anything] because Dr. Bob doesn’t know where [they’ve] been, he only knows what [their] chart says. … It’s another person in a white coat telling [them] that [they’ve] got to stop doing drugs or stop drinking alcohol.”

These anticipated interactions were attributed to an accumulation of stigmatizing experiences:

“Our kids come with a big chip on their shoulder because ‘they’re not good enough.’ And people have stigmatized them … they’ve come into a system that, by and large, had nothing to do with them. But people look at you as the ‘group home kid.’ If something was stolen, ‘it was the group home kid’.”

Participants also recognized that youth may not admit to use of alcohol or drugs due to perceived or real consequences within the system:

“There’s always going to be that fear that it will go to the social worker and everybody’s going to know what they’re doing and then, what they’re going to have to deal with after.”

Confidentiality concerns and power relations caused the focus group participants to suggest that foster care staff not hold the role of interventionist, as this could create a disincentive for client honesty about substance use or other forbidden behaviors:

“…not specifically their case manager, because they wouldn’t want to divulge that information that they’re smoking that much… I think that it would just be all these thoughts in their head that they wouldn’t really divulge the correct information.”

Relevance and Creativity

Participants agreed that, in order for programs to affect substance use, they need to be engaging, relevant, and creative. Group members indicated that information about substance use or MI verbiage could be helpful if the conversation wasn’t forced or mandatory:

“Yeah, I think that’s [engaging the youth in rethinking their substance use] the best thing. You think they’re not listening while they’re texting or talking to their friend, but it stays in their head.”

With reference to texting, another participant suggested that it was a culturally-preferred mode way to communicate with foster children, one in which the clients had mastery:

“…most kids want you to text them. They don’t really want to talk to you face-to-face all the time. …they want the help, but ’send me a text message.’ You have to find some way that you’re going to relate to them.”

Staff mentioned that presenting youth with population-level statistics about alcohol and drug use generally fall flat, but that tailoring such information could have high potential:

“We do … go over all the statistics, although it would be a better impact if it was individually-based that included their risk.”

Discussion

When working with underserved and vulnerable populations, interventions normed on the general population are a potentially poor fit due to a lack of attention to context, The current study supports this notion, as population-specific barriers seem to exist for foster youth seeking substance use services. Specifically, foster care staff, administrators, and parents agreed that breaking off newly formed relationships with human interventionists could be damaging for this group of young people. Foster youth may be reluctant to engage in new relationships and an abrupt ending could further add to a history of transient relationships. Thus, intervention brevity was less related to dose-response theory and more associated with engagement in the intervention and the likelihood of relationship building, a key ingredient in behavior change. Whether the goal in brief intervention is immediate reduction in problematic use or providing a bridge to longer-term care, identification of roadblocks to therapeutic alliance initiation is essential. Results also suggested that substance use disclosure, especially to direct service providers, is unlikely due to real and perceived consequences associated with the foster care system. That is, in addition to legal complications, group members noted that youth could face penalties for drug use or underage drinking if this use became known to foster care parents or managers.

To increase the likelihood of seeking and using substance use services, participants suggested that approaches should be creative and engaging, and proposed a range of prevention and treatment efforts, most of which had the overarching themes of subtlety, innovation, and tailoring.

Limitations

Small sample size, limited sample representativeness (e.g., exclusively female participants), and exploratory approach to this study restrict the ability to generalize our results. The addition of male staff and/or foster parent data would have added to the diversity of opinions. However, staff at the participating agency are exclusively female and, although there are certainly male foster parents, recruitment of this group was not successful. Previous studies of this population have provided basic tabulations on relationships between need and use of services (Casanueva et al., 2011), or demographic patterns (Leslie, Hurlburt, Landsverk, Barth, & Slymen, 2004). While such descriptive data are important, the current study illuminates the practical challenges facing any attempt to improve upon the current system. In addition, our results are limited by the lack of foster youth participation in the study. Given our initial intentions to utilize interventions which would require major agency and parent buy-in, these groups were sampled first. Results suggested a new direction, to be piloted with youth in the near future.

Future Directions

Because our findings suggest that (1) creation and maintenance of relationships can be a delicate process with this vulnerable population, (2) disclosure of substance use to humans (e.g., health providers, case managers) is limited/unlikely, and (3) age- and population-appropriate approaches are needed, the use of computer- and/or other electronic-based methods has the potential to circumvent these barriers. In various populations, computer- and text message-based interventions have been shown to be effective for alcohol and substance use (Moore, Fazzino, Garnet, Cutter, & Barry, 2011; Rooke, Thorsteinsson, Karpin, Copeland, & Allsop, 2010; Suffoletto, Callaway, Kristan, Kraemer, & Clark, 2011) and may be particularly engaging for adolescents and young adults (Laursen, 2010). In addition to delivering intervention content effectively, computer- and mobile phone-based interventions can address many of the aforementioned population-specific barriers.

Specifically, utilizing new technologies can dramatically reduce both actual and labor costs (Newman, Szkodny, Llera, & Przeworski, 2011), as the majority of funds are allocated toward development rather than service delivery. Using computers and mobile phones also increases the likelihood of honest reporting through privacy and confidentiality (Turner et al., 2008; Weisband & Kiesler, 1996). Technology-driven interventions circumnavigate the building and abrupt ending of an important relationship, but could also increase the chances of future work with a health professional. Additionally, the content of these approaches can be tailored to each individual based on initial assessments, ongoing testing, and feedback from the participant. Lastly, computers and mobile phones can be used across many environments, and text-based interventions, specifically, can be available 24 hours per day. Thus, they offer more or longer therapeutic contacts in contexts unreachable by traditional means. Computer and mobile phone technologies may provide an engaging and effective bridge between foster youth service need and receipt.