Supporting LGBTQ+ Foster Teens: Development of a Relationship-Focused, Self-Guided Curriculum for Foster Families

Abstract

LGBTQ+ youth are over-represented in the foster care system. Child welfare systems across the country have been struggling with how to make their systems work better for the LGBTQ+ youth they serve. One strategy is developing foster caregiver trainings that bolster caregivers’ knowledge and support of LGBTQ+ youth in their care. This study has three aims: (1) to provide an overview of a module designed to support relationship building between LGBTQ+ youth in foster care and their caregivers, (2) to describe the theater testing procedure used to assess usability of the developed module with foster caregivers and adults, and (3) to share the results of the theater test. Overall, participants provided positive usability feedback about the module activities, as well as a wide variety of recommendations for strengthening the content for widespread use. Participants felt the module should be directed specifically toward caregiver skill development rather than toward both caregiver and youth support. This module represents one example of how materials focused on building foster caregivers’ knowledge and support have the potential to help LGBTQ+ teens who are overrepresented in the foster care system.

Youth who identify as LGBTQ+ are over-represented in the foster care system. While estimates vary, studies suggest that 15–30% of youth in foster care identify as LGBTQ+ compared to approximately 3–11% of those in the general population (Baams, Wilson, & Russell, 2019; Detlaff, Washburn, Carr, & Vogel, 2018; Gates, 2011; Kann et al., 2016; Scannapieco, Painter, & Blau, 2018; Wilson & Kastanis, 2015). Using data from National Longitudinal Study of Adolescent to Adult Health, Fish and colleagues (2019) found that youth who reported experiencing any attraction to a member of the same sex were 2.43 times more likely than heterosexual youth to report foster care involvement. Though LGBTQ+ youth enter the foster care system for a variety of reasons, a considerable proportion of these youth enter the system as a result of conflict with parents over their sexual orientation or gender identity (Mallon, 2011). In one survey of LGBT youth in out-of-home care settings, 42% reported that they were either removed or ejected from their home because of conflict related to their LGBT identity (Ryan & Diaz, 2005).; in another, 1/3 of LGBT youth in foster care reported experiencing violence after revealing their identity to family members (Laver & Khoury, 2008).

Unfortunately, when LGBTQ+ youth are placed into care, their experiences of discrimination often continue. Youth in care may be faced with case workers or caregivers who are unknowledgeable or intolerant of LGBTQ+ issues and identities and who have not received training on how to support them (Gallegos, et al., 2011; Rosenwald, 2009); services (such as physical or mental health services) that do not meet their needs (Makadon, Mayer, Potter, & Goldhammer, 2015); being placed in highly restrictive placements such as group homes due to a lack of accepting foster home placement options (Wilson & Kastanis, 2015); and being forced into conversion therapy (Abbott, Crow Shoe, Hiniker, Holger-Ambrose, & Staudenmaier, n.d.; Wilber, Ryan, & Marksamer, 2006), among other injustices.

LGBTQ+ youth in foster care experience a higher number of placements than their non-LGBTQ+ counterparts (Wilson, Cooper, Kastanis, & Nezhad, 2014; Wilson & Kastanis, 2015). In one study, 6 of 7 foster parents at a private, faith-based agency who had an openly gay child placed in their home requested that the child be removed for reasons related to their LGBTQ+ identity (Clements & Rosenwald, 2007). LGBTQ+ youth are also more likely to be placed in group homes (Wilson et al., 2014; Wilson & Kastanis, 2015) and more frequently face isolation from other youth, sometimes as a result of the erroneous assumption that youth in the child welfare system need to be “protected” from their LGBTQ+ peers (Wilber et al., 2006).

With every transition an LGBTQ+ youth in foster care experiences, such as a change in placement, a new social worker, or beginning at a new school, the youth must decide to whom it might be safe to disclose their LGBTQ+ identity (Child Welfare Information Gateway, 2013). Because many LGBTQ+ youth have experienced rejection, harassment, or abuse after disclosing their identity, constantly deciding between ‘coming out’ or concealing their LGBTQ+ identity and the fear of being ‘outed,’ can be a significant stressor (D’Augelli, Grossman, & Starks, 2008; U.S. Centers for Disease Control, 2016). Beyond the stress of repeated disclosure and fear of being outed, experiencing a higher number of placements is predictive of school dropout and absence of supportive peer relationships (Jones, Bowen, & Ball, 2018; South, Haynie, & Bose, 2007). This lack of affirming peer connections can be especially detrimental for LGBTQ+ youth, for whom friend support is strongly associated with well-being (Shilo & Savaya, 2011; Snapp, Watson, Russell, Diaz, & Ryan, 2015). LGBTQ+ youth in the child welfare system are also less likely to achieve permanency, whether through reunification or adoption (Mallon, 2011).

In addition to facing intolerance and cultural incompetence, LGBTQ+ youth in the child welfare system are frequently exposed to harassment, discrimination, and abuse in their placements. Many LGBTQ+ youth in care experience verbal harassment and physical violence from their peers (Craig-Oldsen, Craig, & Morton, 2006; McCormick, Schmidt, & Terrazas, 2017; Woronoff, Estrada, & Sommer, 2006). When LGBTQ+ youth are victimized by their peers in the child welfare system, they are sometimes blamed for their victimization by social workers tasked with protecting them, and are often isolated or placed in more restrictive facilities (Wilber et al., 2006). Though this protects the youth from further assault, isolation punishes the victim and often results in “drastically reduced services and [increased] psychological distress for LGBT youth” (Wilber et al., 2006, p. 7). Some LGBTQ+ youth even experience violence and harassment from staff in programs intended to be safe (Dank, et al., 2015). Others are subjected to conversion therapy (Abbott et al., n.d.), a harmful practice predictive of poor outcomes for LGBTQ+ individuals (Substance Abuse and Mental Health Services Adminstration, 2015). These traumatic experiences lead some LGBTQ+ youth to run away, ending up homeless, couch surfing, and/or engaging in survival sex to escape the hostility, harassment, and abuse they experience in the child welfare system (Dank, et al., 2015; Wilson & Kastanis, 2015). In fact, Gragg and colleagues (2007) found that 75% of youth who reported having engaged in survival sex had previously been in a foster care placement. The effects of being in these difficult and dangerous situations are profound and lasting, including the development of post-traumatic stress disorder and other mental health issues that interfere with healthy development (Baams, Wilson, & Russell, 2019; Dank, et al., 2015).

Although the field of social work is still early in its response to developing services, policies and procedures, trainings, and interventions that effectively support LGBTQ+ youth in foster care, efforts have been increasing to support permanency achievement for these youth. One of the first of such programs in the U.S., California’s G.L.A.S.S. (Gay and Lesbian Adolescent Social Services) program was founded in 1984 as the nation’s first group home for LGBTQ+ youth. Since then, a handful of programs have implemented interventions to improve permanency outcomes for LGBTQ+ youth in the child welfare system. The L.A. LGBT Center’s RISE (Recognize Intervene Support Empower) program offers services and supports to LGBTQ+ youth in foster care, including providing cultural competency training to public and private agency staff and assisting youth in establishing connections and addressing barriers to permanency (Los Angeles LGBT Center, 2018). The LGBT Foster Care Project, a collaboration between New York City’s Administration for Children’s Services and the New York City LGBT Community Center, recruits, trains, and supports LGBTQ+ and ally foster parents (City of New York, 2018). These initiatives, while important, are geographically limited in their impact.

Two current pilot projects, Ruth Ellis Center’s Family Preservation Program and the University of Maryland School of Social Work’s National Quality Improvement Center on Tailored Services, Placement Stability, and Permanency, are promising in their approaches to improving outcomes for LGBTQ+ youth in foster care. Ruth Ellis Center’s Family Preservation Program, a collaboration with San Francisco State University’s Family Acceptance Project, began in 2015 and implements a “Family Group Decision Making” model, an adaptation of Family Acceptance Project, to engage, preserve, and support families with LGBTQ+ children (Ruth Ellis Center, 2018). The Quality Improvement Center project will work with multiple sites to implement promising evidence-based practices to improve placement stability, well-being, and permanence for LGBTQ+ youth in care (Phelan, 2016)

Despite the ongoing development of these promising models, the caregivers of LGBTQ+ youth, who play a critical role in their well-being and development, too often lack the support and resources they need to effectively parent them (Wilber et al., 2006). Programming is needed that focuses on providing caregivers with information about the unique challenges that LGBTQ+ youth in foster care face, how to discuss sensitive topics related to gender identity and sexual orientation, and how to better understand what these youth are going through.

Developmental Trajectories of LGBTQ+ Youth

To understand how to best support the needs of LGBTQ+ youth in foster care, it may be helpful to understand the developmental trajectories of LGBTQ+ youth and how these may differ from non-LGBTQ+ youth. Historically, developmental processes of LGBTQ+ youth have been falsely depicted as chaotic, marginalized, and deviating from normative identity formation and integration (Savin-Williams, 2005), when in actuality the developmental processes of LGBTQ+ and non-LGBTQ+ youth are quite similar (Bauermeister et al., 2010; Savin-Williams, 2005, 2011). One difference, however, is sometimes found in psychological development. LGBTQ+ youth are more likely to be exposed to stressful situations than non-LGBTQ+ youth due to negative reactions from the outside world such as prejudice and unfair social treatments derived from heterocentrism; this can result in LGBTQ+ youth navigating their psychological development in a manner at variance from non-LGBTQ+ youth (Savin-Williams, 2005, 2011). Developing coping skills to negotiate stress caused by cultural negativity toward individuals who identify as LGBTQ+ is crucial for the psychological development of LGBTQ+ youth. For example, LGBTQ+ youth may develop specific psychosocial strategies such as psychological adjustment in relation to the formation and integration of LGBTQ+ identity, self-acceptance, positive personal conceptualizations of being LGBTQ+, flexibility, and resilience to overcome distress in the face of discrimination and violence in response to their sexual orientation or gender expression (Harper, Brodsky, & Bruce, 2012; Rosario, Schrimshaw, & Hunter, 2011; Scourfield, Roen, & McDermott, 2008). Understanding these unique stressors, coping skills, and developmental trajectories can be helpful when developing strategies for best supporting these youth in care.

Effects of Parenting Practices on Well-Being of LGBTQ+ Youth

Positive developmental contexts for LGBTQ+ youth such as supportive and caring parents and LGBTQ+-friendly school environments have consistently been found to be related to healthy development (Bregman, Malik, Page, Makynen, & Lindahl, 2013; Hatzenbuehler, 2011; Simons, Schrager, Clark, Belzer, & Olson, 2013; Snapp, Watson, Russell, Diaz, & Ryan, 2015). In particular, parents/caregivers and family systems play a significant role in the health and well-being of LGBTQ+ youth (Bouris et al., 2010; McConnell, Birkett, & Mustanski, 2016; Needham & Austin, 2010). Positive and accepting parenting, aligned with the unique developmental needs and experiences of LGBTQ+ youth, promote well-being by serving as a protective factor that buffers youth from negative responses to their sexual orientation and/or gender identity and related stressors.

A systematic review of parental influences on the health and well-being of LGBTQ+ youth identified two important parenting dimensions associated with improved developmental outcomes for LGBTQ+ youth: parents’ knowledge of and positive response to their child’s sexual orientation and quality of the parent-child relationship (Bouris et al., 2010). First, studies found that parental knowledge of and positive response to their child’s sexual orientation protect LGBTQ+ youth against experiences of victimization and violence, poor mental health, and risky health behaviors (D’Augelli, Grossman, & Starks, 2008; Mustanski & Liu, 2013; Newcomb, Heinz, & Mustanski, 2012; Ryan, Huebner, Diaz, & Sanchez, 2009; Watson, Grossman, & Russell, 2016). In contrast, parents’ negative reactions, rejection, and lack of awareness of their child’s sexual orientation are associated with adverse health outcomes such as suicidal attempts, poor mental health, and substance abuse (Katz-Wise, Rosario, & Tsappis, 2016; Ryan et al., 2009). These findings suggest that supportive resources and educational information about LGBTQ+ youth that widen caregivers’ knowledge and understanding of their child’s sexual orientation would help caregivers of LGBTQ+ youth to use appropriate parenting practices, which in turn promote healthy development of LGBTQ+ youth. Second, a strong parent-child relationship characterized by support, caring, acceptance, closeness, and connectedness is associated with better physical and mental well-being of LGBTQ+ youth. Specifically, LGBTQ+ youth who have supportive and accepting parents/caregivers show lower levels of psychological distress and strong resilience and self-esteem (Needham & Austin, 2010; Ryan, Russell, Huebner, Diaz, & Sanchez, 2010; Simons et al., 2013; Watson et al., 2016). McConnell, Birkett, and Mustanski (2016) demonstrated that LGBTQ+ youth who receive early family support experience greater mental and emotional well-being across adolescence than those with low family support and with nonfamily support. In addition to the health consequences, supportive family environments lead LGBTQ+ youth to more positive life outcomes such as educational attainment and employment (Snapp et al., 2015).

In summary, development of positive caregiver-child interactions; open intra-familial communication; strong attachment and affection for the LGBTQ+ child; and informational, emotional, and social support for caregiver-child dyads are critical to reach healthy LGBTQ+ youth development (Bouris et al., 2010; McCormick et al., 2017). These findings also imply the need for caregiver training interventions that bolster parents’ knowledge and support of LGBTQ+ youth in their care.

Connecting Program and Current Study

The Connecting program was developed to fill a need in the child welfare system for a training program that promotes healthy relationships between caregivers and foster teens (aged 11–15) and protects teens against initiating high-risk behaviors (e.g. substance misuse, delinquency, early sexual activity; Barkan et al., 2014; Storer, Barkan, Sherman, Haggerty, & Mattos, 2012). The program was adapted for use by families involved in the child welfare system from an evidence-based parenting program called Staying Connected With Your Teen (Haggerty et al., 2015). During the pilot test of Connecting, caregivers reported increased communication and teen participation in family rules and expectations, while teens reported a decrease in deviant attitudes and family conflict (Haggerty et. al., 2016). Connecting is currently being tested with a larger group of teens and caregivers in the child welfare system in a randomized controlled trial.

After seeing the need for more supportive resources for caregivers of LGBTQ+ foster teens, we sought to create a supplemental module for the Connecting program that focuses on providing information and supports for caregivers of LGBTQ+ foster teens. The first step in this process was to draft module content based on the scholarly literature, other existing resources, and researcher and practitioner expertise. We then conducted focus groups with stakeholders in the child welfare system (alumni of foster care, caregivers of foster teens, and child welfare workers) to get stakeholders’ feedback on the content and to more generally explore their recommended strategies for building better relationships between LGBTQ+ youth and caregivers (see Salazar et al., 2018 for recommendations emerging from those focus groups). The new module was then further developed and refined based on the focus group feedback. The final steps in our module development process involved theater testing the module with young adult foster care alumni and foster caregivers of teens to determine its usability, and having topical experts conduct a final review of its content. This paper summarizes the components of this new module, the theater testing process and results, and the expert reviews of the module.

Module Overview

The “Caregiving for Youth in Care: Supporting LGBTQ+ Youth Identity Development” module developed for the Connecting Program includes nine activities. While numerous parenting and youth-support resources can be found online, few are specifically tailored for foster youth. However, because many of the existing tools have been created by LGBTQ+ youth for LGBTQ+ youth and their families, many of these resources were used as a starting point when developing the content for this module. It was important when developing this module that the content both honored and reflected the voices of the LGBTQ+ community, that the activities were interactive and engaging, and that it allowed for a range of skillsets, comfort, and experiences. All adapted materials were cited and modified using the guidance of these three priorities.

Some of these activities are intended for the caregiver and the youth to do together and some are intended for the caregiver(s) to complete on their own. As with the rest of the Connecting program, caregivers are encouraged to preview the material and consider their foster youth’s particular circumstances and level of development when deciding how deeply to delve into these activities. The following provides a description of the module components. Table 1 summarizes this information.

Table 1.

Module Activity Overview

Activity	Brief Activity Description	Supporting Source(s)
1. Youth Stories	Tells the stories of two LGBTQ former foster-care youth. Darryn talks about his supportive relationship with his foster mother and Kevin relates experiences with bullying and how affirming adults helped him as he discovered his gender identity. Participants are presented with questions to facilitate reflection on the experiences of LGBTQ youth and expand their receptiveness to subsequent information.	Y.O.U.T.H Training Project, Bay Area Academy of San Francisco State University, 2005
2. Know, Heard, New	Provides an introduction to the world of language around the LGBTQ community including relevant terms (e.g. asexual, cisgender, gender non-binary, pansexual, queer), the importance of using correct gender pronouns, and appropriate use of gender-neutral pronouns.	The Trevor Project, 2017; Sylvia Rivera Law Project, n.d.; Human Rights Campaign, 2018; University of Wisconsin-Milwaukee Lesbian, Gay, Bisexual, Transgender Resource Center, 2018
3. Myths & Realities	Discusses common beliefs about gender roles and the LGBTQ community and walks participant briefly through scientific research around each common belief. For example, a common myth is that in same-gender relationships, one partner usually plays the masculine role while the other play the feminine role. In reality, relationship roles vary with personal likes and skills and are not based on sexual orientation or gender.	Bergen, S., Chiu, L., Curry, T., Gilbert, C., Reyes, C., & Wilbur, S., 2015; Case Western Reserve University Lesbian Gay Bisexual Transgender Center, 2018
4. Roadblocks to Acceptance	Introduces invalidating youths’ experiences, questioning, providing solutions, judging, and using wrong terminology as roadblocks to supporting LGBTQ youth and provides ideas for more helpful alternative responses. For example, providing a solution such as, “This is why I want you to play sports,” does not provide youth an opportunity to become involved. Instead, try asking them a question such as, “What options have you considered?”	Ramaswamy, Phillips, McGovern, & Akiva, 2013; the Connecting parent curriculum
5. Conver-sations about Discrimi-nation	Presents information and statistics on LGBTQ victimization and discrimination (e.g. 42% of LGBT youth say their community is not accepting of LGBT people) and strategies to help LGBTQ youth stay safe. Sections on trauma-informed parenting strategies (e.g. trustworthiness, collaboration, empowerment), roadblocks to good communication (e.g. making the behavior a character trait: “You’re just lazy!”), and active listening steps (i.e. listening, asking questions, “I” statements, paraphrasing) are included.	American Psychological Association, 2002
6. Make a Plan	Provides an opportunity to build on Activity 5, offering ideas and preparation with LGBTQ youth to stay safe in potentially dangerous situations. For example, have the youth text you an X if they are in trouble and you will come pick them up, with no questions asked until the next day. An emergency contact card is also included for youth and caregiver to complete together.	Developed by research team
7. Sensitive Conversation Strategies	Lists unhealthy (e.g. drug use, avoidance, risky sexual behavior) and healthy (e.g. exercise, humor, art) coping mechanisms that youth often rely on to deal with trauma, along with tips for conversations with youth. For example, ask, “Is there someone special in your life?” rather than “Do you have a girlfriend?”	The Connecting parent curriculum
8. Are You in Crisis?	Addresses how to recognize and respond to a youth who might be in suicidal crisis by following the suicide prevention steps (L.E.A.R.N.): Look for warning signs, Empathize and listen, Ask directly about suicide, Remove the danger, and Next level of care. Includes LGBTQ affirming crisis lines and resources.	Forefront Suicide Prevention, n.d.
9. Seeking Appropriate Healthcare	Covers challenges to finding healthcare resources for LGBTQ youth and presents the Q card as a tool to help the youth start an open and honest conversation with their health care provider about their confidentiality and healthcare needs.	Q Card Project, 2018

1. Know, Heard, New

This activity is an opportunity for the caregiver and the teen (if deemed appropriate) to explore the language and terminology used to refer to sexual orientation, gender identity, and related terms surrounding the LGBTQ+ communities. They use a worksheet with a list of terms to identify and discuss whether they know the term, have heard of it before, or if the term is new to them. Expanding upon the glossary of terms created by The Trevor Project (Trevor Support Center, 2017), the worksheet is followed by a list of associated definitions. In addition, caregivers and/or teens have an opportunity to list additional terms that they may prefer or are familiar with. There is also an emphasis on information about using youth-identified gender pronouns and the importance of doing so.

2. Myths and Realities

Myths and Realities is intended to be a caregiver and teen (if deemed appropriate) activity to explore and debunk myths and stereotypes surrounding gender roles and the LGBTQ+ community. The purpose of the activity is to learn the research-based facts regarding these myths and to refute any biased ideas that caregivers and youth may have. This activity was originally designed by Bergen et al. (2015) as a training activity for supporting LGBTQ+ youth involved with the juvenile justice system, but was shortened and modified to be an individual, or one-on-one, pen-and-paper activity. In addition, other relevant myths and stereotypes were added from the Lesbian, Gay, Bisexual, Transgender Center (2016).

3. Youth Stories

This activity is intended to help caregivers understand what LGBTQ+ youth in the foster care system may be experiencing. Caregivers view and reflect on two digital stories created by foster youth that describe their experiences in foster care and the challenges they faced related to their developing an understanding of their sexual orientation and gender identity (SOGI). The Youth Stories videos were from the Breaking the Silence: Lesbian, Gay, Bisexual, Transgender, and Queer Foster Youth Tell Their Stories collection of digital stories produced by the Center for Digital Storytelling.

4. Roadblocks to Acceptance

This is a caregiver activity designed to support the caregiver in reflecting on ways he/she may be unconsciously undermining his/her intention of providing a welcoming and supportive home to a LGBTQ+ teen. The activity parallels an activity from the Connecting materials related to roadblocks to communication and provides different examples of roadblocks to acceptance into which caregivers may be likely to fall. These include invalidating the teen’s experience, questioning, providing uninvited solutions, judging, and refusing to use the teen’s preferred terminology. The activity offers explanations for how each can undermine communication and acceptance and offers alternative responses for caregivers to try. The activity emphasizes the importance of leading with empathy, openness, and acceptance.

5. Conversations about Discrimination

This section provides ideas to caregivers on how to have a conversation with their teen about LGBTQ+ discrimination and personal safety. It encourages caregivers to learn about the reality of discrimination and safety for LGBTQ+ individuals and to build the teen’s awareness in this area as well. The primary goal is to encourage conversation about experiences the teen may have or have had with respect to discrimination or personal safety risks, discuss effective ways to respond, and make a plan for what to do if the teen ever experiences an uncomfortable or potentially dangerous situation.

6. Make a Plan

This activity is an opportunity for the caregiver and the teen (if deemed appropriate) to build on the discussion above and make a plan for what to do in any situation that may be dangerous or uncomfortable, whether related to being LGBTQ+ or not. Using real parenting strategies employed by foster parents, it encourages the teen and caregiver to make a plan and ensure that the teen has important emergency contact information at hand.

7. Sensitive Conversation Strategies

The goal of this section is to build the caregiver’s awareness of the likely impact of trauma on their foster teen. It offers approaches for caregivers to use to support their teen’s use of healthy and positive ways to cope. For example, one strategy suggests that caregivers recognize when their teen might benefit from speaking to someone who shares their identity, such as an LGBTQ+ adult mentor.

8. Are You in Crisis?

This activity is an opportunity for the caregiver and the teen (if deemed appropriate) to address whether the teen is in crisis and potentially contemplating suicide. It provides LGBTQ+-friendly/specific resource links and contact information for the teen if they are in crisis. It also provides guidance and a strategy for how caregivers can voice their concerns following the LEARN™ suicide prevention steps created by Forefront Suicide Prevention (n.d.).

9. Seeking Appropriate Healthcare

This section addresses the challenges of finding appropriate healthcare for LGBTQ+ teens. It encourages the caregiver to be aware of and advocate for their teen as to whether he/she/they are getting the care they need, if the healthcare provider is sensitive to the teen’s sexual identity and/or gender identity issues, and if the social worker is aware and supportive. It provides information about and links to a Q Card (www.qcardproject.com) which is an easy-to-use communication tool designed to empower LGBTQ+ youth and educate healthcare providers. It helps the youth to have an open and honest conversation with their healthcare provider about their healthcare needs. The section also provides links to numerous other resources.

Theater Testing the Usability of Module Content

Method

Sample.

Participants were recruited according to specific criteria. We were seeking to recruit six caregivers and six young adults who had been in the foster care system. Eligibility criteria for caregivers included having extensive foster caregiving experience. While there was no requirement that caregivers be a part of the LGBTQ+ community themselves, we sought caregivers who had experience or were comfortable fostering LGBTQ+ youth. All young adults were required to identify as part of the LGBTQ+ community and have experience with the foster care system (either lived or worked). Many participants for the theater test were recruited from those who participated in focus groups that occurred earlier in the study (for more information, see Salazar et al., 2018). In addition, a wide variety of child welfare agencies and local nonprofits that serve youth in foster care and LGBTQ+ young adults were contacted and asked to refer interested young adults and caregivers to us to learn about participation.

Seven caregivers and seven young adults participated in the theater test. All seven of the caregivers had also participated in our earlier focus groups, while four of the young adult theater test participants had participated in the focus groups. Out of five female and two male caregivers, six identified as Caucasian and one identified as Asian. Six caregivers identified as ‘100% Heterosexual’ and one identified as ‘Bisexual.’ All caregivers had extensive experience as foster parents. All young adults identified as LGBTQ+, with a wide range of sexual identities represented: one identified as ‘100% Homosexual,’ two as ‘Mostly Homosexual,’ three as ‘Bisexual,’ and one as ‘100% Heterosexual.’ Four participants were male (including one transgender man) and three female (including one transgender woman). One participant identified as Two-Spirit [a culturally specific term used in Native American culture to describe individuals “who believe they embody both masculine and feminine characteristics/traits in one physical body” (Mayo & Sheppard, 2012)]. The young adults were also racially diverse, with three identifying as Caucasian, one as African American, and three as mixed race (Native American and Black, Latino and White, and unidentified). They ranged in age from 20 to 23. As part of our eligibility criteria, all young adults had experience with the foster care system. Four of the young adults were alumni of the system itself. One had been emancipated as a minor and had extensive experience with child welfare services. Two had experience working in the foster care system.

Theater test process.

Theater testing is a research and evaluation methodology most commonly used in market research to evaluate products with their target audiences. Social scientists have similarly used this approach in assessing the usability of new and adapted behavioral interventions with their target populations (e.g., Wingood & DiClemente, 2008). Theater tests typically involve gathering members from the target population, exposing them to the new or adapted product or intervention, and getting their feedback and recommendations for improvement.

The theater test for this project lasted 3.5 hours and followed a protocol developed by the research team that was similar to the one used in the overall Connecting development study (Barkan et al., 2014). Participants received $100 for their participation. At the theater test, participants were provided with (a) an overview of the theater test agenda and goals, (b) an overview of the Connecting curriculum, (c) an introduction to the LGBTQ+ module and its purpose, (d) a description of the role-playing process they would be participating in to try out and give feedback on the LGBTQ+ module activities, and (e) a simulation from the Connecting curriculum by two research staff to serve as an example of how they would be role-playing the LGBTQ+ module activities. Caregiver and young adult participants were then separated into two rooms for the activity roleplaying and feedback process. Participants were separated for two purposes: to give young adults more privacy so they would feel more comfortable sharing their feedback on the activities, and to have a smaller number of participants in each discussion group so participants would have more opportunities to speak. In the caregiver group, the seven caregivers were paired up with each other with one role-playing a caregiver and one role-playing a youth in foster care aged 11 – 15 (due to an uneven number of participants, one group had two caregivers roleplaying as youth), resulting in two pairs and one triad. In the young adult group, one to two young adults were paired with a research staff member, resulting in two pairs and a triad and three pairs and one singleton depending on the activities being tested. The staff member roleplayed the caregiver while the young adults roleplayed the 11- to 15-year-old foster youth. Participants were free to roleplay their roles as themselves or as a fictional caregiver/youth.

Participants then roleplayed the full LGBTQ+ module, which was broken into four separate activity sets. Each activity set was allotted approximately 15 minutes for participants to engage in its content.

1. Activity set 1 included the module summary; the Know, Heard, New activity; and the Myths and Realities activity. For this activity set, pairs/triads made their way through the material as they would if they were doing it on their own at home.

2. Activity set 2 included the two Youth Stories videos. For this set, participants were shown the first video and given time to roleplay the related discussion questions from the module. They were then shown the second video, followed again by time to roleplay its discussion questions.

3. Activity set 3 included the Roadblocks to Acceptance; Conversations About Discrimination; and Make a Plan content. For this set, pairs/triads made their way through the material as they would if they were doing it on their own at home.

4. Activity set 4 included the Sensitive Conversation Strategies; Are You in Crisis?; and Seeking Appropriate Healthcare content. Because this set of material was mostly geared toward caregivers and did not involve a caregiver-youth activity, participants were all asked to review this material independently as if they were a caregiver.

Data collection and analysis.

Immediately following each activity set, participants (a) completed a brief six-item survey to reflect on their impressions of the activities tried during the set, and (b) participated in a brief discussion about that set’s activities. The six-item survey asked participants whether they understood what they were supposed to do in that set’s activities, what they liked and did not like about the activities, how interesting and useful the material was, and how helpful the material was in increasing their confidence about approaching the topic. In the brief discussions, participants were asked to reflect on what they liked about that set’s activities, what concerns they had, how they felt going through that set’s activities, and what recommendations they had for improving the activities tried during that set. At the completion of all four activity sets, the two groups reconvened for one final large group discussion on their overall impressions of the module. Note takers took notes on all discussion sessions. Data analysis included descriptive statistics of quantitative brief survey items and a review of open-ended survey responses and discussion notes for representative feedback.

Results

Brief survey quantitative results.

Overall, participants provided positive feedback about the module activities, and participant understanding of what they were supposed to do in the self-guided activities was nearly universal. Mean responses to close-ended questions can be found in Table 2. For activity sets 3 and 4, no youth data is available because different youth tried out different components of the activities due to time constraints. In terms of participants’ reported interest levels in activity content, mean interest ratings ranged from 5 to 6, and all were above the “Neutral” rating of 4. For young adults, the most interesting activity set on average was activity set 1 (Know, Heard, New; Myths and Realities; $\overline{x}$=6, SD=0.8), while for caregivers, activity set 1 was the least interesting activity ($\overline{x}$=5.6, SD=0.7), although only slightly less so than the other activities. In terms of helpfulness, young adults rated activity set 2 (Youth Stories videos) as least helpful ($\overline{x}$=4.6, SD=2.0), though still slightly higher than “Neutral.” Caregivers rated activity set 1 (Know, Heard, New; Myths and Realities) as least helpful ($\overline{x}$=5.3, SD=1.0) and activity set 4 (Roadblocks to Acceptance; Conversations About Discrimination; Make a Plan) as most helpful ($\overline{x}$=6.1, SD=1.1).

Table 2.

Activity Set Ratings by Participant Type

	I understood what I was supposed to do. (Yes/No) % Responding Yes		How interesting was the material? (1 = Not Interesting to 7 = Very Interesting) Mean (SD)		How helpful was this activity in increasing your confidence in approaching this topic? (1 = Not Helpful to 7 = Very Helpful) Mean (SD)
	Young Adults	Caregivers	Young Adults	Caregivers	Young Adults	Caregivers
Activity Set 1	100.0%	83.3%	6.0 (0.8)	5.6 (0.7)	5.4 (1.2)	5.3 (1.0)
Activity Set 2	100.0%	100.0%	5.0 (1.8)	6.0 (0.8)	4.6 (2.0)	5.7 (1.1)
Activity Set 3^	--	100.0%	--	5.9 (0.7)	--	5.7 (0.8)
Activity Set 4^	--	100.0%	--	6.0 (0.8)	--	6.1 (1.1)

^{^}Note: different youth tried out different components of Activity sets 3 and 4, so no data are available for these activities.

Open-ended survey question and discussion question results.

For activity set 1 (Know, Heard, New; Myths and Realities), the caregivers who did not know much about the LGBTQ+ community found this material informative and fun. Many of the caregivers did worry that the information contained in this activity, particularly in the “Know, Heard, New” activity, was too much and too dense to review with a teenager; however, the young adult participants disagreed and felt the content was straightforward, worthwhile, and important for caregivers to be familiar with. Both participant groups shared various recommendations for additional terms to include, such as gender non-binary. In addition, participants recommended ways to reorganize the material for easier consumption, such as breaking up the terms into more manageable categories.

For activity set 2 (Youth Stories), feedback from young adults differed quite a bit from that of caregivers. Most of the caregivers found the “Youth Stories” videos very powerful and informative, appreciated the personal stories and positivity reflected in the videos, and felt they may serve as an effective “ice breaker” before jumping into the more dense/academic content covered in activity set 1. However, many of the young adults worried that these stories could be too distressing to watch for a young person who is struggling with their identity, and worried that a youth might feel a caregiver was putting pressure on them to “come out” if they were to show them these stories. Young adults suggested that this activity may work better as a caregiver-only activity, or at least a youth-optional activity if youth were not yet feeling ready to watch the videos.

For activity set 3 (Roadblocks to Acceptance; Conversations about Discrimination; Make a Plan), both young adults and caregivers appreciated the practical application of the “Make a Plan” activity, although they did suggest simplifying the planning page so that the information collected on it would be easier for youth to carry around in their wallet and/or memorize. Both participant groups also really liked the “Roadblocks to Acceptance” as this activity gave caregivers specific and concrete examples of how to talk without invalidating identity and how caregivers’ current behaviors may impede relationship development. Participants felt it could be particularly helpful for caregivers with little experience talking about sensitive topics. Some participants suggested shortening the material so it is easier for users to remember.

For activity set 4 (Sensitive Conversation Strategies; Are You in Crisis?; Seeking Appropriate Healthcare), caregivers in particular appreciated the tips related to supporting youth who are exhibiting symptoms of suicidal ideation, as well as encouraging youth to not hide these feelings. Many caregivers in the group had had previous experience talking with their youth about suicide, and appreciated the explicit, open acknowledgement of this crucial topic in the module. Youth appreciated the Q Card resource included in the module. Participants recommended adding in additional content on self-harm, more examples of ways to engage in sensitive conversations, and additional resources to include on the local and national resource list included in the module.

In terms of overall module feedback, many caregivers felt that the module was too wordy, and that its density might prevent some caregivers from putting it to full use. Some also felt that the module would be more helpful for some foster caregivers and less so for others who already have a broad education about this topic. Most notably, many participants, and the youth participants in particular, felt that the module overall might work best for caregivers only, or primarily for caregivers but with certain activities noted as youth-optional if caregivers felt it would be appropriate and wanted to invite youth to take part in the activity. In support of this, some young adult participants worried that some of the material might be distressing for younger youth or youth struggling with their identity, and that many of the activities were designed primarily to teach caregivers how to be supportive instead of to support youth; thus, focusing on caregivers may be the best strategy for the module. Without exception, the young adults felt that this information would have been incredibly valuable for their caregivers. One young adult commented on how he would have loved to have seen a module with a rainbow on the cover in his home. He said it would indicate that his caregivers were taking interest in his development, even if he was not yet ready to talk with them directly about his own gender identity

Revisions and Module Finalization

Revisions based on theater test.

Most changes made to the module were organizational, although substantive content was also changed, deleted, and added. A table of contents was added for clarity and organization. The Youth Stories activity was moved to the beginning of the module in order to provide context for participants on what the content would include. The section on gender pronouns was moved to the “Know, Heard, New” activity and was expanded to include information on gender-neutral pronouns (e.g., “they/them/their”). We added a card cutout in the “Make a Plan” activity on which youth could write emergency contact information. The card was designed to allow youth to fold it in half and place in a wallet. The resources list was also expanded and broken into “local” and “national” sections in order for the module to have broader appeal and use. As per young adult suggestions, we added language about bullying. Other organizational changes included simplifying wording, eliminating dated terminology, and creating more white space to make the content appear less dense.

Based on young adult feedback, we made a major revision to how the module is intended to be used: it is now intended to be used primarily by caregivers. There was concern from theater test participants that the material could be too stressful or feel like pressure to “come out” for younger youth. In particular, the “Youth Stories” activity caused concern about emotional distress. Furthermore, there was concern that the module would only be used if a caregiver felt that his or her youth might identify as LGBTQ+. We made changes to reflect these concerns by encouraging caregivers in the chapter summary to be thoughtful about which activities they might share with their youth. We included language to encourage caregivers to read through the module and familiarize themselves with the unique experiences of LGBTQ+ foster youth, regardless of their youth’s sexual identities. This will allow caregivers to be allies and to be prepared if their youth do eventually approach them with questions. Furthermore, we included headings for each activity indicating whether it was appropriate for youth and caregivers, or just for caregivers. The tone and wording of the module reflect this major change, as we encourage caregivers throughout the chapter to assess what they could do alongside their youth, and what they should do by themselves.

Content expert reviews.

After edits were made based on theater test feedback, we asked five topical experts to review the module. The experts had lived and/or professional (service provider, foster parent) experience with LGBTQ+ youth in care. The topical experts were given a copy of the module and asked to review the content and consider how well the module met the goal of giving foster caregivers additional knowledge and tools to help them understand some of the unique challenges that LGBTQ+ youth in care face; how to have more effective conversations about sensitive topics; and how to better understand each other and get along. Feedback received from these experts was reviewed and revisions were made to the content. For example, additional content was added in from the Connecting curriculum to provide access to key material that those using the standalone version of this module would not otherwise have access to. This included content on trauma-informed parenting and strategies for active listening. Some additional information was added regarding the intersectionality of race, LGBTQ+ identity, and HIV/AIDS risk. The language describing Safe Spaces was also updated to better reflect the importance of them serving as havens from oppression. Finally, some language was simplified to be more accessible to individuals at various reading levels. These changes were incorporated into the module, bringing us to a final version.

Discussion

It is clear that young people who identify as LGBTQ+ are overrepresented in the foster care system and that the system is seeking ways to provide better training and support for caregivers (Detlaff et al., 2018; Kann et al., 2016; McCormick et al., 2017; Wilson & Kastanis, 2015). Overall, both caregivers and young adults who had experience in the foster care system felt that the Connecting LGBTQ+ module met the goals of bolstering caregiver knowledge and support for LGBTQ+ issues and promoting more positive social supports for youth in their care related to sexual orientation and gender identity. While originally intended to be a module that caregivers and teens (aged 11 – 15) complete together, the young adults in the theater test identified the sensitivity of the information and the need for youth to be able to discuss these issues at their own pace. While caregivers were enthusiastic about the materials, the young adults cautioned about the need to be sensitive to the developmental appropriateness of the information being shared. This was most pronounced in differences in how caregivers and young adults viewed the helpfulness of the video stories. While caregivers viewed them as powerful examples of being able to “come out” in the system, the young adults felt they might be pushing a difficult developmental task. They noted that being overly eager or too enthusiastic could be detrimental, and potentially harmful, to young people who are questioning their identity development. Thus, the teens in particular were all very supportive of reworking this into a module primarily for caregivers, with the option of including teens where caregivers felt it was appropriate.

Sometimes a teen’s sexual orientation and gender identity development can seem to be at odds with a caregiver’s values and norms. In these situations, caregivers often act in ways they believe to be in the youth’s best interest but that are actually highly damaging to the youth, such as blocking access to LGBT friends and resources, telling the youth that God will punish them, and/or subjecting then to conversion therapy (Ryan, 2009). Many caregivers engage in these behaviors, which are experienced as rejecting and harmful to LGBTQ+ youth, in an effort to “help” the youth in some way. In an in-depth qualitative study of LGBT youth and their families and caregivers (including youth in foster care), Dr. Caitlin Ryan and the Family Acceptance Project at San Francisco State University concluded that, in general, “Families want the best for their children – even if the way they express their care and concerns is experienced as rejection by their LGBT children.” (Ryan, 2010, p. 11). A key priority in the development of the module for the Connecting program was to allow for a range of skill sets, comfort and experiences, which addresses a critical training need. Regardless of a caregiver’s comfort in being an “out” ally, faith community, and/or current levels of knowledge and experience supporting members of the LGBTQ+ community, this module provides caregivers with knowledge and skills to facilitate positive and supportive interactions with LGBTQ+ youth in their care (whether or not these youth are out to the caregiver), which may contribute to fewer placements, more positive coping skills, and lower likelihood of depression and attempting suicide. In fact, research by the Family Acceptance Project shows that small changes in parental behavior have a direct impact on LGBTQ+ youth outcomes, with highly rejected youth being six times more likely to report high levels of depression and eight times more likely to attempt suicide than youth who experienced little or no rejection (Ryan, 2009). These small changes in caregiver behavior are driven by education, and the module developed and tested in the current paper is a simple tool that, if widely utilized by foster families, has the potential to have a profound positive impact on the lives of LGBTQ+ youth in the foster care system.

Implications

With input from theater testing and content experts, we have revised the module to focus mostly on caregiver knowledge and support. The theater testing participants agreed that while designed as a module to the Connecting program, it has the potential to be a powerful stand-alone tool for foster caregivers caring for teens. We anticipate providing the module to families in the Connecting program in the future and working with our local Department of Children, Youth, and Families (DCYF) to make the module available as a stand-alone resource. It will be important to work with DCYF to conduct more rigorous testing of this resource for foster caregivers before it is used more widely.

Limitations

The primary limitation of the theater testing portion of this study was that it only included participants from the Seattle/King County area, an area of the country that is particularly accepting of LGBTQ+ individuals. Had theater tests been held in other parts of the state or country, feedback on the module content may have looked quite different. In addition, only one theater test was held with 14 participants; additional theater tests may have elicited more and different recommendations for content revision. Several theater participants were also involved in the preceding focus groups that informed the module design, which may have influenced their response to the module. Another limitation is that the survey measures used in the theater test were post-test only; collecting pre-post test data on caregiver knowledge and confidence may have been more informative. Finally, retesting the module after making the changes emerging from the theater test would have been helpful in order to determine whether participants felt that activities had increased in their helpfulness and degree of interest.

Conclusion

The Connecting program is designed to provide support for foster caregivers to promote stronger relationships and prevent behavior problems in the teens they are caring for. Offering resources for caregivers of LGBTQ+ foster teens focused on knowledge and acceptance is an important part of providing such support for caregivers. This module represents one example of how materials focused on building foster caregivers’ knowledge and support have the potential to help LGBTQ+ teens who are overrepresented in the foster care system.