Homelessness and Aging Out of Foster Care: A National Comparison of Child Welfare-Involved Adolescents

Systematic Review and Meta-Analysis of Policies and Interventions that Improve Health, Psychosocial, and Economic Outcomes for Young People Leaving the Out-of-Home Care System

Young people who transition to adulthood from out-of-home care (OOHC) are more likely to experience a range of poorer outcomes relative to their same-age peers in the community. This systematic review assessed the effectiveness of policies or interventions (hereafter "interventions") aimed at improving housing, health, education, economic, and psychosocial outcomes for youth leaving OOHC (hereafter "care leavers"). Eleven databases of published literature were reviewed along with gray literature. Eligible studies used randomized or quasi-experimental designs and assessed interventions that provided support to care leavers prior to, during, or after they left OOHC. Primary outcomes were housing and homelessness, health and well-being, education, economic and employment, criminal and delinquent behavior, and risky behavior, while secondary outcomes were supportive relationships and life skills. Where possible, results were pooled in a meta-analysis. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. Fourteen studies published in 27 reports were identified that examined independent living programs (ILPs) (n = 5), intensive support services (n = 2), coaching and peer support (C&PSP) (n = 2), transitional housing (n = 1), health information or coaching (n = 2), and extended care (n = 2). All but one study was conducted in the United States. Twenty small meta-analyses were undertaken encompassing ILPs and C&PSP, with two showing results that favored the intervention with certainty. The level of confidence in each meta-analysis was considered very low. A significant risk of bias was identified in each of the included studies. While some interventions showed promise, particularly extended care, the scope and strength of included evidence is insufficient to recommend any included approach.

Understanding how young people transitioning from out-of-home care acquire and develop independent living skills and knowledge: A systematic review of longitudinal studies

Young people leaving state care often experience hardship in many areas of their life. At a population level, their outcomes in early adulthood are poorer compared to general populations. Effective preparation for leaving care and post-care support systems is vital to improving outcomes. Individual and systemic support for young people to acquire Independent Living Skills (ILS) in the following eight ILS domains have been identified: Financial Management, Knowledge of Accessing Available Supports, Managing Housing, Education Planning, Job Seeking, Health Risk Management, Domestic and Self-help Task, and Managing Relationships. This systematic review aims to identify, summarise, and appraise longitudinal studies that address ILS across these ILS domains to understand better how outcomes could be improved. Seven databases (CINAHL, Embase, ProQuest, PsychINFO, PubMed, Scopus, and Web of Science) were searched on 20th July 2023. In total, twenty-seven studies published between 1994 and 2022 from various countries met the eligibility criteria. The included studies reported on 2-4 waves and adopted different methodological approaches. Study quality was scored using Qualsyst. Study characteristics and details of the interventions are presented in tables. Studies cover overlapping ILS domains, which are mapped in a matrix. Results revealed that nearly three-quarters (74% or 20 out of 27) of studies explored four or fewer of the eight ILS domains. The most frequent ILS domain covered was 'Knowledge of Accessing Available Supports' (19/27 studies). The main conclusion considers the concept of independence as a misnomer, with ILS covering multiple, intersecting, and interdependent domains, which ultimately help and hinder one another. Further research is required to adopt a more comprehensive approach encompassing all the domains to better inform policy, programs, and practice. A limitation is that a meta-analysis was not conducted for this review. This study registered a 'Protocol' with OSF Registries (DOI: 10.17605/OSF.IO/MJ3ZX) on June 5th, 2022.

Trajectories of homelessness and association with mental health and substance use disorders among young people transitioning from out-of-home care in Australia

BACKGROUND

Researchers have examined sub-groups that may exist among young people transitioning from out-of-home care (OHC) using various theoretical models. However, this population group has not been examined for trajectories of homelessness risk.

OBJECTIVES

To examine whether different subtypes of homelessness risk exist among young people transitioning from care and whether these trajectories of homelessness are associated with mental health and substance use disorders.

PARTICIPANTS AND SETTING

A retrospective population-based cohort study was conducted from a population of 1018 young people (aged 15-18 years) who transitioned from out-of-home in 2013 to 2014 in the state of Victoria, Australia, with follow-up to 2018.

METHODS

Latent Class Growth Analysis was conducted using linked data from homelessness data collections, child protection, mental health information systems, alcohol and drug use, and youth justice information systems.

RESULTS

Three sub-groups of young people were identified. The 'moving on' group (88 %) had the lowest levels of homelessness, with the slope of this trajectory remaining almost stable. The 'survivors' (7 %) group started off with a high risk of homelessness, followed by a sharp decrease in homelessness risk over time. The 'complex' (5 %) group started off with a low risk of homelessness but faced sharp increases in the risk of homelessness over time.

CONCLUSIONS

Our study demonstrates that subgroups of young people transitioning from care exist with distinct longitudinal trajectories of homelessness, and these classes are associated with different risk factors. Early intervention and different approaches to tackling homelessness should be considered for these three distinct groups before transitioning from care and during the first few years after leaving care.

A Systematic Review of Resilience Factors for Psychosocial Outcomes During the Transition to Adulthood Following Childhood Victimisation

Exposure to childhood victimisation (i.e. abuse, neglect, domestic violence or bullying) can detrimentally impact later psychosocial adjustment. However, this is not the case for all victimised children; some do well despite their experiences and are considered to be resilient. Understanding the factors associated with such resilience is important to inform interventions to support better psychosocial outcomes among victimised children. This review provides an overview of the extant research examining resilience factors for psychosocial outcomes during the transition to adulthood following exposure to childhood victimisation. Studies were identified through a systematic literature search of Embase, PsychINFO and Ovid MEDLINE databases. The 26 included studies spanned a range of psychosocial outcomes between ages 18-25, including education and work, housing and independent living, criminal behaviour, victimisation, and social and psychological adjustment. For each outcome, a variety of putative resilience factors had been investigated including those related to the individual, their family and the wider community within which they lived. However, because few studies had comparable resilience factors and psychosocial outcomes, it is difficult to draw conclusions about which factors are consistently associated with resilience to a particular psychosocial outcome. Additionally, this review revealed that the included studies were of variable methodological quality - many were limited by cross-sectional designs with retrospective self-reports of childhood victimisation, and convenience or unrepresentative samples. In this review, we also highlight gaps in knowledge about the co-occurring impact of multiple resilience factors in combination and the need for studies conducted in non-Western and low- and middle-income countries.

Meeting housing needs of child welfare-involved families: Policy insights from simulation modeling

BACKGROUND

Inadequate housing contributes to the risk of family separation in nearly one-quarter of child maltreatment investigations. Child welfare struggles to identify and address the demand for housing assistance. A range of housing interventions shows promise for stabilizing families. Still, aid remains difficult to access, and little evidence exists for prioritizing households to interventions. Inefficient decisions about who to serve with scarce housing resources threaten to diminish resources and unintentionally place children at greater risk.

OBJECTIVE

The present study leverages computational modeling to simulate the complex dynamics of coordinated child welfare response to inadequate housing. Simulations address the lack of microdata on current service delivery to inform policy-making that protects children from family insecurity.

PARTICIPANTS AND SETTINGS

A series of simulated policy experiments test strategies for maximizing access to appropriate housing assistance and minimizing system-wide family separations using US estimates of housing insecurity and child welfare involvement. Models incorporate the feedback loops involved in seeking and waiting for needed services, using information on national rates of housing insecurity among child welfare-involved families.

RESULTS

Results demonstrate population-level improvements in family stability from enhanced targeting of housing assistance to families most likely to benefit, plus expanded access to housing interventions. Neither improved screening procedures nor more housing supports alone improve child welfare outcomes.

CONCLUSIONS

Findings emphasize the importance of data-driven upstream policies for protecting inadequately housed children at risk of maltreatment.

Do Independent Living Services Protect Youth Aging Out Foster Care From Adverse Outcomes? An Evaluation Using National Data

OBJECTIVE

Youth aging out foster care are at high risk of experiencing adverse outcomes. Federal funded programs have provided independent living services (ILSs) to these youth. This study evaluated the effectiveness of the continuity of ILSs at ages 17-19 in protecting youth aging out foster care from homelessness and incarceration at ages 19-21.

METHOD

This study used data on 4,853 foster youth from the National Youth in Transition Database and the Adoption and Foster Care Analysis and Reporting System. Logistic regression was used to regress two binary outcomes on seven ILS variables and covariates.

RESULTS

The results suggest that remaining in foster care, continuous receipts of academic support, and financial assistance services at ages 17-19 protected foster youth from experiencing homelessness. Remaining in foster care and continuous receipt of financial assistance services at ages 17-19 protected foster youth from incarceration at ages 19-21. But, surprisingly, continuous receipt of housing education and home management training, and health education and risk prevention training at ages 17-19 were each associated with increased risk of homelessness at ages 19-21. The results also showed statistically significant effects of several covariates.

CONCLUSION

Implications are provided based on the importance of financial assistance and academic support services.

Attachment Theory: A Barrier for Indigenous Children Involved with Child Protection

BACKGROUND

Attachment theory is an established theoretical understanding of the intimate relationships between parental figures and children. The theory frames the ways in which a child can be supported to develop within a secure base that prepares them for adulthood, including entering into and sustaining intimate relationships. The theory, built on the work of John Bowlby following World War II, has extensive literature supporting its application across multiple cultures and nations, although its roots are heavily tied to Eurocentric familial understandings. However, the theory has also been heavily criticized as not being appropriate for child intervention decision-making. Further, its application to Indigenous caregiving systems is also under question. Yet courts rely heavily on applying the theory to questions of sustaining Indigenous children in non-Indigenous care when return to biological parents is deemed impossible.

METHODS

This article draws upon the consistent arguments used in leading Canadian child welfare legal decisions and case examples to show how Attachment Theory is applied relative to Indigenous children and families.

RESULTS

Attachment Theory drawing upon Eurocentric framing, and as applied in Canadian child protection systems, as seen in precedent court decisions, is given priority over living in culture. This occurs even though the research reviewed has shown that the traditional dyadic version of the theory is not valid for Indigenous peoples.

CONCLUSIONS

While all children will attach to a caregiver or caregiving system, such as kinship or community, leading legal decisions in Canada tend to rely on Eurocentric versions of the theory, which is contrary to the best interests of Indigenous children. Child protection needs to reconsider how attachment can be used from appropriate cultural lenses that involve the communal or extended caregiving systems common to many Canadian Indigenous communities. Child protection should also recognize that there is not a pan-Indigenous definition of attachment and child-rearing, so efforts to build working relationships with various Indigenous communities will be needed to accomplish culturally informed caregiving plans. In addition, continued advocacy in Canada is needed to have child protection decision-making conducted by the Indigenous communities, as opposed to Eurocentric provincial or territorial agencies.

COVID-19 Vaccination Perspectives Among Young Parents with Foster Care Backgrounds

The COVID-19 pandemic has brought unique stressors for youth in foster care and recent foster care alumni, particularly those who are also parenting young children. One way the pandemic can be mitigated is through vaccination of the general population. Yet, some young adults have been slow to choose to be vaccinated. As has been demonstrated, simple availability of the COVID-19 vaccine will not guarantee its uptake, especially among marginalized populations. In order to better understand the nuances of vaccination among youth in foster care and recent foster care alumni, we conducted in-depth, semi-structured focus groups and interviews with 23 parenting youth with foster care histories aged 18-26 years. Data regarding vaccine attitudes were analyzed using thematic analysis. Participating youth, who were majority Black, Indigenous, and people of color (BIPOC) and often lived in multigenerational households, had significant concerns about the COVID-19 vaccine. They expressed varying degrees of intention to get vaccinated. Young people, especially those who belong to marginalized populations, need opportunities to openly discuss their vaccination-related questions without judgment. Science communicators should consider these questions and address youths' concerns through diverse voices and channels to ensure youth have the information they need to make an informed decision regarding COVID-19 vaccination.

Protocol for a systematic review of policies, programs or interventions designed to improve health and wellbeing of young people leaving the out-of-home care system

BACKGROUND

Relative to their counterparts in the general population, young people who leave, or transition out of, out-of-home (OOHC) arrangements commonly experience poorer outcomes across a range of indicators, including higher rates of homelessness, unemployment, reliance on public assistance, physical and mental health problems and contact with the criminal justice system. The age at which young people transition from OOHC varies between and within some countries, but for most, formal support ceases between the ages of 18 and 21. Programs designed to support transitions are generally available to young people toward the end of their OOHC placement, although some can extend beyond. They often encourage the development of skills required for continued engagement in education, obtaining employment, maintaining housing and general life skills. Little is known about the effectiveness of these programs or of extended care policies that raise the age at which support remains available to young people after leaving OOHC. This systematic review will seek to identify programs and/or interventions that improve outcomes for youth transitioning from the OOHC system into adult living arrangements.

METHODS

This review will identify programs, interventions and policies that seek to improve health and wellbeing of this population that have been tested using robust controlled methods. Primary outcomes of interest are homelessness, health, education, employment, exposure to violence and risky behaviour. Secondary outcomes are relationships and life skills. We will search, from January 1990 onwards, MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, Cochrane CENTRAL, SocINDEX, Sociological Abstracts, Social Services Abstracts, NHS Economic Evaluation Database and Health Technology Assessment. Grey literature will be identified through searching websites and databases, e.g. clearing houses, government agencies and organisations known to be undertaking or consolidating research on this topic area. Two reviewers will independently screen all title and abstracts and full text articles with conflicts to be resolved by a third reviewer. Data extraction will be undertaken by pairs of review authors, with one reviewer checking the results of the other. If more than one study with suitable data can be identified, we plan to undertake both fixed-effects and random-effects meta-analyses and intend to present the random-effects result if there is no indication of funnel plot asymmetry. Risk of bias will be assessed using tools appropriate to the study methodology. Quality of evidence across studies will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology.

DISCUSSION

Previous reviews were unable to identify any programs or interventions, backed by methodologically rigorous research, that improve outcomes for this population. This review seeks to update this previous work, taking into account changes in the provision of extended care, which is now available in some jurisdictions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020146999.

Predicting youth at high risk of aging out of foster care using machine learning methods

BACKGROUND

Youth who exit the nation's foster care system without permanency are at high risk of experiencing difficulties during the transition to adulthood.

OBJECTIVE

To present an illustrative test of whether an algorithmic decision aid could be used to identify youth at risk of existing foster care without permanency.

METHODS

For youth placed in foster care between ages 12 and 14, we assessed the risk of exiting care without permanency by age 18 based on their child welfare service involvement history. To develop predictive risk models, 28 years (1991-2018) of child welfare service records from California were used. Performances were evaluated using F1, AUC, and precision and recall scores at k %. Algorithmic racial bias and fairness was also examined.

RESULTS

The gradient boosting decision tree and random forest showed the best performance (F1 score = .54-.55, precision score = .62, recall score = .49). Among the top 30 % of youth the model identified as high risk, half of all youth who exited care without permanency were accurately identified four to six years prior to their exit, with a 39 % error rate. Although racial disparities between Black and White youth were observed in imbalanced error rates, calibration and predictive parity were satisfied.

CONCLUSIONS

Our study illustrates the manner in which potential applications of predictive analytics, including those designed to achieve universal goals of permanency through more targeted allocations of resources, can be tested. It also assesses the model using metrics of fairness.

Socio-Educational Support Deficits in the Emancipation of Protected Youth in Spain

Background

The process of transition to adult life of youth with a record of protection is crucial to overcome the difficulties to achieve an independent life.

Objective

This research aims to analyze the conditions under which protected youth are emancipated, as well as the factors that facilitate emancipation.

Method

A qualitative study was performed with three samples: longitudinal follow-ups with youths when they exit the system and during 12 months (N = 24); life stories of youths who have exited the child welfare system at least 2 years ago and a maximum of 5 years ago (N = 22); interviews with professionals conducting their intervention in adolescent protection resources (N = 18).

Results

The results indicate that protective action is not enabling youths’ learning in normalized contexts, which negatively affects the conditions under which emancipation occurs. The experience of the protective action conditions the tendency to benefit from the post-majority socio-educational accompaniment.

Conclusions

The importance of socio-educational intervention continuing during the first moments of emancipation, providing professional accompaniment to the entire collective, is highlighted.

Pediatrician Guidance in Supporting Families of Children Who Are Adopted, Fostered, or in Kinship Care

The child welfare system strives to provide children and adolescents in foster care with a safe, nurturing environment through kinship and nonkinship foster care placement with the goal of either reunification with birth parents or adoption. Pediatricians can support families who care for children and adolescents who are fostered and adopted while attending to children's medical needs and helping each child attain their developmental potential. Although this report primarily focuses on children in the US child welfare system, private and internationally adopted children often have similar needs.

Long-term benefits of providing transitional services to youth aging-out of the child welfare system: Evidence from a cohort of young people who use drugs in Vancouver, Canada

BACKGROUND

Youth aging-out of the child welfare system (CWS) experience numerous vulnerabilities including, elevated rates of substance use and substance use disorders. Calls to improve services to transition youth to independence are common; however, evidence of the long-term impacts associated with transitional service utilization is scarce. Further, existing services frequently lack appropriate supports for substance using youth and it is unknown if youth are able to access such services. In the present study, we assess the relationship between transitional service utilization and health and social outcomes among a cohort of people who use drugs (PWUD) that aged-out of the CWS.

METHODS

Data were obtained from two harmonized cohorts of PWUD in Vancouver, Canada. Those who reported aging-out were asked about service utilization, availability, barriers, and interest across seven categories of transitional services. Multivariable logistic regression analyses were conducted to assess the relationship between having previously utilized transitional services and current health and social outcomes.

RESULTS

Between December 2014 and November 2017, 217 PWUD reported having previously aged-out of the CWS. Across service categories, reported service utilization prevalence ranged from 16.6-61.8% while unmet demand ranged from 64.8-78.4%. In multivariable analyses, compared to individuals who utilized ≤1 service while aging-out, having utilized 4-7 services was significantly associated with reduced odds of current homelessness (adjusted odds ratio [AOR]=0.29) and engaging in daily drug use (AOR=0.35) (both p<0.05).

CONCLUSION

Findings suggest that this understudied high-risk population of PWUD and aged-out of the CWS experience long-term benefits associated with transitional service utilization and are interested and willing to engage in these services. However, given high unmet demand, findings also highlight considerable gaps in service delivery and support calls for extending the age of emancipation for all youth in the CWS and in particular, for additional harm reduction and substance use supports embedded into service models.

Solving Homelessness from a Complex Systems Perspective: Insights for Prevention Responses

Homelessness represents an enduring public health threat facing communities across the developed world. Children, families, and marginalized adults face life course implications of housing insecurity, while communities struggle to address the extensive array of needs within heterogeneous homeless populations. Trends in homelessness remain stubbornly high despite policy initiatives to end homelessness. A complex systems perspective provides insights into the dynamics underlying coordinated responses to homelessness. A constant demand for housing assistance strains service delivery, while prevention efforts remain inconsistently implemented in most countries. Feedback processes challenge efficient service delivery. A system dynamics model tests assumptions of policy interventions for ending homelessness. Simulations suggest that prevention provides a leverage point within the system; small efficiencies in keeping people housed yield disproportionately large reductions in homelessness. A need exists for policies that ensure reliable delivery of coordinated prevention efforts. A complex systems approach identifies capacities and constraints for sustainably solving homelessness.

Predictors and correlates of unstable housing experiences among a child welfare-involved sample

The study examined whether youth demographics, family factors, and maltreatment type were related to unstable housing and whether unstable housing predicted delinquency and marijuana use. Participants included 216 child welfare-affiliated adolescents (mean age = 18.2 years). Youth with more lifetime residences were more likely to experience unstable housing although Latino youth (compared to White, Black, or multiethnic/biracial) were less likely to experience unstable housing. Unstable housing was associated with subsequent delinquency. Caregiver type (parent vs. relative/unrelated caregiver) was not related to unstable housing, thus homelessness prevention programs should include youth who remain with their parents and those with non-parent caregivers.

Housing and Child Well Being: Implications for Research, Policy, and Practice

Inadequate housing and homelessness represent significant barriers to family stability and child development. An accumulating body of evidence documents the relatively high risk of family separation among families experiencing housing instability and homelessness, the extent of housing problems experienced by families involved in the child welfare system, and the disproportionately high rates of homelessness among youth aging out of foster care. Vulnerable youth and families interact frequently with various social service programs intended to mitigate multifaceted and multilevel risks, however, systems efforts and resources are rarely coordinated and results to date are mixed. We introduce 13 papers that are part of a burgeoning, increasingly sophisticated body of scholarship that inform coordinated responses to inadequate housing experienced by families involved in child welfare and related interventions. We note emergent themes and state a pressing need for research that accounts for ecological and contextual influences, examines the differential impact of housing and service interventions, identifies critical ingredients of effective housing and service interventions, and positions for scale-up. We distill findings into a set of observations and recommendations that align with best intentions to improve quality of life and promote well being among some of society's most vulnerable individuals.

Housing and Child Welfare: Emerging Evidence and Implications for Scaling up Services

Inadequate housing threatens family stability in communities across the United States. This study reviews emerging evidence on housing interventions in the context of scale-up for the child welfare system. In child welfare, scale-up refers to the extent to which fully implemented interventions sustainably alleviate family separations associated with housing instability. It incorporates multiple aspects beyond traditional measures of effectiveness including costs, potential reach, local capacities for implementation, and fit within broader social services. The framework further encompasses everyday circumstances faced by service providers, program administrators, and policymakers who allocate resources under conditions of scarcity and uncertainty. The review of current housing interventions reveals a number of systemic constraints for scale-up in child welfare. Reliance on rental assistance programs limits capacity to address demand, while current practices that target the most vulnerable families may inadvertently diminish effectiveness of the intervention and increase overall demand. Alternative approaches that focus on homelessness prevention and early intervention must be tested in conjunction with community initiatives to increase accessibility of affordable housing. By examining system performance over time, the scalability framework provides an opportunity for more efficient coordination of housing services within and outside of the child welfare system.