Abstract
Occupational therapy practitioners are qualified to address the needs of young adults transitioning out of the foster care system; yet, to date, the degree to which practitioners have addressed these needs has been limited. The literature on foster care clearly documents the myriad of long-term challenges that this population faces as a result of their lack of preparedness in independent living, academic, and vocational skills. Moreover, it is clear that existing programs are inadequate for meeting the needs of this population because they rarely include individualized, occupation-based, client-centered approaches for skill development. In this article, we argue that by design, the foster care system marginalizes its “members.” Occupational therapy’s emphasis on occupational justice provides practitioners with an ideal opportunity to remediate the injustice that this population often experiences. To support our position, we describe exploratory work that has been conducted with stakeholders and transitioning youth in Miami, Florida.
Keywords
According to the U.S. Department of Health and Human Services (HHS; 2000), foster care is defined as “24-hour substitute care for children placed away from their parents or guardians and for whom the State agency has placement and care responsibility” (p. 1). Although most people are familiar with the single foster family home model, placements may include group homes, emergency shelters, large residential facilities, or homes of relatives (kinship care). This system of foster care has been described as bureaucratic in nature, consisting of many layers (Paul-Ward, 2009). Although these layers were developed to increase accountability among service providers and to lead to youth success after foster care, long-term outcomes, such as educational achievement and employment attainment, have not improved for this population (Courtney et al., 2005).
A paucity of literature within the field of occupational therapy highlights opportunities for intervention with children in foster care at both the individual and community levels. Specifically, occupational therapy practitioners can intervene at the individual level by assisting transitioning youth to develop future goals and the skills needed to achieve them. At the community level, practitioners can be instrumental in the planning, delivery, and evaluation of occupation-based transitional programs in which youth become successful by doing. Lessons learned from an ongoing exploratory study provide the backdrop for the argument that occupational therapy practitioners’ service is sorely needed in independent living and vocational skill programs that help foster care youth advance toward adulthood.
With the recently implemented Patient Protection and Affordable Care Act (2010; Pub. L. 111–148), both the focus and funding of health care will probably shift to prevention and community-based practice (Sheldon Fields, PhD, ARNP, personal communication, August 2014). This trend bodes well for occupational therapy and opportunities for working with this historically marginalized population because prevention is delineated as a specific approach to intervention in the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; American Occupational Therapy Association [AOTA], 2014).
Background
In the United States, more than 250,000 children are placed in foster care each year (Zlotnick, Tam, & Soman, 2012), with 58% from minority groups (HHS, 2014a). In addition, children in the foster care system have higher rates of physical, psychological, and social problems than children not in foster care (Zlotnick et al., 2012). For example, it has been estimated that between 40% and 60% of children in foster care have at least one psychiatric disorder and that about 33% have three or more psychiatric diagnoses (Stein, Rae-Grant, Ackland, & Avison, 1994). These disorders include depression, substance use, oppositional defiance, anxiety, adjustment, posttraumatic stress disorder, learning disorders, and attention deficit disorder. Treatment for these disorders often includes medications that require ongoing management and adherence to be effective (dosReis, Zito, Safer, & Soeken, 2001).
As U.S. adolescents transition into adulthood, they are typically expected to finish school, gain independence from their parents, and become contributing members of their communities (Arnett, 2000; Chadsey-Rusch, Rusch, & O’Reilly, 1991; Hiebert & Thomlison, 1996). The term aging out is used to describe youth ages 18 yr and older who are no longer eligible to remain in foster care and who receive related state services or have chosen to leave the system. The age at which youth are mandated to leave the system varies by state. For many young people, the process of aging out of the foster care system presents many challenges. In particular, most youth lack financial resources as well as familial and other supports, placing them at risk for developmental disruptions and other negative outcomes (e.g., low educational attainment, homelessness, employment and financial difficulties, mental and physical health problems; Barth, 1990; Blome, 1997; Collins, 2001; Courtney, Piliavin, Grogan-Kaylor, & Nesmith, 2001; Lemon, Hines, & Merdinger, 2005).
Youth in foster care typically have higher rates of absenteeism, grade retention, disciplinary referrals, and behavior problems than the general K–12 population (Berliner & Lezin, 2012). This group also tends to test below grade level on standardized measures and is twice as likely as the general student population to leave school without a diploma. For example, recent data from the Michigan Alumni Study (White et al., 2012), which examines the demographics and experiences of former foster care youth, revealed that foster care alumni are more likely to complete high school by earning a general equivalency diploma rather than a diploma. In addition, the study found that less than half of the alumni (43.1%) were employed at least 10 hr/wk. About 1 in 4 (26.2%) were working at least 35 hr/wk, which is lower than in the general population (57.3%). Moreover, only one-third of alumni (32.3%) reported having a household income that was greater than the Federal Poverty Level (FPL), and only 12.3% reported having a household income that was at least 3 times greater than the FPL (HHS, 2014b).
Eventually, the lack of independent living, vocational, and health maintenance skills results in many former foster care youth receiving services as adults through the criminal justice system (i.e., arrested, convicted, or incarcerated) or the welfare system (Jonson-Reid & Barth, 2000; Needell, Cuccaro-Alamin, Brookhart, Jackman, & Shlonsky, 2002; White et al., 2012). For example, Courtney et al. (2005) found that one-third of former foster children who were tracked in their study of three Midwestern states had high levels of involvement with the criminal justice system. This less than successful transition into adulthood inevitably leads to health and disablement issues in later life, creating more problems both at the individual and societal levels and resulting in the need for more care and higher expenditures, including funds for institutionalization.
Each year, roughly 24,000 youth age out. Research documents numerous barriers that they must overcome to be successful adults. These barriers include poverty, mental health problems, lack of preparedness for the future, history of trauma, involvement with the criminal justice system, and unstable or unsupportive living and school environments (e.g., Blome, 1997; Collins, 2001; Courtney et al., 2001; Kushel, Yen, Gee, & Courtney, 2007; Lemon et al., 2005). Another concern is that many of these youth do not have the opportunity or training necessary to acquire and master the independent living and employment skills needed for successful community living (Barth, 1990; Blome, 1997; Mech, 1994; Rashid, 2004). Typically, independent living skills are acquired gradually over time, in family environments, through observation and experience, and through guidance from nurturing adults. Instability in living situations and lack of consistent or healthy role models can impede development of these needed independent living skills.
Most states provide some form of independent living program for youth who have aged out, in response to the Independent Living Initiative (1986; Pub. L. 99–272) mandating transition services for this population. These programs are intended to prepare this population for adult independence by addressing a broad spectrum of independent living skills ranging from activities of daily living to education and vocation. Although these programs are mandated for youth preparing to transition out of foster care, they are underused. For example, only 42,600 youth in 40 states (about 60% of all eligible youth) received some type of independent living service in 1998 (Georgiades, 2005; U.S. General Accounting Office [GAO], 1999).
Reasons for underutilization of independent living programs may include poor communication with youth regarding available resources, programs that lack appeal and are not designed with young adults in mind (i.e., they are frequently delivered in offices through pen-and-paper activities and bear no resemblance to the activities and occupations young adults encounter in their everyday lives), and young adults’ perception that they already possess the skills necessary for independent living and reluctance to further entrench themselves in a disempowering system (Paul-Ward, 2009). In addition, foster parents often play little, if any, role in the programs offered by case management agencies.
Even when programs have been used, they have not been effective (GAO, 1999; Stoner, 1999, as cited in Reilly, 2003). Agencies are often not equipped with the appropriate staff to assess each client and to provide client-centered services to address individual needs. The result is that staff often do things for transitioning youth rather than assist them in learning how to do them for themselves (e.g., find housing, arrange for assistance for nonpayment of utility bills and resulting service termination). This situation may create learned helplessness in transitioning youth, teaching them to expect others to fix their problems rather than develop the skills needed to solve them. Learned helplessness can have negative life consequences for these young adults and place a huge financial and public health burden on society. Therefore, child welfare advocates have called for new intervention approaches to improve independent living and vocational skills in foster care youth (e.g., see http://www.chapinhall.org/ and http://www.cwla.org).
Research to Understand the Needs of Transitioning Youth
Although the challenges and barriers to development of independent living skills have been identified, no individualized, occupation-based, client-centered interventions have been created or evaluated with controlled, experimental studies to address this important need (McMillen et al., 2005). To begin to fill this research void, exploratory work was conducted by Paul-Ward (2009) to collect qualitative data pertaining to perceptions of the foster care system. Findings from this ongoing research have indicated that youth preparing to exit foster care do not access available independent living programs in a personally meaningful way. According to the participants, this lack of utilization is due to several factors, including lack of knowledge of available services, lack of motivation and confidence to ask for such services, perceptions that these services are not for them, and the didactic and unengaging format of the services (i.e., programs use paper-and-pencil exercises rather than opportunities for experiential learning).
Other problems have been that most youth leaving foster care do not have a bank account; most of Paul-Ward’s (2009) study participants reported having difficulties with budgeting. The study also indicated a disconnect between young people’s perceptions of their abilities and their actual possession of skills needed for successful transition to adulthood. Moreover, Paul-Ward has suggested that society holds higher expectations for adolescents in foster care than for teenagers in more stable family situations by imposing the need for self-sufficiency during the time they age out (i.e., ages 18–23 yr). The study also found no consistency across agencies regarding information about availability of independent living skills classes, resulting in poor attendance rates. A considerable number of study participants who had participated in independent living programs reportedly relied on the independent living staff to solve all problems. The result, as reported by staff, was that staff felt they were often reacting to emergencies rather than working proactively with clients to ensure that they learned and mastered problem-solving skills.
The lack of youth engagement and the didactic format of many independent living programs can result in adolescents leaving the foster care system with their skill needs unmet. However, practitioners working with foster care youth, regardless of disciplinary perspective, can move beyond the existing didactic models and implement innovative programs. These transition programs must be developmentally appropriate and provide opportunities for these youth to acquire the behaviors needed to master independent living, vocational, and health maintenance skills. Moreover, it is clear that a critical piece is missing from the program development process, namely, a client-centered approach that takes into account the target audience’s perspectives and ideas about what constitutes useful programming. By offering innovative and client-centered approaches, these programs have the potential to provide a unique opportunity to engage professionals and transitioning youths in a meaningful, experientially driven process that supports the acquisition of the skills needed for these youths to become successful, self-sufficient adults.
Opportunities for the Profession
Because young people transitioning from foster care face so many disadvantages and because existing interventions have failed to achieve positive outcomes, it is critical to adopt new theoretical and programmatic approaches to address their independent living, vocational, and health needs (see HHS, 2008). Occupational therapy practitioners are ideally suited to address these needs but traditionally have not been included in foster care programs. Occupational therapy is based on the understanding that meaningful occupations and activities, with their inherent power to maintain, restore, and transform one’s sense of competency, are fundamental to health and well-being (Mee, Sumsion, & Craik, 2004; Wilcock, 1998). When people engage in meaningful occupations, their physical, mental, and emotional health are enhanced (Townsend, 1997).
As part of a generalist education, occupational therapy practitioners have acquired the knowledge and skills necessary to intervene at both the individual and the community levels. According to the Occupational Therapy Practice Framework, examples of interventions at the individual level may target client factors, such as emotional regulation and self-concept; performance skills, such as process and social interaction skills; activity patterns, such as engagement in health-promoting roles and routines; and occupations, such as activities of daily living, instrumental activities of daily living, education, and work. Additionally, practitioners can evaluate all aspects of the environment (most notably, the social and physical environments) to ensure that necessary supports are in place to promote success.
Much work has yet to be done at the individual level of foster care transitioning, and most occupational therapy practitioners are perhaps more familiar with the skills and interventions at this level than at the community level. However, to address the larger community and to build on the broader movement of social justice, practitioners cannot ignore the fundamental right of all people to participate in meaningful occupations, or occupational justice. Occupational injustice occurs when a person’s participation in meaningful occupation is barred, limited, undeveloped, disrupted, or marginalized (Townsend & Wilcock, 2004). This notion is relevant to foster care because by design, the foster care system tends to marginalize its “members” by institutionalizing them, not necessarily within physical structures but through systemic barriers (Paul-Ward, 2009). For example, the system disrupts occupations because children are often moved from one foster care home to another. Moreover, many of the factors associated with foster care lead to children’s underdevelopment in the areas of exploration and mastery of independent living skills, a phenomenon not typically seen in children in stable environments.
Empowerment, the process of giving voice and opportunities for participation to people regarding the decisions that affect their lives, is an important concept related to occupational justice. This process emphasizes a person’s responsibility to control his or her own life and resources. Therefore, use of an empowerment approach that moves the development of independent living, vocational, and health maintenance skills out of didactic classroom settings into the community, providing opportunities for experiential learning for real-life problem solving, is crucial to promoting successful transitions. We argue that instead of preparing youths in foster care with the skills necessary to overcome challenges, currently available programming suppresses their ability to assume responsibility by facilitating a culture of learned helplessness that serves to perpetuate the challenges they face.
The foster care literature has shown that a clear need exists to develop programs that address the challenges of foster care youth during transition, specifically, programs that increase the likelihood that these youth are equipped with the necessary skills to live independently, find employment, and maintain health and well-being (Courtney et al., 2005; McMillen et al., 2005). AOTA's (2007) Centennial Vision recognizes the opportunities for occupational therapy practitioners to work in a broad range of settings with people who have diverse needs. The overarching areas of practice identified include mental health, children and youth, health and wellness, disability, and participation, all of which are relevant to the needs of youth transitioning out of foster care. With the Centennial Vision in mind, the needs of this population clearly identified, health care shifting toward a greater emphasis on community-based prevention and care, and a professional calling to serve as agents of change and voices of advocacy, practitioners stand poised to meet the occupational needs of this underserved population.
The challenge for occupational therapy practitioners in delivering services to transitioning foster care youth is logistical because there is little precedent to do so. The independent living, vocational, and health maintenance skills needed by these youth are typically not reimbursable for practitioners working in community-based settings. The primary mechanism for reimbursement of such services in the community is Medicaid. To bill for these services under Medicaid, the practitioner must be recognized as a qualified mental health practitioner (QMHP). Currently, only a few states recognize occupational therapy practitioners as QMHPs. Although efforts have been made at both the state and national level to change the Medicaid status of occupational therapy practitioners, the struggle to adequately deliver services to community populations is ongoing. Despite this struggle, the profession cannot shy away from the challenge of meeting the needs of the underserved.
As health care reform rolls out, occupational therapy practitioners are positioned to play a larger role than before in the community. Now more than ever, the profession needs to identify alternative routes for service delivery and advocate for an occupational therapy presence in the community. One possible alternate route includes filling nontraditional roles in which practitioners can have a positive influence on the future outcomes of transitioning foster care youth without holding the title of occupational therapist or occupational therapy assistant. One such role includes functioning as a living skills provider. In this way, practitioners would have a direct impact on the service delivery model of developing independent living, vocational, and health maintenance skills in transitioning foster care youth. Occupational-based learning would be central to the process, and the match between the client and the activity could be tailored for success.
Another route to meeting this need includes developing partnerships between academic institutions and community-based programs that serve youth in foster care. Partnerships might involve service learning, program development, nontraditional fieldwork placements, or research projects (e.g., see Paul-Ward [2009]) to meet the occupational needs of these youth, which are currently not being adequately addressed by the system. In the early stages of these partnerships, intermural and extramural grants can fill the gap until traditionally recognized avenues of funding (e.g., insurance or third-party payer systems) become available.
Yet another route is to consider other professional activities that would increase awareness about occupational therapy services in foster care among stakeholders who are involved in foster care issues. For example, by publishing more widely in youth-oriented journals, occupational therapy practitioners who are working on foster care issues can add to the dialogue on policy and programmatic issues for improving foster care outcomes. In addition, to overcome limited financial resources, practitioners can serve as consultants to foster care agencies to incorporate experiential learning activities to help transitioning youth learn developmentally appropriate independent living, vocational, and health maintenance skills. Practitioners can also provide educational workshops that help agency staff better incorporate just-right activities for youth in their care.
Conclusion
The time has come for the occupational therapy profession to embrace community practice to help marginalized youth transitioning out of foster care. The current shift in the health care system toward prevention creates an environment that necessitates the need for occupational therapy practitioners and other care providers to assume leadership roles for tackling challenges in service delivery. It is imperative that occupational therapy as a profession embraces these new opportunities to provide much needed services to underserved youth, thereby answering the call to meet society’s occupational needs (AOTA, 2007).