University of Groningen ‘What I really needed was a voice’ Steenbakkers, Annemarie Theodora

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‘What I really needed was a voice’

Steenbakkers, Annemarie Theodora

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Steenbakkers, A. T. (2018). ‘What I really needed was a voice’: The psychosocial needs of youth in family foster care and the impact of traumatic experiences. Rijksuniversiteit Groningen.

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The psychosocial needs of youth in family foster care

and the impact of traumatic experiences

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Cover design Jamie Marijnissen

Layout Nicole Nijhuis

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ISBN 978-94-034-0563-6

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The psychosocial needs of youth in family foster care

and the impact of traumatic experiences

Proefschrift

ter verkrijging van de graad van doctor aan de Rijksuniversiteit Groningen

op gezag van de

rector magnificus prof. dr. E. Sterken en volgens besluit van het College voor Promoties.

De openbare verdediging zal plaatsvinden op donderdag 17 mei 2018 om 11.00 uur

door

Annemarie Theodora Steenbakkers

geboren op 18 februari 1989 te ‘s-Gravenhage

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Copromotores

Dr. S. van der Steen Dr. I.T. Ellingsen

Beoordelingscommissie

Prof. dr. J.M. Boddy Prof. dr. D. Shemmings Prof. dr. M.C. Timmerman

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waar je behoefte aan hebt.’

Nicole (pseudoniem), 23 jaar oud

‘What I really needed was a voice. That someone would ask me and that we then discuss this together. Because in that moment, it is very hard to describe what your needs are.’

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Chapter 1. General introduction 9 Chapter 2. The needs of children in foster care and how to satisfy them: 21

A systematic review of the literature

Chapter 3. Psychosocial needs of children in foster care and the impact of 39 sexual abuse

Chapter 4. Do foster parents and care workers recognize the needs of youth 57 in family foster care with a history of sexual abuse?

Chapter 5. How do youth in foster care view the impact of traumatic experiences? 73 Chapter 6. ‘To talk or not to talk?’: Youth’s experiences of sharing stories 89

about their past and being in foster care

Chapter 7. General discussion 109

References 135

Summary 149

Samenvatting 155

About the author 161

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CHAPTER 1.

General introduction

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1 Introduction

All children have the right to grow up in a safe and supportive environment that contributes to their well-being (Convention on the Rights of the Child, United Nations, 1989). If, for any reason, children cannot be raised by their own parents, they can be placed in a foster family that aims to provide them with a nurturing home and stimulate their development and health (Pasztor, Hollinger, Inkelas, & Halfon, 2006). Family foster care is the preferred type of out-of-home care, because this setting most closely resembles a ‘normal’ family environment with stability of caregivers (Berrick & Skivenes, 2012; Schofield & Beek, 2005; United Nations General Assembly, 2009). In the Netherlands, over 20.000 children are in foster care each year, either temporarily or for a longer period of time (Pleegzorg Nederland, 2017a).

Children placed in family foster care come from high-risk backgrounds. The majority of children are placed out-of-home because of harmful caregiving environments, therefore it is not surprising that these children are disproportionately exposed to physical and sexual abuse, neglect, caregiver mental health issues, domestic violence and substance abusing caregivers (Oswald, Heil, & Goldbeck, 2010; Turney & Wildeman, 2017). Research on the impact of child maltreatment and childhood trauma shows the long-lasting consequences this can have on children’s development, health and psychological well-being (R. Gilbert et al., 2009; Van Der Kolk, 2005). Moreover, being separated from their parents, even if their care was inadequate, is another traumatic event that children experience (Bowlby, 1980; Mitchell, 2017). This high-risk background of children can contribute to the problems and obstacles they encounter, such as problems with attachment, internalizing and externalizing behavior, school, traumatic stress and placement stability (Greeson et al., 2011; Piescher, Colburn, LaLiberte, & Hong, 2014; Schofield & Beek, 2005; Villodas et al., 2016). Children in family foster care are therefore often portrayed as vulnerable children with high care needs. That said, these problems are not universal and children in foster care can show resilience (P. A. Fisher, 2015).

Internationally, between 4 to 35 percent of the children in family foster care have experienced sexual abuse (Oswald et al., 2010), and children in the Netherlands seem to be at the upper bound of these estimates (Grietens, Van Oijen, & Ter Huizen, 2012). A history of sexual abuse can put children specifically at risk for negative outcomes. Studies have shown that these children are more likely to experience behavioral problems, placement instability, depression and that they drop out of school at higher rates (Dubner & Motta, 1999; Edmond, Auslander, Elze, McMillen, & Thompson, 2002; Eggertsen, 2008). Children who were sexually abused possibly have needs that are not as urgent for other children in care, for example related to giving and receiving affection, managing their personal boundaries, and learning about sexuality and appropriate sexual behavior (Farmer & Pollock, 2003; Pollock & Farmer,

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2005). Moreover, they are often poly-victimized, meaning they experienced other types of maltreatment, which increases their vulnerability even further (Edmond et al., 2002; Pollock & Farmer, 2005). These children require foster parents who are particularly trauma-sensitive and can help them to process their experiences. However, foster parents are rarely aware of the history of sexual abuse, making it more difficult to meet the specific needs of this group of children (Pollock & Farmer, 2005).

The above-mentioned studies show that children in foster care can indeed be perceived as vulnerable. However, a mere problem and risk orientation can result in a one-dimensional understanding of the development and health of these children. Furthermore, it can contribute to the stigma children feel is attached to being in care and increase feelings of helplessness (Gingerich & Eisengart, 2000; Madigan, Quayle, Cossar, & Paton, 2013). In order to understand how the well-being of children in family foster care can be supported and stimulated, this thesis focuses on their psychosocial needs. Meeting the needs of children is expected to enable them to make a positive developmental turn (Berrick & Skivenes, 2012; Nelson et al., 2007). Compared to the more one-dimensional vulnerability discourse, psychosocial needs cover multiple aspects of well-being, ranging from individual and safety aspects, to interpersonal and growth aspects (Maslow, 1943). Furthermore, need satisfaction can be scaled from satisfied to unsatisfied. A needs perspective is therefore not only concerned with problems regarding the health and development of children, but rather emphasizes necessities for the most optimal development and well-being of children in a more holistic way. An orientation towards these necessities can enhance children’s sense of self-efficacy and help them to achieve the envisioned change (cf. Gingerich & Eisengart, 2000).

Psychosocial needs

Needs are motivating forces that direct the behavior, thoughts and emotions of a person, and meeting the basic human needs contributes to a healthy development (Deci & Ryan, 1985; Maslow, 1943). Maslow’s theory of human motivation (1943) describes five basic needs that are organized in a hierarchy in which lower order needs have to be adequately satisfied before higher order needs can be attended to. The lowest level in the hierarchy are the physiological needs, which aim to maintain an adequate homeostasis of the body with for example food, water and shelter. The next level is the need for safety; both physical safety, such as freedom from pain, and emotional safety, such as freedom from psychological stress. The third level is that of a sense of belonging. People need love and affectionate relationships with others and to feel connected to (groups of) people. When the needs for love and belongingness are satisfied, the desire for a stable and firm evaluation of the self emerges. People need to have self-esteem based on their capacities and to feel that others appreciate their capacities as well. Finally, on the highest level is the need for

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self-actualization, which is the desire to become everything a person can become. The four upper layers of the hierarchy can be considered the psychosocial needs, which is the main focus of this thesis, while the physiological needs can be considered biological needs (see Figure 1.1).

Figure 1.1. Maslow’s hierarchy of needs (1943).

Satisfying these needs is a continuous process; successful need satisfaction leads to (further) growth and well-being, while failing to meet needs can inhibit this. Unmet needs can be satisfied by changing environmental factors, or changing individual or interpersonal actions, thoughts or feelings (Deci & Ryan, 2012; Maslow, 1943). Out-of-home placement is an example of a change in the environment, while the upbringing by foster parents can be considered a set of changes in interpersonal actions. Sensitive caregiving by foster parents is specifically important in meeting children’s needs, as it may reverse the damage of previous adverse caregiving environments and can support children in acquiring the life-skills for adulthood (Schofield & Beek, 2005). Many other people and environments are involved in meeting the needs of children in family foster care and can contribute to their development and well-being. Examples of other actors are care workers, therapists, teachers, friends, extended family members and neighbors, while living in a new neighborhood, attending leisure activities and school are examples of other environmental changes that can occur in family foster care. Most importantly, it should not be forgotten that children themselves are important actors in their own lives (James & Prout, 1997). Within a supportive atmosphere, they are able to express their needs and how these should be satisfied. Furthermore, children have the ability to satisfy their own needs.

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Voices of children in foster care

Despite that children in family foster care are often portrayed as vulnerable and in need of protection, they have the right and capacities to provide their own views in all matters that affect them (Dillon, Greenop, & Hills, 2016; United Nations, 1989; van Bijleveld, Dedding, & Bunders-Aelen, 2014). Children actively construct their own lives, the lives of those around them and the society in which they live, therefore the sociology of childhood underscores the importance of studying children in their own right (James & Prout, 1997). Participation not only pertains to their day-to-day lives, but children should also be able to voice their opinion in policy development and research that deals with matters affecting them (Lundy, 2007; Winter, 2010). In research, active participation of children can result in more socially and culturally valid outcomes, because academic knowledge is combined with real-world knowledge and expertise (Cargo & Mercer, 2008; R. Sinclair, 2004). Including the voices of children in research about their experiences in foster care can provide unique insights into how they perceive and make meaning of these experiences, and can address and respect the diversity of their opinions and situations (McLean, 2005; Warming, 2006). The stories they share reflect which life events they find most meaningful and illustrate the less tangible aspects of their experiences (Whiting, 2000). This knowledge can inform service planning, provide insights to improve outcomes, and assist care professionals to better understand and meet their needs (Warming, 2006; Whiting, 2000).

In order for children to participate in a meaningful way in matters that affect them, they should be able to provide their views on the subject under investigation and have their views given due weight (United Nations, 1989). Preconditions for meaningful participation are giving children thorough information about their right to participate and about the subject under investigation, and giving them space and opportunity to participate throughout the investigation (Lundy, 2007; Pölkki, Vornanen, Pursiainen, & Riikonen, 2012). In research, children can contribute to shaping the purpose and scope of the study, conducting the study, interpreting results and disseminating outcomes. Participation of children in research occurs across various degrees, ranging from equal co-researchers that are active in all phases of the study, to active advisors and contributors in parts of the research process (Cargo & Mercer, 2008; Kirk, 2007; Langhout, 2010).

Participation of children in decisions regarding their care is believed to have benefits for their well-being (Cashmore, 2003; Vis, Strandbu, Holtan, & Thomas, 2011), and similar benefits seem to exist when children participate in research (McClinton Appollis et al., 2017). Sharing their stories can help them make meaning of their experiences and can have therapeutic qualities (McLean, 2005; Orb, Eisenhauer, & Wynaden, 2001; Whiting, 2000). Moreover, having their views heard and contribute to scientific advancement provides children with a sense of value and empowerment (Cargo & Mercer, 2008; Warming, 2006). However, having children participate in research, especially regarding sensitive issues such as foster care and

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traumatic experiences, can also bring risks to their well-being and thus requires particular ethical sensitivity of researchers (R. Sinclair, 2004). Asking children questions about difficult and traumatic experiences may trigger painful memories and cause distress or hyperarousal (Hanney & Kozlowska, 2002; Orb et al., 2001). Another ethical issue is that participating in research often does not directly affect children’s situation. Children and researchers should be aware that researchers are not always in the position to help children when current issues are brought forward. In addition, the dissemination and implementation of study results can be difficult to perceive for children, because these are often distributed among scientists and professionals, and because the timeframe for implementation in practice is too long for them to benefit from the results of a study (Kirk, 2007). Finally, researchers should be sensitive to the power difference between them and their participants, both with regard to their older age and their position as researchers (Hutchfield & Coren, 2011; Kirk, 2007; Whiting, 2000). Here, a dilemma arises: while considerations about the particular vulnerability of children in foster care might be appropriate, not letting them participate could add to this vulnerability and further limit their possibility to influence the matters affecting them (N. Lee, 1999). Since children provide unique insights into their lived experiences, and because children themselves have indicated to value participation (Warming, 2006; Whiting, 2000), we decided in this study to focus on the voices of children and have them participate despite the possible challenges. In addition to applying good ethical practices within the study design, such as gaining ongoing informed consent and ensuring participants anonymity, confidentiality and opportunities for after-care (Hutchfield & Coren, 2011; Kirk, 2007), researcher reflexivity and sensitivity are key when addressing the ethical issues that come with this decision. This means that researchers should keep negotiating their ethical practices throughout the study and be sensitive to how their beliefs and position influences the acquired knowledge (Phelan & Kinsella, 2013).

Methodological considerations

Children in foster care are not a homogenous group. They can differ greatly in their pre-care experiences, age of entering pre-care, placement trajectories, the quality and frequency of contact with their birth parents, school engagement, behavioral and mental health problems, and so forth (e.g., Atwool, 2013; Oswald et al., 2010; Petrenko, Culhane, Garrido, & Taussig, 2011). Consequently, children are expected to differ regarding how they view their needs: both with regard to which needs are satisfied and which still require satisfaction, and also with regard to how they prefer their needs to be satisfied. These individual differences in views and attitudes between children can be difficult to grasp using quantitative methods (Ellingsen et al., 2010; Watts & Stenner, 2005). Therefore we employed qualitative methods to gain an in-depth understanding of the needs as experienced by children (Flick, 2014). Since we wanted to cover a broad range of experiences children can have in family foster

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care, also those experiences when children are nearing the end of the placement, we asked older adolescents and young care leavers (from here on referred to as ‘youth’) to retrospectively reflect on their needs during family foster care.

A constructivist paradigm follows from the assumption that children in foster care differ in how they view their needs. Constructivism assumes that people actively make meaning of their world through interactions and cognitive and affective operations. This thesis does not aim to observe one objective truth, but instead to understand how people interpret and make sense of their experiences (Denzin & Lincoln, 2005; Watts & Stenner, 2012). In cooperation with the researcher, participants reconstruct their subjective understanding in the (participatory) research process. Bruner (2004) in this respect differentiates ‘life as it is’, ‘life as experienced’ and ‘life as told’. The first relates to the objective facts of a person’s life, which are then given meaning to by people in the ‘life as experienced’. Although constructivist research aims to understand the latter, there is always a difference between the experiences of someone and what is told and revealed during the research process. The ‘life as told’ in research differs from ‘life as experienced’ because people are selective in their memory and in what they share with researchers. The voices of children in family foster care were elicited in this thesis by conducting two complementary studies: a Q methodology study and an episodic interview study (Flick, 1997; Watts & Stenner, 2012).

In order to explore the different viewpoints of youth in foster care regarding their psychosocial needs, a Q methodological study was conducted. The aim of Q methodology is to reveal patterns of subjectivity among groups of people, such as views, beliefs and opinions (McKeown & Thomas, 1988). Subjectivity is not only a way of thinking about a certain subject, but also a range of behavioral activities that communicates a person’s point of view (Watts & Stenner, 2012). In order to elicit their viewpoints, participants sort a set of statement cards regarding the topic of interest in a grid with a quasi-normal distribution. These statement cards should be self-referenced instead of factual, because they need to be scaled from most like to most unlike a person’s viewpoint (Stephenson, 1980). Individual Q sorts are subsequently correlated and factor analyzed in order to reveal groups of participants with similar viewpoints (McKeown & Thomas, 1988). Which factors emerge depends how the participants sort the cards; all that is required to identify a factor are two individuals whose Q sorts bear a degree of similarity (Brown, 2006). Each factor displays the statements that are typically viewed positively and negatively by participants loading on that factor (Ellingsen et al., 2010). The overall configurations of the factors are subsequently interpreted and compared to identify which viewpoints about the subject under investigation are present among the participants (Watts & Stenner, 2005). Q methodology can therefore be considered a qualitative method applying quantitative techniques (Shemmings & Ellingsen, 2012).

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One of the advantages of Q methodology is that it both showcases common viewpoints held by many people and viewpoints held by only some people (Brown, 2006). The statement cards should therefore be representative of all the possible opinions and viewpoints regarding the subject under investigation, also known as the concourse (Ellingsen et al., 2010; McKeown & Thomas, 1988). In order to most accurately represent the possible viewpoints on the subject, interviews and focus groups can be conducted to identify the concourse, and to choose the final selection of statements (Cross, 2005). The statements should be understandable and familiar to everyone performing the Q sort (Stephenson, 1980), but by actively ranking the statements the participants decide which statements are meaningful from their own perspective (Corr, 2001; Watts & Stenner, 2005). The sorting task can therefore be viewed as a built-in participatory feature of Q methodology. Statement cards can even mean something different for each person sorting the card, even if they agree on the importance of the statement (Watts & Stenner, 2005), which illustrates the constructivist aspects associated with this methodology (Watts & Stenner, 2012).

Another advantage is that the sorting task can be conducted about almost any subject and is particularly suitable for studies including children and studies regarding sensitive issues (Ellingsen et al., 2010; Stephenson, 1980). When there is a representative selection of statements, participants do not have to rely on their verbal abilities to provide their viewpoints, whether their viewpoint is common or uncommon. Moreover, participants do not have to elaborate on their viewpoints to the researcher as they would for example do in an interview, which can reduce the emotional burden when investigating sensitive issues (Ellingsen et al., 2010). That said, participants may wish to elaborate on their sorting, which offers additional insights into the emerging perspectives. The sorting task is often viewed as an engaging activity, because the statement cards provide participants with an accessible way to share their views (Ellingsen et al., 2010; Stephenson, 1980). Moreover, it can stimulate self-awareness and self-reflection, because sorting the statements in the quasi-normal distributed grid requires participants to identify their level of agreement on each statement in relation to all the other statements (Corr, 2001). These characteristics of Q methodology make it very suitable for this study.

Prior to the Q methodology study, a narrative interview study among youth (formerly) in foster care was conducted using episodic interviewing (Flick, 1997). The aim of an episodic interview is to ask participants about what the concept under investigation means to them, how this relates to their biography and how everyday experiences relate to this concept. In this study, interviews focused on the psychosocial needs of youth while in family foster care and the actions of themselves and others with respect to satisfying these needs. Three broad themes were discussed by participants, namely what did it mean to be a child living in a foster family, what were your needs while in care, and what was the impact of traumatic experiences on you? Participants were asked to talk about everyday experiences

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and memories of the foster care period. In order to reduce the emotional burden of the interview, participants were not questioned about maltreatment and abuse prior to their foster care placement. Moreover, the interview had an open structure, allowing participants to determine which stories they shared and how deeply these were discussed.

The episodic interviews served two purposes. First, the interviews were used to identify the concourse for the following Q methodological study. By asking youth in foster care directly and indirectly about their needs while in foster care, all relevant information about this subject was collected (Cross, 2005; Ellingsen et al., 2010). The youth interviews were also supplemented with interviews among care workers, but the views of the youth were central in selecting the statement cards. Together with participants, the final selection of statements for the Q sort was made. Secondly, the episodic interviews were conducted to gain an in-depth understanding of some specific needs related to the traumatic background of children in family foster care. Where the results of a Q methodological study provide an overview of different perspectives of youth regarding the overall configuration of their psychosocial needs (Corr, 2001; Watts & Stenner, 2005), the episodic interviews provide insight into how specific aspects of these needs are experienced in every-day life (Flick, 2014). The interviews are retrospective, therefore participants had time to reflect on their experiences, on the meaning they attach to their experiences, and on how they changed their perception of these experiences over time. Although ‘life as told’ in a research setting differs from ‘life as experienced’ by the participants (Bruner, 2004), the interviews provide an insight into the realities of participants and what experiences were most meaningful to them (Flick, 2014). It is important that we understand the meanings children in foster care attach to their experiences, because as the Thomas Theorem states, when a person defines a situation as real, this situation is real in its consequences (Flick, 2014). By using thematic analysis, recurring themes across the interviews can be found that illustrate how youth make meaning of specific needs throughout the foster care placement related to traumatic experiences prior to care (Braun & Clarke, 2006).

Objectives

Children in family foster care have the right to grow up in a safe and supportive environment that contributes to their well-being. In order to help them grow and cope with their traumatic experiences, it is important that their psychosocial needs are met in a way that aligns with their individual circumstances. This thesis aims to describe what these needs are according to adolescents and young care leavers, as experts of their own stories. Because children in care are a very diverse group, we used two participatory qualitative approaches aimed, firstly, at identifying groups of youth with similar configurations of needs (Q methodology), and secondly at understanding in detail how specific needs related to traumatic events are experienced in every-day life (episodic interviews). These approaches are chosen to

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understand the lived experiences of children in family foster care while respecting their different experiences, personalities and situations, which provide results that can easily be disseminated to practice. Furthermore, this thesis aims to explore what the impact is of the traumatic and adverse backgrounds of youth on their needs, with a specific focus on sexual abuse experiences prior to care. Children in foster care with a history of sexual abuse may have specific needs, which are possibly not as urgent for non-sexually abused children, for example related to giving and receiving affection (Pollock & Farmer, 2005). The voices of youth are central in achieving these aims, which leads to the following main research question: ‘What are the psychosocial needs of youth (formerly) in foster care and what is the impact of their traumatic background on these needs?’

Thesis outline

Based on the research question and aims stated above, the thesis is organized in the following chapters.

Chapter 2 presents the results of a systematic literature review on the needs of children in

family foster care based on Maslow’s need hierarchy. The review 1) systematically describes the needs of children in foster care and the ways to satisfy them and 2) examines how the literature conceptualizes those needs. This coherent overview of the needs of children in foster care can guide future research on their needs and assist practitioners when trying to meet these needs.

Chapter 3 describes the psychosocial needs youth in family foster care experience and

how they prioritize these needs. Furthermore, the differences between youth with and without a history of sexual abuse are explored. Through Q methodological analysis, different viewpoints held by these two groups of youth are explored and subsequently compared, which provides insight into differential approaches to satisfying the needs of youth in foster care.

Chapter 4 assesses whether foster parents and care workers recognize the needs of

youth. Since they play an important role in satisfying the needs of youth and often advocate for youth and their needs in decision-making, it is important to know how closely they understand the viewpoints of youth and what differences exist. We focus on the needs of youth with a history of sexual abuse, because this experience is often not disclosed and difficult to discuss.

Chapter 5 presents the results of a qualitative inquiry into what youth experience as

the impact of traumatic events prior to living in foster care. Youth in foster care have been disproportionately exposed to traumatic events, but this is often researched through a clinical lens. Youth’s views on the impact of these experiences can inform both their direct environment and the larger system around them about how to meet the needs stemming from these experiences.

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Chapter 6 focuses on if and when youth want to talk about their experiences prior to

care and about being in care. Sharing these stories can benefit youth, because it enables them to make meaning of their experiences and to connect with their conversation partner. Understanding when and to whom youth want to share these stories can assist the people around them to be sensitive to the conditions under which they want to talk about their experiences.

Chapter 7 provides a general discussion in which the results of the preceding chapters

are critically examined and the methods of this thesis are reflected upon. In addition, it addresses avenues for future research and details the implications for practitioners in the field of family foster care.

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CHAPTER 2.

The needs of children in foster care and

how to satisfy them:

A systematic review of the literature

This chapter is based on:

Steenbakkers, A., Van Der Steen, S., & Grietens, H. (2018). The needs of foster children and how to satisfy them: A systematic review of the literature. Clinical Child and Family Psychology

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Abstract

Family foster care deeply influences the needs of children and how these are satisfied. To increase our knowledge of the needs of children in foster care and how these are conceptualized, this paper presents a systematic literature review. Sixty-four empirical articles from six databases were reviewed and categorized (inter-rater agreement K = .78) into four categories: medical, belongingness, psychological, and self-actualization needs. The results give a complete overview of needs that are specific to children in foster care, and what can be implemented to satisfy these needs. This study shows psychological needs are studied more often compared to the other categories, which specifically relates to much attention for mental health problems. Furthermore, most articles focus on how to satisfy the needs of children in foster care, and provide no definition or concrete conceptualization of needs. Strikingly, many articles focus on children’s problems instead of their needs, and some even use these terms interchangeably. This review illustrates that future research should employ a proper conceptualization of needs, which could also initiate a shift in thinking about needs instead of problems.

Keywords

Foster care ∙ Foster families ∙ Development ∙ Needs ∙ Need satisfaction ∙ Systematic literature review

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2 Introduction

Worldwide, estimates are that 143 million children are separated from their birth families, and for most of these children (about 95%), family foster care is where they find a caring and nurturing home (Courtney, Dolev, & Gilligan, 2009; McCall, 2011). Many children in foster care have a history of maltreatment and are struggling with behavioral problems and complex trauma (Greeson et al., 2011), which often cause placement disruptions (Eggertsen, 2008). In addition, many of them experience out-of-home placement to be a great loss and feel lonely at the start of a foster family placement (Herrick & Piccus, 2005; Schofield & Beek, 2005). Foster parents are vital in providing a secure base for these children (Schofield & Beek, 2005), enabling them to make a positive developmental turn and deal with their traumas (e.g., McLaughlin, Zeanah, Fox, & Nelson, 2012; Nelson et al., 2007). Meeting the needs of children in foster care provides them with a more stable and secure placement in which they can thrive (Berrick & Skivenes, 2012). The needs of these children are therefore a recurrent theme in the literature.

Basic human needs

The literature defines needs as necessities for a healthy development. Satisfying needs is a continuous process; successful need satisfaction leads to (further) growth and well-being, while failing to meet needs can inhibit this (Deci & Ryan, 1985; Maslow, 1943). Need satisfaction is formed by environmental factors, or changes in individual or interpersonal actions, thoughts or feelings (Deci & Ryan, 2012; Maslow, 1943).

Maslow (1943) was among the first to develop a theory encompassing both the biological and psychological needs of humans. According to this theory, people have physiological needs (e.g., the need for water and food), a need for safety, a need for love and belongingness, a need for self-esteem and a need for self-actualization. For any need, frustration results in increased desire, while satisfaction results in decreased desire, with the first needs mentioned being most desired when frustrated. Other need theories focus more on either survival needs, such as the terror management theory (Greenberg, Solomon, & Pyszczynski, 1997), or on psychological and self-actualization needs, such as the self-determination theory (Deci & Ryan, 1985) and the core social motives theory (Fiske, 2003).

This article focuses on how needs are presented in the foster care literature. Maslow’s need hierarchy is used as theoretical framework, because of the broad range of needs it encompasses. That said, researchers have criticized this theory for emphasizing nature more than nurture, and for the inconclusive evidence of the hierarchical structure of needs (Neher, 1991). Nonetheless, recent studies have successfully used Maslow’s hierarchy as a framework to examine children’s needs, such as for children in Kindergarten (Medcalf,

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Hoffman, & Boatwright, 2013), children living in poverty (Noltemeyer, Bush, Patton, & Bergen, 2012), and children with disabilities (Lygnegård, Donohue, Bornman, Granlund, & Huus, 2013). This not only indicates the applicability of this theory to the needs of children today, but also for children growing up in specific and vulnerable conditions.

The needs of children in foster care

Children’s environment plays a significant role in defining the specific needs and how they can be satisfied (Deci & Ryan, 2012; Harper & Stone, 2003). Adverse experiences prior to care, the out-of-home placement and living in foster care cause children to develop specific needs (Berrick & Skivenes, 2012). For example, children in foster care are at risk to develop medical, behavioral and emotional difficulties (Oswald et al., 2010; Smith, Johnson, Pears, Fisher, & DeGarmo, 2007), and their cognitive abilities and school achievements often lag behind (Jacobsen, Moe, Ivarsson, Wentzel-Larsen, & Smith, 2013; Vacca, 2008). In addition, children in foster care live apart from their biological parents. This disturbs the development of attachment and sense of belonging to their biological family, while they also have to form new relationships with their foster carers (Schofield & Beek, 2005). Moreover, traumas experienced in their childhood can cause post-traumatic stress symptoms and internalizing behavioral problems (Greeson et al., 2011). Despite these circumstances, children in foster care are able to make a positive developmental turn when growing up in a secure and nurturing environment (McLaughlin et al., 2012; Schofield & Beek, 2005). It is therefore important to satisfy children’s needs in an age-appropriate way, with their personal histories kept in mind (Berrick & Skivenes, 2012). To our knowledge, however, there is no overview of the broad range of needs and how these can be satisfied specifically pertaining to children in foster care.

This article therefore focuses on two things: 1) systematically review the needs of children in care and the ways to satisfy them and 2) examine how the literature conceptualizes those needs. The aim is to create a coherent overview of the needs of children in foster care, useful for both researchers and practitioners. This overview can guide future research on the needs of children in foster care, and assist practitioners when trying to meet the needs of these children.

Method

A computer-based systematic literature search was conducted following the PRISMA statement (Moher, Liberati, Tetzlaff, & Altman, 2009). The search was conducted on 14-06-2017, using the databases ERIC, PsychInfo, Medline, PUBmed, Web of Science and Elsevier Science Direct. To identify articles related to children in foster care, the following search terms were included: (“foster child*” OR “child* in care” OR “child* in foster care” OR “foster

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care child*” OR “child* in substitute care” OR “substitute care child*” OR “child* in out-of-home care” OR “out-of-out-of-home care child*”), wherein ‘child’ was also substituted by ‘youth’, ‘teen’, ‘adolescent’, ‘boy’ and ‘girl’. Moreover, search terms were added that pertained to the needs of children in foster care: (need* OR demand* OR requir*).

The titles and abstracts of 2471 articles were read and a selection of relevant articles was made on the basis of three criteria. First, although there were no constraints on publication date, only peer-reviewed empirical articles were included that were conducted in western countries. The empirical study should focus on cases of children, thus excluding policy analyses or studies inquiring other people (such as professionals and other stakeholders) about the needs of children in foster care as a group. Second, the main target group had to be children living in family foster care between the ages of 6 and 18. Younger children were excluded because self-actualization needs are less prominent for this age category. Articles covering a wide range of ages that also incorporated our target group of age 6-18 were included, but needs specific for younger children will not be described. We chose to focus on family foster care because this reduced the amount of variation between countries and welfare systems. Moreover, differences were expected in belongingness needs between children growing up in a family environment compared to group or residential facilities. Articles that compared children in family foster care to other groups of children were included, as well as studies on children in out-of-home care of which at least 70% of the target group consisted of children in family foster care. Third, the article had to focus on the needs of these children as directly stated in the title, abstract or keywords. This excluded articles that might pertain to the needs according to Maslow’s hierarchy, but do not name it as such. In addition, articles regarding the needs of care leavers and adolescent mothers in care were excluded. After this selection and deletion of duplicates, a total of 218 articles remained.

The full texts of the remaining articles were read by three researchers who again decided whether an article met the inclusion criteria. Most articles that were excluded in this phase did not describe the needs of children, but only mentioned the terms ‘needs’ once or twice without further explanation. Other reasons articles were excluded were because they were conducted in non-western countries, did not adequately describe the sample of participants, were not empirical examinations of child cases, or focused on the needs of foster parents. This final selection process resulted in 64 articles for this review.

While reading the articles, the researchers specifically searched for the term needs, requirements and demands in order to find the relevant information about these concepts. This information was used to summarize and discuss the reviewed articles in the results section. Additionally, the authors extracted from each article the definition of needs, target group (age, N, care setting), country of the study, and the research methods employed to identify needs.

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In order to cluster the needs, a categorization system was formulated based on the five needs of Maslow: physiological, safety, belongingness, self-esteem and self-actualization needs. When going through the articles however, these categories were not sensitive enough to incorporate all articles and make a clear enough distinction between the various topics. Medical needs were often encountered within the articles, which pertains to both physiological needs (i.e., for food and water) and physical safety needs. No other needs regarding physiology were identified, thus this category was named Medical needs. The relational aspects of the safety needs were included in the belongingness category, which covered all aspects of relationships of children in foster care. The self-esteem needs, the need for prestige and accomplishment, were combined with other individual psychological needs, such as mental health, autonomy and coping. Therefore, this category was named Psychological needs. Lastly, articles about education, leisure, and employment were categorized within Self-actualization needs. See Table 2.1 for a description of each need category.

Two authors independently coded the final selection of articles according to these categories. An article had to be placed in at least one category, but could have as many as four category labels. The inter-rater agreement was calculated on the selected articles (90%, p < .0001, K = .78), and could be considered as good (Altman, 1991), indicating similar coding and straightforward categories. Coding differences were subsequently discussed between the two researchers and resolved. As can be seen in Table 2.1, there was an uneven distribution of articles across the four need categories, with psychological needs being the most frequently mentioned. In the result section, the needs and how these can be satisfied will be described for each category, as well as common challenges mentioned in the literature. In line with human need theories, needs were considered as necessities for a healthy development, while satisfying needs can be accomplished by environmental factors and individual or interpersonal actions, thoughts or feelings that lead to a change in the level of need satisfaction (Deci & Ryan, 1985; Maslow, 1943). Furthermore, a section regarding challenges was added because many of the articles represented problems and other challenges as (an indication of) the needs of children in foster care.

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Table 2.1. Overview of the Four Needs Categories Category N Description

Medical needs 21 Needs regarding physical health, physical development, and treatment and identification of medical conditions.

Belongingness needs 17 Needs regarding relationships with others, such as (foster) parents and peers, and related constructs, such as attachment and permanency.

Psychological needs 43 Needs about (individual) psychological phenomena such as self-esteem, mental health, autonomy and coping.

Self-actualization needs 14 Needs about learning, education, leisure and employment.

Note. Multiple categories per article are possible. N_total = 64

Results

As Table 2.2 depicts, the majority of the articles were written between 2000 and 2017 and conducted in Anglo-American countries. Other western countries are not or barely represented in the retrieved articles. Regarding the age of the children, 45% of the articles only included children within the age categories of 6-18, while 55% of the articles included a broad range of ages including younger children. To identify the needs of children, various methods such as standardized questionnaires (e.g., Child Behavior Checklist), case file analyses, and interviews with people involved in foster care were employed. Most articles did not conceptualize or elaborate on the term needs (84%), but some provided an operational definition (e.g., scores on a questionnaire), defined children with high needs (those with physical handicaps or medical conditions), or provided a definition of specific needs (secure attachment).

Medical needs

The medical needs of children in foster care are described in 21 articles and are commonly researched in combination with psychological needs (66%).

Needs. Although many articles indicate that children in foster care have more complex

medical needs compared to their peers, the articles neglect to describe actual needs, but instead focus on medical problems and diseases. What can be concluded from the articles, however, is that children need to be physically and developmentally healthy, or at least as healthy as their specific medical conditions allow them to be. One study comments on this aspect, indicating that health screenings can only be effective when promoting health rather than screening for diseases (Hill & Watkins, 2003).

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Table 2.2. General Characteristics of the Articles in this Review

Year of publication < 1990 1

1990-1999 6

2000-2009 21

2010-2017 36

Country of conducted research United States of America 39

Australia 8 United Kingdom 5 Canada 6 The Netherlands 3 Sweden 1 Ireland 1 Multiple (meta-analysis) 1

Age range 6-12 years old 3

12-18 years old 12

6-18 years old 14

0-12 years old 5

0-18 years old 30

Method of need identification a _{Standardized questionnaire(s)} ₂₃

Interview/survey children 20 Interview/survey professionals 11

Case files 18

Interview/survey foster parents 9

Child assessment 5

Open-ended questionnaire(s) 5

Other 2

Definition of needs No definition 52

Operational definition 10

Broad definition of high need children 1

Specific need defined 1

Note. a_{Multiple categories per article are possible. N}

total = 64

Satisfying needs. When medical problems are identified, personal treatment plans

should be written, and treatment and other services should be implemented in order to improve the health outcomes of children in foster care (Rodrigues, 2004; Rubin, Alessandrini, Feudtner, Localio, & Hadley, 2004). What these services are, differs per health problem, but a multidisciplinary team should preferably determine the treatment plan (Kaltner & Rissel, 2011). Adolescents specifically need tailored interventions to stimulate safe sex and to prevent early pregnancy and STD’s (Becker & Barth, 2000). A study among 442 foster parents showed that 83% of the foster parents are convinced that the medical needs of their child are met (Hayes, Geiger, & Lietz, 2015). Foster parents caring for children with complex

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medical conditions indicate that training helped them provide the necessary care for these children (Lauver, 2008).

Challenges. Many articles report on the increased medical health problems of children

in foster care; depicting medical problems as medical needs. Studies differ with regard to the reported prevalence of medical problems, ranging from one third of the children in foster care (Ringeisen, Casanueva, Urato, & Cross, 2008; Sullivan & van Zyl, 2008), to about half of them (Steele & Buchi, 2008; Takayama, Wolfe, & Coulter, 1998), and even up to 90% (Chernoff, Combs-Orme, Risley-Curtiss, & Heisler, 1994; Hochstadt, Jaudes, Zimo, & Schachter, 1987; Nathanson & Tzioumi, 2007). Based on over 30.000 case files, about 6% of children in foster care have so-called complex needs, which means having co-occurring physical health problems, emotional problems and the need for specialized services (Yampolskaya, Sharrock, Armstrong, Strozier, & Swanke, 2014). The most common health problems mentioned in the literature are incomplete immunization (Hill & Watkins, 2003; Kaltner & Rissel, 2011; Kling, Vinnerljung, & Hjern, 2016; Nathanson & Tzioumi, 2007; Raman & Sahu, 2014; Rodrigues, 2004), vision problems (Chernoff et al., 1994; Nathanson & Tzioumi, 2007; Steele & Buchi, 2008; Takayama et al., 1998), and respiratory problems (Nathanson & Tzioumi, 2007; Ringeisen et al., 2008; Rodrigues, 2004; Takayama et al., 1998). Other medical conditions that are also often encountered in the foster care population are obesity, dental problems, skin conditions, STD’s, infections, and allergies. A complete list is beyond the scope of this article, so we refer the reader to the above articles and these additional manuscripts (Arora, Kaltner, & Williams, 2014; Becker & Barth, 2000; Lauver, 2008; Ogg et al., 2015; Rubin et al., 2004). While many articles report children in foster care have higher rates of medical health problems (e.g., Ringeisen et al., 2008), a study by Raman and Sahu (2014) did not find any differences between children in foster care and children at-risk living in with their parents. The identified at-risk factors for developing medical problems are being male, being older, having a longer stay in foster care and having had multiple placements (Ringeisen et al., 2008; Rubin et al., 2004; Sullivan & van Zyl, 2008).

Children should be assessed and screened for medical conditions by a multidisciplinary team of health professionals (Kaltner & Rissel, 2011; Ogg et al., 2015; Rodrigues, 2004), which should be administered as soon as a child comes into foster care (Chernoff et al., 1994; Steele & Buchi, 2008). Nevertheless, not all children receive a medical examination (Rodrigues, 2004). Nathanson, Lee and Tzioumi (2009) argue that screening is not only important when entering care, but also throughout the foster care period. Lastly, many studies have identified a major gap between the medical issues of children in foster care and the services provided (Feigelman et al., 1995; Hill & Watkins, 2003; Kaltner & Rissel, 2011).

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R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15 R16 R17 R18 R19 R20 R21 R22 R23 R24 R25 R26 R27 R28 R29 R30 R31 R32 R33 R34 R35 R36 R37 R38 Belongingness needs

Seventeen articles on belongingness needs of children in foster care were found. While most articles focus on (foster) family relationships, other adults and peers are also mentioned.

Needs. Children in foster care generally need continuity of the relationships with their

birth family members (Kufeldt, Armstrong, & Dorosh, 1995; Mason, 2008). Especially sibling contact can be a point of continuity in unstable times, as they have lived in the same circumstances and had similar experiences (Kothari et al., 2014; Waid & Wojciak, 2017). Establishing caring and supportive relationships with the foster family is considered a crucial need of children (Bell, Romano, & Flynn, 2015; Kufeldt et al., 1995; Mason, 2008; Quest, Fullerton, Geenen, & Powers, 2012). Preferably, these relationships are characterized by secure attachments, a sense of permanency, mutual trust and emotional intimacy (Ashley & Brown, 2015; Mason, 2008; Steenbakkers, van der Steen, & Grietens, 2016). Schofield and Beek (2009; 2005) illustrate how infant attachment concepts also apply to children and adolescents in family foster care, because they need their foster parents to provide a secure base. Besides (foster) family members, other adults, such as a neighbor or family friend, and professionals can play an important role in the social networks of children in foster care. These people can provide emotional and practical support, and a sense of stability and continuity of relationships (Bell et al., 2015; Clausen, Ruff, Von Wiederhold, & Heineman, 2012). Lastly, friends and positive peer interactions are an important need of children in care (Mason, 2008).

Satisfying needs. In order to establish loving relationships with foster parents, children

should be provided with a stable, affectionate and safe home environment (Fernandez, 2008; Kufeldt et al., 1995). Foster parents can create a secure base for children in their care by being available, helping them manage their behavior and feelings, building their self-esteem, helping them feel effective, and helping them to belong in the foster family (Schofield & Beek, 2009; 2005). A high perceived quality of caregiver relationship can lower the risk of depression for children in foster care (Guibord, Bell, Romano, & Rouillard, 2011). Children indicate that at the start of a placement foster parents can help them by showing an understanding of the difficulties of coming into care, and help them to become familiar with their new home, routines and responsibilities (Mitchell, Kuczynski, Tubbs, & Ross, 2010). Conversations with foster parents about their past, when characterized by trust and interest, can contribute to youth finding emotional support from their foster parents (Steenbakkers et al., 2016). A culturally sensitive facilitator to meet the attachment needs of African American youth is by assisting them with their hair care (e.g., braiding), since this provides the opportunity for healthy touching and nurturing (Ashley & Brown, 2015).

Contact with birth family members can repair disrupted ties, and children with more contact tend to view their parents more positively (Kufeldt et al., 1995). To facilitate sibling contact, specific interventions have been established that promote sibling contact

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and support (Kothari et al., 2014; Waid & Wojciak, 2017). Lastly, children in foster care sometimes require help to understand and manage the complex family relationships with their birth and foster family (Kufeldt et al., 1995; Quest et al., 2012).

Supportive relationships with other adults should be characterized by a sense of safety, positive regard and commitment (Clausen et al., 2012; Fernandez, 2008; Mason, 2008; Quest et al., 2012). Moreover, these relationships with adults can help youth to learn social skills (Clausen et al., 2012), as well as give them tools to take on future obstacles (Guibord et al., 2011).

Challenges. Children in foster care can have difficulties with establishing and maintaining

social relationships. They show less prosocial behavior (Fernandez, 2008), and a recent meta-analysis shows that age-appropriate social functioning does not improve during foster family placement (Goemans, van Geel, & Vedder, 2015). Compared to other types of out-of-home care, children in family foster care require specific attention for attachment related difficulties (Leloux-Opmeer, Kuiper, Swaab, & Scholte, 2017). Contact with their birth family can be problematic due to the problems of their birth parents (Kufeldt et al., 1995). Lastly, children are at risk to experience abuse while in foster care by their foster parents, birth parents or other children. Steps should therefore be taken to protect children, especially those who already experienced abuse prior to care (Hobbs, Hobbs, & Wynne, 1999).

Psychological needs

In total, 43 articles explicitly focus on the psychological needs of children in foster care, which is about two-thirds of the articles selected for this review.

Needs. The well-being and everyday functioning of children in care depends partly on

them developing self-esteem (Coholic, Lougheed, & Cadell, 2009; Fernandez, 2008). LGBTQ youth in foster care specifically need to develop a positive self-identity about their sexual orientation (Gallegos et al., 2011). Children in foster care were often exposed to multiple traumas at a young age, and therefore they need to learn how to cope with past experiences and construct a coherent life story (Coholic et al., 2009; Nathanson & Tzioumi, 2007; Steenbakkers et al., 2016). Similar to the medical needs category, articles about mental health needs focus on mental illness and problems, with the exception of one article (Hill & Watkins, 2003).

Satisfying needs. Attentive and sensitive parenting is important for satisfying the needs

for self-esteem, coping skills and self-regulation skills (Fernandez, 2008; Gallegos et al., 2011; Mitchell et al., 2010; Schofield & Beek, 2009; Schofield & Beek, 2005; Stoner, Leon, & Fuller, 2015). Specifically, children in foster care need the people around them to understand their personal history; so that their environment can be sensitive to the signals they convey (Steenbakkers et al., 2016). This is important because a better adjustment to trauma has been indicated as a good predictor for reduction of depression (Stoner et al., 2015). In

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order to satisfy the need for autonomy and individuality, children should be included in the decisions about their care (Mason, 2008).

When mental health problems are present, children should preferably receive individualized treatment and care in order to meet their mental health needs (Cantos & Gries, 2010; Ringeisen et al., 2008; Rodrigues, 2004; Shin, 2005; Steele & Buchi, 2008; Sullivan & van Zyl, 2008; Takayama et al., 1998). Studies show that mental health service use by children in foster care ranges from 25% to 53% (Bellamy, Gopalan, & Traube, 2010; Petrenko et al., 2011; Rodrigues, 2004). When treatment is provided, it is important to differentiate among children based on their characteristics and maltreatment history (Bell et al., 2015; Reifsteck, 2005). In addition, the required facilities should be close to the foster home and continuously accessible (Arora et al., 2014). Regarding the type of treatment, authors have argued that mental health needs are often treated with multiple psychotropic medications, while the child might be better off with therapeutic interventions (Coholic et al., 2009; McMillen et al., 2004), wherein the relationship with the therapist is key (Clausen et al., 2012). Moreover, adolescents are likely to receive the most invasive and stigmatizing mental health services such as inpatient and residential programs, while not always receiving community based services before this (McMillen et al., 2004). Some authors suggest to not only treat the child as client, but also the family and community around the child (Love, Koob, & Hill, 2008; Yampolskaya et al., 2014). In addition to providing help, youth themselves also seek out help for their mental health issues, which is affected by their expectations of the care system and previous help-seeking experiences (Johnson & Menna, 2017).

Challenges. The articles about mental health needs additionally provide information

about the prevalence and types of mental health problems, often named in articles as mental health needs. Although the operationalization differs between studies, prevalence of mental health problems among children in foster care seems to fall between 44% and 66% (Arora et al., 2014; Bellamy et al., 2010; Maaskant, van Rooij, & Hermanns, 2014; McNicholas et al., 2011; Scozzaro & Janikowski, 2014). While this prevalence is high, children in family foster care have fewer mental health issues compared to children living in more restrictive out-of-home placements (Lardner, 2015; Leloux-Opmeer et al., 2017; McNicholas et al., 2011). Around 6% of children in foster care seem to experience a complex combination of medical and mental health problems (Yampolskaya et al., 2014). The mental health issues mentioned are related to dealing with separation and loss (Chernoff et al., 1994; Nathanson & Tzioumi, 2007), exposure to drugs and alcohol (Chernoff et al., 1994), emotion or behavior regulation (Arora et al., 2014; Bell et al., 2015; Bellamy et al., 2010; Fernandez, 2008; Goemans et al., 2015; Guibord et al., 2011; McMillen et al., 2004; McNicholas et al., 2011; Ogg et al., 2015; Ringeisen et al., 2008; Rodrigues, 2004; Steele & Buchi, 2008; Stoner et al., 2015; Sullivan & van Zyl, 2008; Yampolskaya et al., 2014), sexual abuse or inappropriate sexual behavior (Chernoff et al., 1994; McMillen et al., 2004), self-harm and violent behavior (Chernoff et

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al., 1994; McNicholas et al., 2011), and substance abuse (Gabrielli, Jackson, & Brown, 2016; Guibord et al., 2011). Mental health problems are positively correlated with the child’s current age, the age at the time of placement, maltreatment history and the number of placements (Cantos, Gries, & Slis, 1996; Gabrielli et al., 2016; Maaskant et al., 2014; Shin, 2005; Steele & Buchi, 2008).

Mental health problems of children in foster care should be regularly screened and assessed in order to provide timely interventions, preferably by multiple informants (Cantos & Gries, 2010; Nathanson et al., 2009). Although many children receive mental health services, some authors warn about a gap between children’s mental health issues and the referral rate (Fontanella, Gupta, Hiance-Steelesmith, & Valentine, 2015; Hill & Watkins, 2003; Kaltner & Rissel, 2011; Ogg et al., 2015; Petrenko et al., 2011; Shin, 2005). Only 23% of foster parents are assured that the mental health needs of their child are met (Hayes et al., 2015). A meta-analysis by Goemans and colleagues (2015) shows that internalizing and externalizing behavioral problems do not improve during placement in a foster family, questioning the effectiveness of treatment and care children receive. That said, a recent study reports adequate service delivery to 128 children in foster care with mental health problems in the United States (Scozzaro & Janikowski, 2014).

Two additional issues are mentioned regarding the psychological needs of children in foster care. First, the multiple traumas children were exposed to during their youth can have a negative impact on their psychological development (Leloux-Opmeer et al., 2017). Secondly, overprotection and forced support can have a disempowering effect on children, and does not meet their need for autonomy (Mason, 2008).

Self-actualization

The literature on children’s self-actualization needs is very recent, with 12 out of 14 articles (86%) written in the last decade.

Needs. While all articles in this need category focus on the educational outcomes of

children in foster care, most study how this can be accomplished (need satisfaction) and what hinders children to achieve well in school (challenges). The majority of the articles focus on education, except one article that showed that participation in extracurricular activities lowers the risk of substance abuse and depression among children in foster care (Guibord et al., 2011).

Satisfying needs. Stability and connection to the same school can greatly assist children

with completing their education (Piescher et al., 2014). Foster parents should support children with their school career, and provide stimulation and input for their cognitive development (Fernandez, 2008; Mendis, Gardner, & Lehmann, 2015; Zetlin, Weinberg, & Shea, 2010). In addition to foster parents, other significant adults can stimulate youth to go to school and help with decisions about school, work and college (Hudson, 2013; Mendis et