ARTICLE

 

Transition from care to adulthood: a systematc review of intervention programs

 

 

Luciana Cassarino-Perez^I; Vitória Ermel Córdova^II; Carme Montserrat^III; Jorge Castellà SarrieraIV

^IOrcid.org/0000-0003-4075-2832. Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
^IIOrcid.org/0000-0003-1629-339X. Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
^IIIOrcid.org/0000-0001-5062-1903. Universitat de Girona, Catalunha, Espanha
^IVOrcid.org/0000-0001-8297-4957. Universitat de Girona, Catalunha, Espanha

Mailing address

 

 

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ABSTRACT

The objective of this study was to map the scientific production of the last decade on intervention programs to favor the emancipation of youth leaving the protection system after turning 18 years old. Twenty articles were selected through a systematic review of literature. These articles were indexed in the following databases: Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), PubMed, PsycINFO, Pro Quest Psychology Journals and Web of Science. The majority of the articles were written in North America, using either longitudinal or transversal quantitative design. The studies evaluated the interventions using three types of evaluation design: process (15), effect (15) and impact (2). The programs differed in type (housing, short-term and or long-term); content (independent life skills, education and work); and method (different degrees of participation). Besides exploring the strengths and weaknesses of each intervention program, this article discusses the relevance of the evaluation processes to scientific advance in this field. As a conclusion, it is argued that to favor the transition process the intervention should have the following characteristics: in long-term basis; combine independent life skills with emotional, social and community support; to consider participants individual and cultural differences as well as their capability of making decisions.

Keywords: Residential care, foster care, adolescence, intervention.

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The emancipation of former foster youth and individuals with a history of group home placement has received increasing attention in the scientific literature, and has been the subject of a considerable number of publications in the past ten years. Though most articles on the subject are in international journals rather than Brazilian publications, there has been significant national interest in this area of study, as evidenced by several recent articles (Martinez & Soares-Silva, 2008; Rosa, Nascimento, Matos, & Santos, 2012), theses and dissertations (Costa, 2012; Medrado, 2010; Moreira, 2013; Romanelli, 2013).

Though foster families are mentioned in Brazilian law, foster care accounts for only 5% of placements among children and adolescents in state custody, with most individuals housed in institutional shelters or group homes (National Council of the Public Ministry [CNMP], 2013). As they approach maturity, adolescents who live in these institutions are required to take responsibility for their own lives, whether or not they are ready for the transition. A recent survey performed by the CNMP found that 1,141 adolescents aged out of foster care between March 2012 and March 2013. This figure is highest in south and southeastern Brazil, with the majority of cases occurring in the states of São Paulo and Rio Grande do Sul.

According to the literature, individuals who age out of foster care are at a disadvantage relative to youth raised by their families (Hudson & Nandy, 2012; Mersky & Janczewski, 2013). Institutional care is associated with several developmental risk factors, such as neglect, abandonment, maltreatment, sexual abuse and poverty (Siqueira & Dell'Aglio, 2006). In addition to these sources of risk, foster youth must also face a sudden transition to independent living as they age out of government or state care (Federación de Entidades con Proyectos y Pisos Asistidos [FEPA], 2014; Montserrat, Casas, & Sisteró, 2015).

These circumstances increase the vulnerability of former foster youth, placing them at higher risk of unemployment (Stewart, Kum, Barth, & Duncan, 2014), illicit substance use (Hudson & Nandy, 2012), health problems (Rahamim & Mendes, 2016), early childbearing (Oshima, Narendorf, & McMillen, 2013), conflict with the law (Mersky & Janczewski, 2013) and homelessness (Dworsky, Napolitano, & Courtney, 2013). However, studies have also investigated resilience in these individuals, discussing their ability to overcome the risk factors to which they are exposed. Studies conducted in Spain and the United States have identified varying levels of adaptation to the transition from foster care to adulthood, classifying former foster youth from least adapted to most resilient (del Valle, Bravo, Alvarez, & Fernanz, 2008; Yates & Grey, 2012). These studies have found that many adolescents overcome adversity, but note that resilience may be limited to only some domains of functioning, highlighting the need for more global interventions (cognitive, social, emotional, physical, etc.) in this population.

The emancipation of foster alumni is a unique and personal journey, influenced by the individual's ties to their birth family and shelter institution, as well as their personality traits. The influence of context on emancipation underscores the need for specific public policies and programs to facilitate this dynamic and complex process when it occurs outside one's birth family. When action plans that consider the individual characteristics of youth are put in place, the transition process is likely to be successful (FEPA, 2014).

The past few decades have seen growing efforts from first, second and third sector institutions and organizations in several countries to facilitate the transition of foster youth into adulthood both before and after they leave the protection system. These interventions include the Foster Care Independence Act (P.L. 106-169), in the United States; the Área de Apoyo a los Jóvenes Tutelados y Ex-Tutelados (ASJTET), in Catalunya, Spain;the Grupo Nós at the Fazendo História Institute, in Brazil; the Punt de Referência program, in Spain; the Strive program, set up by the Young Women's Christian Association (YWCA) in Canada; and the Corporate Parenting program, in the United Kingdom. The aim of these initiatives is to facilitate the transition from foster care to adulthood. As such, they address issues such as living arrangements, daily life activities, education and preparation for work, interpersonal relationships, community participation and life projects.

Interventions consist of activities planned to effect a specific change and solve a particular problem (European Union, 2014). Psychosocial interventions targeting issues such as the transition from foster care to adult life are especially complex, as they must extend to several domains (e.g., personal, relational, community) in order to achieve the desired outcomes (Nelson & Prilleltensky, 2005). Therefore, psychosocial interventions must be carefully planned and precisely executed according to specific guidelines. The development of an intervention program is usually conducted according to the following steps: needs and context assessment; program design; viability assessment; implementation; dissemination and evaluation of the intervention (Blanco & Valera, 2007; European Union, 2014).

Both evaluation and dissemination aim to investigate the extent to which the program contributed to the desired change, but also to share the results with the community and provide research returns. The present systematic review focused on studies which sought to address the actual needs of a particular group of people. The overall goal was to describe the scientific literature of the past ten years pertaining to interventions aimed at facilitating the emancipation of aged-out foster youth. The main findings of these studies were summarized, to provide the basis for future research, interventions and public policies directed at this population.

 

Method

This systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, which separates the process into four stages: Identification, Selection, Eligibility and Inclusion (Liberati et al., 2009). The identification stage took place between September and December 2016, at which point an electronic search was conducted in the following databases: Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), PubMed, PsycINFO, ProQuest Psychology Journals and Web of Science. The keywords used in the search consisted of the following: "Foster care"; "foster youth"; "young adult"; "young people"; "transition from"; "aging out"; "leaving"; "independent living" and "autonomy". Most of these terms are not indexed as Health Science Descriptors (Descritores em Ciências da Saúde; DeCS). As such, the identification of the most adequate terms for the search involved a review of the keywords used in existing articles on the topic, and consultation with other researchers in the area. Keyword combinations were generated using an "a + b + c" format, where: (a) context (foster care; residential care; out of home care; care system); (b) situation (transition from; aging out; leaving; independent living; autonomy); and (c) sample (foster youth; young adult; young people). Each combination was used in a separate search until all possible combinations were exhausted. No filters were used in the search. Searches were also conducted using keywords in Spanish and Portuguese. In Spanish, the general term "jovenes ex-tutelados" was used, while in Portuguese, the following keywords were combined: "egressos" or "jovens", with "acolhimento institucional" or "abrigo" or "sistema de proteção". A total of 2163 articles were retrieved in the search.

The selection stage involved screening for duplicates in the findings. This procedure identified a total of 1585 unique articles, whose abstracts were then screened for the following inclusion criteria: (1) empirical studies; (2) published in the past 10 years; (3) in English, Portuguese or Spanish; (4) sample consisting of adolescents and/or young adults aged between 15 and 24 years, with a history of institutionalized care; (5) discussion and/or evaluation of programs and/or services to facilitate the transition between foster care and adult life. Abstracts were independently analyzed by two researchers and disagreements were resolved by consensus, resulting in a total of 32 articles which met all inclusion criteria.

In the eligibility stage, 12 articles were excluded after full text reading for the following reasons: (a) discussion of exploratory studies rather than intervention programs; (b) interventions pertaining to the transition to adulthood in populations other than former foster youth; (c) intervention programs with objectives other than facilitating the transition to adulthood. As such, in the inclusion stage, data extraction and qualitative analysis were performed in a final sample of 20 articles.

 

Results

Study Characteristics

A total of 14 studies were performed in the United States, while the remaining articles discussed investigations conducted in South Africa, Australia, Canada, Finland, Ghana and Ireland, as shown in Table 1.

In order to achieve their objectives, researchers adopted designs ranging from quantitative and cross sectional (2, 10, 13 and 18) or longitudinal (1, 5, 6, 8, 14 and 17), mixed-methods cross-sectional (11, 16, 19 and 20) or longitudinal (9) to qualitative cross-sectional (3, 4, 7, 12 and 15). Studies which evaluated participants multiple times included two, three or even four follow-up assessments. The length of time between the first and last assessment in longitudinal studies ranged from three months to five years.

Most articles described observational studies (65%), while the remaining investigations were either cross-sectional, case studies or experimental and quasi-experimental. The latter two cases accounted for only 15% of studies, and involved the assessment of interventions through control group comparisons.

Although all interventions were directed at a similar population, the age of participants ranged from 12 to 40 years. The wide range in participant age is attributable to the fact that studies included either (a) only adolescents preparing to leave foster care; (b) participants who were both preparing to leave and those who had already left institutional care and (c) only young adults who had already left the foster system. The distribution of publication years indicated that studies were distributed in a nearly uniform fashion until 2013, with the years of 2014 to 2016 accounting for a slightly higher percentage of publications (40% of the total sample).

Characteristics of Intervention Programs

All interventions involved activities aimed at facilitating the transition process; however, they varied in terms of their focus and comprehensiveness, as can be seen in Table 2.

Most programs addressed at least three general domains of emancipation (e.g. work; study; living situation; interpersonal relationships; daily life activities). Three studies discussed programs which focused on encouraging continued education (2, 15, and 20). Although their main goal was to improve academic performance, these programs also contributed to other aspects of the transition, such as financial, social and emotional support.

The format of the interventions also varied widely among studies, with services being offered in one of three modalities: housing; short-term interventions; and long-term interventions. The programs which offered housing involved institutions which provided both accommodation and services to prepare youth for emancipation (3, 8, 10 and 19), or supportive group housing for young adults transitioning between shelters and independent living (1, 17 and 18). The aim of supportive housing is to prevent homelessness, but also offer educational activities, health care and skills training, in addition to emotional and social support.

Short-term interventions included programs offered by institutions other than those where the adolescents lived, with predetermined content and duration. These included summer camps (9), courses and workshops (6, 13 and 14) and group meetings or psychotherapy (4 and 15). The length of short-term interventions ranged from four days to eight months. These programs tended to adopt one of two methodological approaches. Some involved knowledge transmission without the active participation of the adolescents themselves (6 and 13), while others relied on participatory methodologies and practical or experiential activities, despite having a fixed format (4, 9, 14 and 15).

Long-term interventions were also offered by institutions other than those where participants were sheltered, but included the systematic follow-up of adolescents and/or young adults, with varying frequency and intensity. This category includes some of the programs offered by universities (2 and 20), especially those which sought to maximize the opportunity for former foster youth to pursue higher education. The structure of these programs varied by institution, although all continued to monitor studies throughout their university years.

Long-term interventions with objectives reaching beyond academic performance (5, 7, 11, 12 and 16) involved the presence of mentors. The role of the mentor varied depending on the program, as did the individuals who took on this role, and the frequency and intensity of contact between the mentors and the adolescents. Nevertheless, across all programs, the main goal of mentoring was to facilitate the construction of a significant bond with an adult on whom the adolescents could count after leaving the shelter system.

Assessment and Results of Intervention Programs

The type of assessment performed by each study ranged from process evaluations, to assessments of the impact and effect of intervention programs. Articles which conducted process evaluations (2, 3, 4, 7, 8, 9, 10, 11, 12, 14, 15, 16, 18, 19 and 20) did so in order to examine the execution of intervention programs, analyzing the procedures and resources used through interviews, observations, focus groups and ad hoc questionnaires, conducted during or after the intervention. This type of assessment often relied on the opinions of program participants and coordinators regarding intervention functioning and possible improvements in future editions.

Fifteen studies also assessed the effect of interventions at the end of the program by investigating changes in the desired direction. This was achieved using interviews; document reviews (records, institutional registries, etc.); psychometric scales; ad hoc questionnaires; and focus groups.

Two studies (5 and 6) used control group comparisons to evaluate the impact of an intervention on a given set of outcomes. The studies did not identify a significant association between the type of program offered and the analyzed outcomes over time. Therefore, these were among the few articles whose overall assessments were categorized as negative. Only one other program (13) received a negative assessment, after researchers found that participation in an independent living program was not associated with session goals and contents. Two of the programs which received a negative assessment (6 and 13) adopted an expositional approach, and identified the "classroom-like" structure of the intervention as a possible reason for their unsatisfactory findings.

As can be seen in Table 3, although 85% of studies obtained positive results, many acknowledged that modifications to the programs may have resulted in even more beneficial outcomes. Nevertheless, studies were also able to identify several strengths of each intervention.

The discussion of strengths and weaknesses (areas of improvement) shared some commonalities across studies. The first pertains to the importance of integrating participants in the community and adapting the program to its sociocultural context in order to maximize the likelihood of positive results. Another shared point of concern was the need to use participative methods and align the program with the interests and needs of participants. Many authors used the term "empowerment" to highlight the fact that adolescents and adults should be encouraged to make their own decisions and develop autonomy.

Though most intervention programs focused mainly on autonomy, several studies (2, 3, 7, 10, 14, 15, 16, and 18) also discussed the importance of bonding with adult attachment figures as an important contributor to positive outcomes. Be it as a main strength of the program, or a suggestion for improvement in future editions, social support and stable relationships had a central role in the results described by authors.

The last issue to be discussed by multiple studies is the apparent paradox between the need to invest in the assessment of intervention programs, and the difficulties in actually carrying this out. According to the authors, the obstacles to assessment included scarcity of resources and personnel, difficulty accessing participants, and ethical concerns.

 

Discussion

The present findings lay the groundwork for interesting reflections, both about the programs and their contributions to future research and interventions, but also about the different types of assessment conducted and the importance of these processes for the advancement of knowledge in the area.

Most programs chose to focus their efforts on education and preparation for the job market, as well as basic independent living skills (finding a place to live, shopping, financial management, paying bills, orienting oneself and using different means of transportation, cooking, etc.). These choices may reflect the findings of a series of investigations and policies developed in the 1990s and early 2000s, with a focus on independent life skills training (Mallon, 1998; McMillen, Rideout, Fisher, & Tucker, 1997). There is no question in the literature regarding the importance of preparing former shelter youth for independent living and occupational functioning. However, as suggested by the present findings and those of other recent exploratory studies, intervention programs which seek to prepare foster youth for adulthood must also focus on additional domains.

Studies involving Brazilian adolescents and young adults transitioning to independent living have found them to be unprepared to handle daily activities (Martinez & Soares-Silva, 2008), but also identified several areas of concern such as the ambiguity of wishing for freedom while being afraid to leave the institution (Medrado, 2010); stigma in society (Costa, 2012; Medrado, 2010); and the adolescents' individual needs (Martinez & Soares-Silva, 2008). These issues were also highlighted by participants in the studies reviewed. Many of the strengths and suggestions for improvement in the intervention programs pertained to the inclusion of additional goals for the interventions to help participants overcome difficulties beyond those associated with the practical aspects of daily living. Some of the factors identified by participants as essential to ensure a healthy transition process were relationships with adult reference figures, support networks, socioemotional support and satisfactory relationships with educators or institutional caretakers.

Some of the programs analyzed, such as the Foster Care Chronicles (Nsonwu et al., 2015), Moving On and the Friendship Group (Goyette et al., 2016), had already elected to focus on social and emotional issues. The idea that the transition to adult life is influenced by a series of factors beyond individual responsibility prompted these programs to focus their interventions on the expression of emotions associated with leaving foster care and the construction of healthy relationships (Goyette et al., 2016). Programs such as The Outreach (Greeson et al., 2014) and Keyworking (Holt & Kirwan, 2012), on the other hand, turned to mentoring as a method of helping youth develop a social support network, while also providing life skills training. Mentoring programs have proved to be an effective strategy for promoting resilience and helping youth traverse the arduous journey faced by those with a history of institutional care (Greeson, 2013).

In addition to the content of the interventions, the method of delivery was found to exert a major influence on program success. Two important points must be highlighted in relation to this issue: (1) interventions must promote the active participation of adolescents and youth, (2) the format of the intervention must be adapted to the context and necessities of participants. These two concepts are interrelated: in the context of psychosocial interventions, active participation ensures the respect of individual and contextual differences among participants (Montero, 2004). Programs will be effective as long as they consider adolescents and young adults to be capable of making their own decisions, encouraging a sense of empowerment (Horochovski & Meirelles, 2007).

In this systematic review, the sample consisted exclusively of international articles, which may speak to the scarcity of literature on the subject in Brazil. Nevertheless, national public policies pertaining to institutional care appear to be in line with the present findings, supporting many of the factors identified in this review as positive contributors to autonomy. This can be illustrated by legislation such as the Statute of Children and Adolescents (Estatuto da Criança e do Adolescente - ECA; Lei n. 8.069, 1990), the National Plan for Family and Community Living (Plano Nacional de Convivência Familiar e Comunitária - PNCFC; Conselho Nacional dos Direitos da Criança e do Adolescente [CONANDA], Conselho Nacional de Assistência Social [CNAS], Secretaria Especial dos Direitos Humanos [SEDH], & Ministério do Desenvolvimento Social e Combate à Fome [MDS], 2006) and the Technical Recommendations for the Institutional Care of Children and Adolescents (CONANDA & CNAS, 2009). The main goal of the PNCFC is to change the model of care applied to children and adolescents. Its guidelines include "strengthening the autonomy of children, adolescents and young adults as they construct their life projects" (CONANDA et al., 2006, p. 71), through a participative methodology which encourages shelter youth to take a leading role in their own development. The technical recommendations for institutional care, on the other hand, introduce the concept of group homes as a form of supported living for those leaving the shelter system. These arrangements consist of intermediate steps in the construction of autonomy, by allowing for self-determination, while also offering support and opportunities for the development of solutions and life projects (CONANDA & CNAS, 2009).

However, in practical terms, these policies do not appear to have been implemented. Group homes are not available in many Brazilian states: in 2014, only 39 officially registered institutions catered specifically to youth, with most (26 units) located in southeastern Brazil (MDS, 2015). There is also a long way to go in terms of the changes required in the model of care available for shelter youth. Many of the goals set for the PNCFC in 2015 were directly related to the development of autonomy among adolescents and young adults, enlisting the support of several sectors of civil society in the process. However, recent studies highlight the unpreparedness of Brazilian youth as they leave institutional care, as well as the lack of living arrangements, education and occupational prospects for these individuals (Martinez & Soares-Silva, 2008; Moreira, 2013; Romanelli, 2013; Rosa et al., 2012).

One way to ensure the effective implementation of public programs and policies is through continuous evaluation. The assessment of program outcomes and repercussions could then be used as a basis for decisions regarding the continuity of interventions (Cohen & Franco, 1993). The studies analyzed in this review evaluated the process, effects and impact of several interventions. A complete assessment process should include all three of these items, starting with process evaluation, to ensure all activities are taking place as expected and in accordance with the initial planning. Effect assessment determines whether, and to what extent, the desired changes were observed. Lastly, impact assessment helps to verify whether the changes identified can be attributed to the intervention itself (Blasco & Casado, 2009; Cohen & Franco, 1993).

No consensus has yet been reached regarding the way these assessments should be conducted, or the design, method and techniques to be used at every stage. The confusion generated by this lack of standardization can be observed in some of the studies analyzed in this review, which claimed to have performed impact assessments, while their outcomes corresponded to evaluations of the effect of different interventions. Only two of the studies reviewed conducted impact assessments, comparing two groups of shelter youth, only one of whom participated in a given intervention. The studies found that the changes identified were not attributable to participation in the program, which underscores the importance of this type of procedure for goal assessment and program redesign. Another important issue pertaining to the assessment of intervention programs was the presence of numerous difficulties and obstacles reported by researchers during the assessment process. According to Blasco and Casado (2009), some factors are especially difficult to measure since they refer to abstract constructs, as is the case of autonomy. The need to measure a phenomenon which is by nature immeasurable presents a significant challenge, as researchers select the methods, instruments and measures that are most appropriate for the task at hand. In addition to these obstacles, researchers may have difficulty accessing participants, securing the financial resources to do so, and managing the ethical concerns that arise when studying populations with a history of vulnerability.

These obstacles have not prevented countries and institutions from evaluating their interventions for former shelter youth. However, most results are presented in the form of reports and local publications, which are not always available in electronic form. This explains the absence of articles pertaining to well-known programs such as Grupo Nós (Brazil) and Punt de Referéncia (Spain) in the present review. The lack of information on the outcomes of these and other programs in indexed journals may compromise the scientific advancement of institutional care, creating a gap between the professionals who work in the area and the researchers who study it.

According to Piccinini (1996) there should be constant interaction between research and practice, and neither can progress without the other. On the one hand, evaluation procedures are crucial for the comprehension of phenomena and the effective development of future programs and interventions (Ajuntament de Barcelona, 2017). On the other, services for former shelter youth, and the professionals who deliver them, are in a privileged position to help overcome the difficulties and challenges associated with conducting research in the area (Fernández, 2003). The distance between research and practice must be bridged, to allow for more comprehensive publications on which to base progressively more efficient interventions in the context of institutional care.

 

Conclusion

This systematic review identified some factors as crucial for the efficacy of programs to assist in the transition from shelters to adult life. Firstly, the format of the interventions must respect individual and contextual differences between participants. Longer-term programs which assist participants both before and after leaving institutional care received the highest approval ratings and had the most perceptible and persistent effects. The content of interventions must include both independent life skills training, as well as socioemotional support and community insertion. Lastly, program efficacy was found to be influenced by the method of delivery, with participatory methods, in which adolescents take a leading role in decision making, resulting in more positive outcomes.

One limitation of the present study is the fact that its sample was limited to scientific articles. Many of the programs reviewed publish their findings in reports, official documents, or even theses, dissertations and books. This may limit the present findings, though it does not diminish their relevance. There is a need to increase scientific productivity in the area. This is especially true for Brazil, where there is an urgent need for studies of this population on which to base interventions to promote quality of life and resilience. Professionals involved in this type of intervention are encouraged to evaluate their outcomes and publish their results. On the other hand, the scientific literature is encouraged to provide more opportunities for publications on the subject.

 

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Mailing address:
Luciana Cassarino-Perez
Universidade Federal do Rio Grande do Sul, Grupo de Pesquisa em Psicologia Comunitária
Rua Ramiro Barcelos, 2600, sala 122
Porto Alegre, RS, Brazil 90035-003
Phone: (51) 3308-5239
E-mail: lucicaspe@gmail.com

Received: 25/04/2017
1^st revision: 06/05/2017
2^nd revision: 1º/06/2017
Accepted: 14/06/2017

 

 

Authors' Contributions
Substantial contribution in the concept and design of the study: Luciana Cassarino-Perez; Jorge Castellá Sarriera e Carme Montserrat.
Contribution to data collection: Luciana Cassarino-Perez e Vitória Ermel Córdova.
Contribution to data analysis and interpretation: Luciana Cassarino-Perez; Jorge Castellá Sarriera e Carme Montserrat.
Contribution to manuscript preparation: Luciana Cassarino-Perez e Vitória Ermel Córdova.
Contribution to critical revision, adding intelectual content: Jorge Castellá Sarriera e Carme Montserrat.
Conflicts of interest
The authors declare that they have no conflict of interest related to the publication of this manuscript.