Necessary but Not Sufficient: Improving Community Living for Youth after Residential Mental Health Programs 9781487535933

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NECESSARY BUT NOT SUFFICIENT Improving Community Living for Youth after Residential Mental Health Programs

UNIVERSITY OF TORONTO PRESS Toronto Buffalo London

© University of Toronto Press 2020 Toronto Buffalo London utorontopress.com Printed in the U.S.A. ISBN 978-1-4875-0728-2 (cloth) ISBN 978-1-4875-3594-0 (EPUB) ISBN 978-1-4875-3593-3 (PDF)

Library and Archives Canada Cataloguing in Publication Title: Necessary but not sufficient: Improving community living for youth   after residential mental health programs / Gary Cameron,   Karen M. Frensch, Trudy Smit Quosai, Mark Pancer, Michele Preyde. Names: Cameron, Gary, author. | Frensch, Karen M., 1973– author. | Quosai,   Trudy Smit, 1965– author. | Pancer, S. Mark, author. | Preyde,   Michele, 1964– author. Description: Includes bibliographical references and index. Identifiers: Canadiana (print) 2020016743X | Canadiana (ebook)   20200167448 | ISBN 9781487507282 (cloth) | ISBN 9781487535940   (EPUB) | ISBN 9781487535933 (PDF) Subjects: LCSH: Mentally ill teenagers – Deinstitutionalization. | LCSH:   Mentally ill teenagers – Deinstitutionalization – Case studies. | LCSH:   Mentally ill teenagers – Rehabilitation. | LCSH: Mentally ill teenagers –   Rehabilitation – Case studies. | LCSH: Adolescent psychotherapy –   Residential treatment. | LCSH: Adolescent psychotherapy – Residential   treatment – Case studies. | LCSH: Youth – Mental health services. | LCSH:   Youth – Mental health services – Case studies. Classification: LCC RJ503.C36 2020 | DDC 362.2084/2–dc23

University of Toronto Press acknowledges the financial assistance to its publishing program of the Canada Council for the Arts and the Ontario Arts Council, an agency of the Government of Ontario.

Contents

Foreword ix Acknowledgments xiii 1 Residential Mental Health Programs for Youth: Necessary But Not Sufficient  3 2 Community Adaptation of Children and Youth Accessing Residential Mental Health Treatment  16 3  Theories and Concepts Relating to Community Adaptation  47 4 Pathways and Programs to Improve Youth Educational Processes and Outcomes  62 5  Delinquency Pathways and Programs  81 6 Family  101 7 Youth Transitions from Substitute Care: Outcomes, Pathways, and Programs  116 8  Systems of Care for Youth  137 9  A Case for an Integrated Program  147 Appendices Appendix 1: Description of Review Methods  163 Appendix 2: Description of Research Methods  167 References  171 Index  201

vi Contents

Summaries of Main Patterns Main Patterns: Community Adaptation of Children and Youth Accessing Residential Mental Health Treatment  16 Main Patterns: Youth Educational Processes and Outcomes  62 Main Patterns: Delinquency Pathways and Programs  81 Main Patterns: Family  101 Main Patterns: Youth Transitions from Substitute Care  116 Main Patterns: Systems of Care for Youth  137 Youth Stories Chapter 1 Jane, female, age 17  4 George, male, age 16  5 Chapter 2 Jamie, male, age 20  27 Evan, male, age 11  35 Damian, male, age 16  40 Chapter 4 Scott, male, age 23  63 Megan, female, age 16  66 Cody, male, age 12  79 Chapter 5 Sean, male, age 22  82 Cindy, female, age 18  89 Chapter 6 Kenneth, male, age 16  102 Stan, male, age 20  114 Chapter 7 Kyle, male, age 21  118 Jenna, female, age 20  123 Chapter 8 Keagan, female, age 15  138

Contents vii

Program Exemplars Chapter 4 Check & Connect  77 Pathways to Education  78 Chapter 5 Coping Power  94 SNAP Under 12 Outreach Project  97 Chapter 6 Triple P – Positive Parenting Program  108 Parent Connections  110 Chapter 8 Choices: A Wraparound Program  144 Tables 2.1 Timeline of Program of Research  19 7.1 Overview of Factors Associated with Negative Life Domain Outcomes  125 7.2 TIP Guidelines and Core Practices 132

Foreword

I was a student in 1990 when I heard about a young man who was once in residential mental health treatment. The story was that he had a job driving a truck and played guitar gigs on weekends. The storyteller was a child and youth worker who sought out and connected with youth who had previously received residential mental health treatment at the facility where he worked, among them this young man. At the time, I had no appreciation for the dedication required for the child and youth worker’s efforts, the value of what he learned, or the significance of the successes of these young adults. Some things about residential treatment, or “out-of-home placements,” have changed little since I was a student. It is usually seen as the last resort. It is the most expensive treatment option outside of the hospital system. The children and youth served are facing severe, complex challenges related to both mental health and life in general. Their behaviour is often identified as the reason for treatment, but deep emotional issues are often hidden behind that behaviour, along with their personal strengths. Devoted treatment staff are stretched thin trying to meet the physical, emotional, and mental health needs of the children and youth in their care. Most important for this volume, resources to support transition back to the community are still limited, and systematic follow-up regarding outcomes is still rare. In other ways, out-of-home placements have changed in thirty years. We understand better the effects of trauma on thinking and behaviour and on the structure and functioning of the brain. In particular, we have learned about interpersonal trauma and patterns of attachment in relationships. Behavioural interventions are gradually giving way to trauma-informed approaches. We are better able to identify disorders related to how the brain develops and to appreciate the lifelong implications of such disorders. We have recognized the need to involve

x Foreword

families whenever possible at every stage of treatment. Programs are becoming more flexible and treatment plans tailored more specifically to the needs of individual children, youth, and their families. The treatment system as a whole is also changing. The entire child and youth mental health system in Ontario has been undergoing a transformation for the past few years that will likely continue for years to come. Currently, one focus of these efforts is the redesign of intensive services at the provincial, regional, and local levels. Agencies are reducing the number of treatment beds or closing residential programs altogether. We strive to provide the least intrusive effective treatment. (To the frustration of many providers of out-of-home treatment placements, the word effective is sometimes missing when that goal is stated.) As intensive treatment alternatives to out-of-home placements become increasingly available and popular, the children and youth who are referred to out-of-home placements are more likely to be unmanageable in less intrusive settings and to require extensive supports when they arrive. As programs close, the unfortunate trend is for children and youth to travel farther to receive this intensive treatment when they need it. This trend has significant implications when planning for them to return to their home communities. I have had the privilege of spending most of my career at Vanier Children’s Services in London, Ontario. In 1968, Vanier was the first private treatment centre licenced in Ontario, Canada. The children referred to Vanier have many characteristics in common with children and youth referred to other children’s mental health agencies. Aggression is a common presenting problem for out-of-home placements. We have a school on site, which is needed because the children placed here often have learning disabilities and other cognitive challenges. Most children referred have serious adverse life experiences, and Children’s Aid Societies are involved with about half of the children in out-of-home placements. About half also come from families with household incomes below the low income cut-off. Another common feature within families seeking treatment is that parents have their own mental health challenges. Because Vanier primarily serves a younger population, children at our agency are less likely to have involvement with the police and youth justice system or to use substances than youth at other agencies. Many of these difficulties are chronic and will persist well after the children and youth exit an out-of-home placement. Step-down programs are essential. Finding appropriate classroom placements is an ongoing challenge. In addition, these children and youth often have tumultuous relationships with their families. Supports, such as parent education and training, are needed. One of the challenges is that the

Foreword xi

journey of parents whose children have been placed out-of-home is different from the journey of parents whose children have not, straining scarce family support resources. Families often need respite, which is also scarce. Further, these children and youth are often isolated within their communities. Even when they no longer need the structure of a milieu-based program, they still need coaching before they are ready to participate fully in their communities. Left unchecked, poor social skills and social isolation can contribute to more significant conduct problems. Focusing only on the problems of the children, youth, and families that we serve is not only depressing, it is also inaccurate. I am frequently struck by their resilience. Participants in youth engagement programs run by youth with mental health challenges and their peers frequently talk about the sense of community that these programs provide. Although often at risk for dropping out of school, many of the children and youth that we serve have other skills. Some are gifted musicians, such as the young man I mentioned earlier. Others are exceptional athletes. Some love to cook, to build, or to serve others. These practical skills give them a realistic foundation upon which to build their confidence and self-esteem. When the Partnerships for Children and Families project first started, we were eager to contribute our ideas and assist in recruiting participants. We looked forward to receiving feedback related to our programs, especially in terms of the long-term outcomes. This one project grew into an entire program of longitudinal research. As we redesign the intensive service system, these rich and reliable outcome results are invaluable. This volume not only brings together an impressive body of literature related to their original research; it also weaves in the stories of the children, youth, and their families. I began with the story of a young man who found success after out-of-home placement. I conclude with a hearty thank-you to Dr Cameron and his colleagues for introducing us to so many young adults and their families. Dr Jeff Carter, psychologist Director of Quality Improvement Vanier Children’s Services London, Ontario, Canada Adjunct Assistant Professor, Department of Psychiatry Adjunct Clinical Professor, Department of Psychology University of Western Ontario March 2019

Acknowledgments

Throughout our program of research, we have had the privilege of working with many individuals, all of whom have helped further our collective understanding of community adaptation following involvement in children’s residential mental health programs. Thank you to the children, youth, young adults, and their families and service providers who shared their stories with us. Thank you to our mental health and child welfare partners who supported the research in many ways over the years. Partners include: Avalon Treatment Programs Brant Family and Children’s Services Catholic Children’s Aid Society of Hamilton Children’s Aid Society of Hamilton Children’s Aid Society of London and Middlesex Craigwood Youth Services Family and Children’s Services of Guelph and Wellington County Family and Children’s Services of the Waterloo Region George Hull Centre for Children and Families Halton Children’s Aid Society Carizon (formerly kidsLINK) Lutherwood Lynwood Charlton Centre Vanier Children’s Services WAYS Mental Health Support Research by the Partnerships for Children and Families Project was funded by the Social Sciences and Humanities Research Council of Canada. The original synthesis review from which this book evolved was funded by the Ontario Ministry of Child and Youth Services.

NECESSARY BUT NOT SUFFICIENT Improving Community Living for Youth after Residential Mental Health Programs

Chapter One

Residential Mental Health Programs for Youth: Necessary But Not Sufficient

Introduction Our initial motivation for this volume came to us unexpectedly from a larger program of research we had undertaken that focused on the lives of child welfare clientele and more positive ways of engaging this group. Within this, a small sub-study examined the circumstances of youth and families prior to entering and after leaving residential mental health programs. For most of these youth, residential mental health care was a last resort, often after years of pursuing less intrusive helping options. For some youth, it was an alternative to incarceration. We were disturbed by the stories of extreme difficulty facing these youth and their families when they entered such residential programs. Also, despite benefits to many youth and caregivers from their program involvement, many of these youth experienced worsening community living challenges after leaving these programs. By way of introduction, we present two such stories here. Both are about youth in their first year of community living after leaving a residential mental health program. Jane* is living with her mother and is doing reasonably well, while George was left to live in state care and is having a great deal of difficulty. Jane was 17 years old at her time of discharge from residential treatment. Jane entered a residential program due to her anxiety and depression interfering with her daily functioning and schooling. Along with panic attacks and depressive episodes, Jane had also considered and acted on suicidal ideation in the past. At the time of discharge, Jane returned to her mother’s care. Her discharge plan involved continuing to attend a community school to complete her credits for half-days, along with attending various community counselling programs. * All names are fictitious.

4  Necessary But Not Sufficient Jane, female, age 17 Of her return home, Jane said, “I have more freedom over saying ‘I wanna go to my friend’s this time’ or ‘I wanna work out right now’ instead of it being told for me ... I had a lot more free time so I feel like it was easier for me to get depressed again because I didn’t have things to keep me busy ... I just didn’t really do much ... so it was hard for about a week or two but then I got back into it ... It’s been easier on me and my mom because I’m willing to take more responsibility. “I was depressed ... I didn’t really have too many highs before residential programs ... I had dropped out of school and I was really having a tough time getting my basic needs met, so they felt like instead of sending me back to the hospital, they’d go for an in-between.” When asked about coping strategies at home, Jane said, “I tried to distract myself as much as I could either by watching funny movies or going on the computer, going out with friends, and using therapy skills I had learned at residential program.” Jane spoke of her first few days back at school: “I was worried about what people would think but they were cool with it so ... It was weird, it kinda brought me back to how it was before residential program ... And I wasn’t in the best state of mind so. “I guess you could call it a special school program, because I’m only taking one class ... they transitioned me [to] half days ... so I wasn’t overwhelmed with going back ... but I am working with a therapist right now about second semester because I know that will be really hard for me to go back to four academic-level courses.” When asked about how things were going one year after leaving the residential program, Jane stated, “Generally ... I would say I’ve been doing better. Like I’ve improved over the past 6 months. [Q. And what do you credit that to?] Mmm ... most of the therapy I’ve gotten and maybe it didn’t help right away but CBT and DBT that I’ve done ... There was a lot at the residential program and I’ve also been recommended to counsellors through my psychiatrist ... I do my chores like my laundry and clean my room and stuff and then now I just like do school and see friends every now and then. I’m ... I don’t do things like grocery shopping but, and I, I make my own meals most of the time. “There was in June where I had to go to the hospital a bunch of times ... I was put on the [medications] I’m on now. And things have been generally better since then ... I was very stressed out and anxious. Like I would get panic attacks and I haven’t since I’ve been on the meds I’m on right now. “I just switched over to adult school ... Now I’m doing school and I’m doing well ... I do correspondence, which is I study at home ... Right now grade 11, but I should be done by the end of next year ... It’s at my own pace so I can, like if ... my mood’s going up and I’m feeling really motivated I can get through maybe more lessons that I would in regular school and then when it goes down and I’m slower ...

Residential Mental Health Programs for Youth  5 “Recently I’ve really only been seeing my one friend. But then there’s also 4 or 5 others. And that’s kind of our group ... My friend group knows pretty well how to help each other out.”

George was 16 years old at his time of discharge from residential treatment. George entered a residential program following his aggressive behaviour in multiple foster homes, which led to an assault charge. There were concerns of substance use and drug dealing. George did not have a discharge plan from residential care due to the unplanned circumstances of his departure: a violent assault with a weapon upon a peer. George, male, age 16 “I was in a cell first, then a worker came and got me, and then I went to another foster home ... I stayed there for like three days ... I pushed foster mom three times just like light push though not actually like punch or nothing ... ’cause I was really mad ... the cops came ... and they’re like ‘Uh, yesterday you assaulted [foster mom] ... you’re going to jail you’re charged with assault.’ ... They just put me in a cell for the day. And then when I got out of the cell, that’s when I went to [the residential mental health program]. “I actually like this group home ... First day ... I got in a fight with one of the foster kids ... Well I was actually really depressed ... ’Cause I didn’t know what to do like, all my friends are in [a different city].” George’s child welfare worker commented, “He’s seeking out and finding gangs that he’s involved himself with, which isn’t a positive thing. I think George was seeking ... loyalty ... you have a team on your side.” George had a different perspective: “I’ve got really respectful friends ... like real friends ... I’d take a bullet for them ... they know what I go through ... I tell all my friends that I’m in a group home ... We’re all really close.” The child welfare worker added, “Substance use was a big thing for him ... he was struggling quite a bit ... definitely marijuana and beyond that we don’t know for sure ... We suspected that there were harder drugs coming into play ... him and the two other kids that live in the home decided to rob a couple so they stole their cell phones ... which they got charged for ... Comes back ... I place him on Monday, by Friday he runs away ... he was picked up Sunday for weapons, dangerous, they were planning a robbery of a convenience store ... yeah, robbery, getting involved in fights, rival gangs ... but he’s just hanging out, leaving whenever he wants to, doing whatever he wants to do.” George said, “I don’t feel like anybody at CAS [Children’s Aid Society] cares about like, moving us, like house to house like how that affects us, our friends and everything. They don’t care man, they’re getting paid! They don’t care ... We’re foster kids, they don’t wanna listen to us, ya know? ... That affects us

6  Necessary But Not Sufficient man ... It’s not my fault I’m in foster care ... This world, everybody just cares about themselves ... I’m planning to stay here till I’m 18, but at the same time I don’t know because there’s a lot of rules here ... “I’m gonna be going to school ... I’m forcing myself to go now ... I’ve already missed two years ... I can’t do that anymore... Those full two years, I felt like nobody ... ’cause when you don’t go to school you feel like you have no selfconfidence at all. You don’t feel like you’re going anywhere ... If I don’t go to school, I don’t feel like I’m respecting myself at all ... I should be in like grade 11 right now ... In the next year, I wanna be able to have my grade 9 and grade 10 all my credits for sure ... If I don’t get all the credits I feel like I need, then I’m gonna go to summer school and get it done ... I don’t need help. I’m a smart kid, I’m just lazy ... “When I call my sister it really calms me down ... she helps me through it ... She’s been in group homes too when she was younger, so she knows how it is ... honestly, she’s been keeping me going throughout my life. My dad though, no, not at all ... like he doesn’t speak a lot of English. Plus my dad doesn’t care about me ... so literally I only have my sister and my friends there for me. That’s life though.”

Attention and Active Engagement The foundation for our efforts to focus attention on this youth population and to encourage active engagement with them has always been the community living stories told by these youth and their caregivers. These are discussed in greater detail in chapter 2. There are several reasons why we believe that these youth deserve both our compassion and our explicit efforts to improve their lives. First, they do not cope well when they graduate from residential children’s mental health programs. Indeed, the norm is for most of these youth to encounter distressing difficulties in multiple domains of community living. Second, there is little to no follow-up after these youth leave residential care. They often get lost within larger youth populations (e.g., at school or in state care), where the priority concerns and available resources do not fit well with their realities. In addition, the children’s mental health agencies involved in our program of research knew very little about where youth were living or how they were doing a year after they had left their residential mental health programs. Moreover, even if they knew, they had very little uncommitted capacity to offer useful assistance to such youth living in the community. Finally, a major contention in this book is that useful and feasible program initiatives exist that hold promise for helping these youth achieve better community living outcomes. These deserve more of our attention and resources.

Residential Mental Health Programs for Youth  7

What Works? Academics can be seduced by what is new – for example, a new way of understanding the plight of these youth or an innovative way of helping. Our earlier work focused on emergent understandings of these youth and their caregivers. But not this volume. We became uncomfortable focusing on what was happening in their lives but not on what might be done to foster improved community living outcomes for these youth. Perhaps because of our applied disciplines, we felt an ethical imperative to turn our attention to how to help these youth and their caregivers have better lives. Information about the lives of these youth presented throughout this volume provides a context for thinking about what might be useful to them. Also, our search for programming is grounded in available theory and evidence about what can be expected from various interventions. Clearly, this approach is designed to surface what is known about promising ways of helping – what might work to produce better community living outcomes for these youth and their caregivers. Nonetheless, there is innovative thinking in this book. It concentrates on applications. We need to uncover ways of helping that are relevant to multiple domains of community living – education, family life, criminal justice, personal functioning. In addition, we see the utility in developing program approaches that build upon the resources and skills of the children’s community mental health organizations that serve the youth in our program of research. We cannot undertake such tasks by assuming that we already know how to help these youth succeed in living in the community, or that it is straightforward to articulate what to do, or that it is simple to put such ideas into practice. Indeed, despite our lengthy investments in these challenges, what we propose is only a beginning. A great deal of effort will be required before we can be confident about what to expect from various approaches to helping these youth succeed in moving from residential programs to life in the community. Overview Residential mental health care remains a controversial option. There is a constant questioning of the nature and effectiveness of these residential programs and a search for other programming options (Bettmann & Jasperson, 2009; Brown, Barrett, Ireys, Allen, & Blau, 2011; Clark & Unruh, 2009; Thomson, Hirshberg, & Qiao, 2011). Nonetheless, residential programs remain a core feature of youth mental health service

8  Necessary But Not Sufficient

networks. This volume argues that there often are significant benefits for youth and their caregivers from involvement with these types of residential programs. However, it also presents ample reasons for serious concerns about community living outcomes for most youth after they leave residential mental health programs. The immediate challenges for youth and their families that draw the attention of these residential programs do not require the same configuration of responses as does improving life in the community for these youth over time. Reducing crises for youth and improving their capacity to manage a variety of behavioural and emotional challenges are necessary but not sufficient changes to enable most of these youth to successfully transition to living in the community. Two broad purposes guide this volume: (1) to argue for the urgency of developing programs to support successful community adaptation for youth leaving residential mental health care; and (2) to present theory and evidence-guided parameters for creating community adaptation programming for this youth population. To further these purposes, the following objectives have shaped the volume: 1. to describe the multiple serious challenges this youth population confronts after leaving residential mental health care; 2. to illustrate the community living circumstances of these youth by vignettes and other exemplars drawn from our program of research; 3. to provide an overview of current general theories about improving community living for such youth; 4. to synthesize the available theory, outcome research, and expert opinions about youth community adaptation programming in several life domains, including education, community conduct, and family living; 5. to propose a preliminary broad conceptual framework for creating community adaptation programming for youth leaving residential mental health care; 6. to highlight the urgency of as well as the barriers to responding to the community living challenges for this youth population. Balancing Accessibility and Evidence The intended audience for this book includes policy developers, administrators, and service providers interested in improving community living outcomes for youth leaving residential mental health programs. The book is also designed as a resource for scholars and students interested in this topic. It will be of interest to others concerned about

Residential Mental Health Programs for Youth  9

supporting community living for youth with behavioural or emotional challenges. Much of this book draws upon our longitudinal program of research focused on community living outcomes for youth from their early teens to young adulthood who have graduated from residential mental health programs. This book also uses information from our systematic review of theory, evidence, and expert opinions supporting community adaptation programming in various life domains (see the description of review methods in appendix 1). To support our arguments, this volume necessarily incorporates a significant volume of research evidence. However, to expand the accessibility of the book to multiple audiences, readers interested in the technical details of our program of research are referred to the appendices or to other supporting material (scholars. wlu.ca/pcfp). Most chapters incorporate vignettes of the experiences of children and youth who graduated from residential mental health programs. Vignettes draw from the program of research described in chapter 2. They are intended to give a “more human face” to the general circumstances being considered. They are not designed to support specific arguments being made in any chapter. Collectively these vignettes provide a rich description of the challenges confronting and the responses of these youth and their caregivers after being in residential mental health programs. A list of these vignettes is found at the beginning of this volume. In the chapters focused on improving community adaptation outcomes in various domains of living, one or more program exemplars are presented. Each exemplar describes an application of a program strategy that is worthy of further consideration. Exemplars were chosen for their demonstrated potential to improve community living outcomes for youth and for their incorporation of processes connected conceptually to improved youth community living. They are intended to link the pathways and research evidence presented in each chapter to existing programming efforts. A list of program exemplars is found at the beginning of this book. The concluding summaries of the chapters about pathways and programming in various life domains all follow a similar format. The intent is to allow comparisons across these domains and to facilitate the identification of processes and strategies germane to improving multiple domains of youth community living. In other words, we are hoping that patterns will be repeated in multiple domains, pointing towards more robust programming elements for these youth. These comparisons in turn inform the general community adaptation programming elements discussed in the final chapter.

10  Necessary But Not Sufficient

There are several ways to engage with this volume. All of the research-focused chapters begin with a summary of their content and conclusions. Readers wanting an efficient overview of the volume may choose to read these summaries along with the first and last chapters. A list of these summaries is found at the beginning of this volume. Others interested in specific domains may decide to read all of the selected chapters (e.g., education, delinquency). Those wanting an in-depth understanding of how the arguments and information in every chapter inform the final programming suggestions will prefer to work through the complete volume. Several Qualifications Throughout this volume, the focus on youth with serious emotional and behavioural challenges excludes youth populations in psychiatric institutions and youth in secure juvenile justice facilities. Our attention is on youth residential mental health programs typically hosted by child and youth mental health agencies. While significant overlaps exist with the profiles of youth in these different types of facilities, there are differences as well. Youth with mental health diagnoses requiring specialized psychiatric responses (e.g., schizophrenia, bipolar disorder, incapacitating clinical depression) would not typically be in these types of children’s mental health residences. However, these are differences of degree. Many youth in these residences experience anxiety, depression, hyperactivity, anger, and other personal functioning difficulties, and the use of medication for these is common. Similarly, youth who had been sentenced to a secure facility for a legal offence would not be in this type of mental health residence. However, some youth faced a choice – agree to enter a mental health residential program or go into a secure custody facility. In addition, many of the older youth in these mental health residences have been in some kind of trouble with the law prior to entering these programs. The illustrations of youths’ community living circumstances drawn from our program of research feature the voices of the young people we discuss as well as parents/caregivers. This is an artefact of our program of research, described in chapter 2. It could have been illuminating to have the perceptions and recommendations of various community service providers as well (e.g., in education, psychiatry and mental health, juvenile justice, community recreation and support). Unfortunately, our program of research did not provide access to this scope of information. The focus of this volume is a specific youth population after they have left the care of residential mental health programs. It does make

Residential Mental Health Programs for Youth  11

a case for more extensive and appropriate supports for community living success for these youth. However, this volume is not intended as a critique of existing efforts within service sectors (e.g., mental health, education, child welfare, juvenile justice). Nor does it deny the efforts and innovations within these sectors to support youth functioning. It does argue for a more focused programming for youth graduating from residential mental health programs. While we have drawn extensively on the available literature, our program of research concentrated on southern Ontario, Canada. It is unclear how the patterns identified might vary in other jurisdictions. This volume also does not deal substantially with the experiences of racial, ethnic, or cultural minorities. Additional work is needed to see how these differ. Nonetheless, this volume is intended to support useful insights and speculations. The information here is more than rich enough for these purposes. The Context for Children’s Residential Mental Health Services in Ontario About 10–20 per cent of Canadian children and youth will struggle with some type of mental health problem (such as anxiety, depression, attention deficit hyperactivity disorder [ADHD], conduct disorder, schizophrenia, or substance use disorder) and only one in five will receive mental health services (Mental Health Commission of Canada, 2013). There are approximately one hundred children’s mental health organizations in Ontario that provide “treatment and support to children, youth and families. This includes targeted prevention, early intervention, short- and long-term counselling and therapy, and intensive services such as residential care” (Children’s Mental Health Ontario [CMHO], www.cmho.org). Each local community has its own referral network for determining treatment options, including admission to residential mental health programs. No physician referral is required. While these programs focus on improving the mental health and coping abilities of children and youth, no one model of treatment is practised uniformly across Ontario (CMHO, 2016; Ontario Centre of Excellence for Child and Youth Mental Health [OCECYMH], 2013). Residential children’s mental health treatment is an intensive mental health program available to children and youth who confront complex mental health and behavioural issues that have not improved with community-based treatment (OCECYMH, 2013). Children and youth engaged in residential mental health programs in Ontario typically have been diagnosed with internalizing disorders such as anxiety and

12  Necessary But Not Sufficient

depression or externalizing disorders such as hyperactivity, aggression, and conduct difficulties (Cuthbert et al., 2011). These children and youth come from a variety of backgrounds, and their challenges often affect multiple domains of their daily lives, such as academics, employment, relationships, physical health, substance use/abuse, and contact with the law (Frensch, Cameron, & Preyde, 2009; Grosset, Frensch, Cameron, & Preyde, 2018; Preyde et al., 2016). While intensive community-based mental health services are sought as a less costly and less intrusive alternative to residential care, for a specific group of children and youth who cannot be maintained safely in their homes, schools, and communities, out-of-home mental health treatment is a necessary option. In our program of research, residential children’s mental health programs involved family- and child-centred programming from multidisciplinary teams who created individual service plans for each child based on cognitive behavioural, psycho-educational, brief, and solution-focused models. Children and youth usually lived in residence five days a week and attended either their own community school or an on-site school. Youth usually returned home on weekends; however, those referred by a child welfare agency often remained in residential care on weekends. The expected length of stay was three to nine months. Agencies served children and youth ages five up until their eighteenth birthday. Children’s mental health residential programs represent a major investment of resources in helping children and youth with serious emotional or behavioural difficulties. However, children’s mental health agencies typically invest few resources and little time keeping track of youth after they graduate from their programs (Cameron, Hazineh, Frensch, & Preyde, 2009; Frensch, Hazineh, Cameron, & Preyde, 2010). While there are reasons for concern and much conjecture, few specifics are known about post-program community adaptation outcomes or adaptation processes for these youth (Brown et al., 2011; Davidson-Methot, 2004; Gralinski-Bakker, Hauser, Billings, & Allen, 2005; Rohde, Clarke, Mace, Jorgensen, & Seeley, 2004; Thomson et al., 2011). Consequently, making informed decisions to guide better community adaptation programming and policy development for this population has been extremely difficult. In 2015, the provincial government called for the creation of the Residential Services Review Panel to examine the delivery of children’s residential services in Ontario, including out-of-home care provided by child welfare agencies, custody provision by youth justice, and therapeutic residential care provided by the child and youth mental health service sector. Through a review of available documentation and

Residential Mental Health Programs for Youth  13

extensive consultation with stakeholders (including youth, parents, and service providers), the panel concluded, among other things, “Despite the best intentions of those working in the sector, and the recommendations received over the years, the quality of young people’s everyday experiences [in care], and their outcomes remain uncertain” (Ontario Ministry of Children & Youth Services, 2016, p. 6). Issues of service system fragmentation, understaffing in residences, inconsistency in treatment models and evaluation, and a trend towards serving children and youth with increasingly complex challenges continue to plague the perceived efficacy of children’s residential mental health services. The 2015 formation of the Residential Services Review Panel, along with several key reports produced by Children’s Mental Health Ontario (2016) and the Child and Youth Mental Health Lead Agency Consortium (2019), points to the momentum shift in recent years to re-evaluate the delivery and relevance of residential care within the already changing child and youth mental health system in Ontario. (In late 2018, policy and accountability for child and youth mental health services in Ontario was transferred from the Ministry of Children, Community, and Social Services, formerly the Ministry of Child and Youth Services, to the Ministries of Health and Long-term Care.) Given the huge investment of resources to support residents while in care and the reality that gains made are not easily maintained in the absence of support once children and youth are back in their communities and families, there is an urgent need to prioritize post-discharge transition services for children and youth in residential mental health programs (Casey et al., 2010; Lakin, Brambila, and Sigda, 2004; Tyler, Trout, Epstein, & Thompson, 2014; Wagner & Newman, 2012). In Residential Treatment: Working Towards a New System Framework for Children and Youth with Severe Mental Health Needs (CMHO, 2016), the CMHO identifies building after-care programs as one of the critical components of residential program service delivery moving forward. They articulate a vision for a future model of care, for children and youth with the most complex behavioural and emotional needs, committed to a system framework and funding structure that supports the provision of integrated after-care services for children and youth returning home or transitioning to new living environments. Our offering in this book of a preliminary conceptual framework for creating community adaptation programming – informed by the real-life stories of children, youth, and families involved with residential services and by our synthesis of the research, theory, and expert opinions of promising ways to improve outcomes – is a timely addition to the reimagining of residential care service provision in Ontario.

14  Necessary But Not Sufficient

Organization of the Volume Chapter 2 discusses the findings from our program of research about youth community adaptation outcomes and experiences that motivated the writing of this volume. It provides a context for considering the fit between programming designed to improve community living outcomes for this population and the realities of their lives. Chapter 3 examines the general theories explaining the factors and processes contributing to youth success in community engagement. It examines general youth populations as well as selected groupings facing specific challenges. When considered along with the reviews of these factors and processes in subsequent chapters focused on specific life domains, it provides a conceptual foundation for considering the potential of different approaches to youth community adaptation programming. Chapter 4 reviews the pathways literature about educational successes and failures as well as the evidence for the impacts of different program strategies on these outcomes. Chapter 5 reviews the pathways literature for reducing recidivism among youth leaving juvenile justice detention facilities. It also examines the impacts of a variety of program models designed to reduce recidivism among this youth population. In our program of research, about half of the youth leaving residential mental health programs returned to live with their families of origin. Chapter 6 examines the pathways to youth successfully reintegrating with their families and the evidence about the effectiveness of programming to support this reintegration. Approximately half of the youth in our program of research returned to live in the care of child welfare authorities. Also, this volume prioritizes community living programming for youth leaving institutional living settings. Therefore, it is worthwhile to examine what can be learned from efforts to support youth as they transition from living in state care to independent community living. Chapter 7 focuses on the pathways and the programming that facilitate transitions to independent living for youth in the care of child welfare authorities. Recently, systems of care have been strongly promoted as vehicles for improving community living for youth with serious emotional and behavioural challenges. Despite the tenuous relationship we found between this service system reform focus and helping youth leaving residential mental health programs, given the space this focus continues to occupy in policy and practice discussions, a decision was made to include systems of care. Chapter 8 examines the nature of systems of

Residential Mental Health Programs for Youth  15

care and their relevance to improving community living outcomes for youth leaving residential mental health facilities. This final chapter, chapter 9, summarizes salient points to consider from the earlier chapters when thinking about how to improve long-term community adaptation outcomes for youth leaving residential mental health programs. It also describes a preliminary hypothetical framework (i.e., promising protective processes and programming elements) for community adaptation programming for these youth and their caregivers that builds upon these insights.

Chapter Two

Community Adaptation of Children and Youth Accessing Residential Mental Health Treatment

What happens to children and youth after they leave residential mental health treatment (RT)? How do these youth navigate normative developmental transitions like finishing school, getting a job, and finding a place to live? What types of assistance might facilitate these transitions? Despite the critical importance of these questions for youth and their caregivers, for the education, justice, and mental health systems, and for the development of appropriate transition mechanisms, surprisingly little is known about what happens to these children and youth over time. Professional myths such as that youth with emotional and behavioural disorders leaving these programs mostly end up in jail or in psychiatric institutions or that many will grow out of their childhood disorders partially fill the gap. Children’s mental health professionals well know that these youth often are identified as being in trouble after leaving their care. However, there is little documentation available about what specifically happens to these children and youth. This chapter provides a detailed overview of results from our ongoing program of research focused on community living outcomes for these youth, which began in 2001 as part of the Partnerships for Children and Families Project. Subsequent chapters focus on what can be done to improve these outcomes. The following provides a brief synopsis of the main patterns in this research. Main Patterns • Spanning more than a decade, research by the Partnerships for Children and Families Project offers insights into children’s and youths’ long-term community living adaptation from immediately following exit from RT to approximately five years after discharge. Important

Community Adaptation of Children and Youth  17

domains of community living included family relations, mental health, education and employment, and social and community conduct. • Levels of disruptive behaviour by youth prior to RT made it difficult for families to maintain their child within the home. While family discomfort eased during the time youth resided in RT and families were able to maintain some improvements after RT, family pressures and strained relationships at home persisted well beyond program involvement. • About half of the children and youth in our research were in the care of the Children’s Aid Society as wards of the state. Contact with family members and the importance of family was still paramount for many of these youth in care. Whereas 20 per cent of young adults who previously resided in state care lost touch with their families, 48 per cent were back living with family members following emancipation from child welfare care. • Children and youth in RT continue to live with a variety of emotional and behavioural challenges well beyond program exit, including anxiety, depression, and learning disabilities. Immediately following RT, youth were employing with some success various personal coping strategies learned in treatment. Beyond this initial stage, for some youth difficulties returned to pre-RT levels of disruption and concern. • School difficulties were pervasive among the children and youth accessing RT in our program of research, including absenteeism, poor academic achievement, and problems with peers and teachers. Academic difficulties increased from admission to follow-up, with over 70 per cent of youth in our follow-up studies experiencing serious difficulties. • Increasing proportions of youth dropped out of school over time, with over half of all youth (age 16 or older) no longer in school three to four years following RT. Of those youth not in school, 75 per cent were also unemployed, despite being old enough to have a job. Only about 20 per cent of young adults from our transition age study had graduated high school. • From one-third to half of youth over the age of 12 were involved with police and the youth justice system prior to entering RT. In many cases, these legal entanglements were catalysts for gaining access to RT. Involvement with police continued for half of all youth beyond exit from RT. For about one-quarter of young adults (approximately five years post-RT), engaging in illegal activities became a central feature of their daily living.

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• Poor community adaptation outcomes in one life domain were often seen in combination with negative outcomes in more than one other life domain. For example, school difficulties and trouble getting along with parents were linked with trouble with the law and substance use. As youth transitioned into young adulthood, these challenges had serious impacts in multiple domains of living (e.g., job loss, strained relationships, addictions, legal involvement). Research from the Partnerships for Children and Families Project The program of research started with a qualitative exploration of daily living realities and service experiences of 29 children and families involved in children’s residential mental health programs. In 2005, we began a larger and more systematic investigation of the long-term community adaptation of children and youth one to two years after leaving residential care and intensive family service programs. Additional funding received in 2008 enabled us to continue tracking these youth for another two years. This longitudinal study provided information on the daily functioning of 106 youth and their families three to four years post-residential care and an equal number of children/youth leaving intensive in-home service programs. In 2011, another three years of funding was received to continue studying the community adaptation of youth as they transitioned into early adulthood by interviewing youth from previous phases of the research, as well as additional youth over age 18. At the same time, a synthesis review of promising program elements to improve the long-term community adaptation of youth leaving residential children’s mental health programs was funded by the Ontario Ministry of Child and Youth Services in 2010. In 2014, additional funding allowed our research to focus specifically on youth processes and outcomes within the first year after youth graduated from RT. We highlight key findings from all phases of the research in this chapter. When these are combined, we present information on youth community adaptation from immediately following exit from residential children’s mental health programs to approximately five years after discharge. These findings set the backdrop for this volume’s discussion of programming considerations to support the after-care functioning of this youth population. See table 2.1 for an overview of the research phases, along with sample sizes and length of follow-up after exit from treatment. The strengths of this program of research include its continuity over different age cohorts of youth and the diverse types of information gathered about youth and their caregivers. However, because the community mental health organizations in this study did not track youth

Community Adaptation of Children and Youth  19 2.1  Timeline of Program of Research Research Phase (Years) Time of Follow-Up Sources of Information (After Exit from Treatment) Phase 1 (2001–2003) Initial exploratory study

1 to 3 years

29 parents and guardians

Phase 2 (2005–2008)

1.5 to 2 years

33 youth 106 parents and guardians Treatment files

Phase 3 (2008–2011)

3 to 4 years

79 parents and guardians Treatment files

Phase 4 (2011–2014) Transition age study

Approx. 5 years

60 young adults Treatment files

Phase 5 (2014–2018)

Within first year

22 youth 24 parents and guardians 22 RT service providers Treatment files

leaving their care, and given the great challenges in maintaining contact over years with youth in the research, it proved impossible to study a large cohort of these youth for multiple years after leaving mental health treatment. Consequently, we used multiple research cohorts to represent youth in the different phases of this program of research. Sample recruitment and maintenance proved to be very slow and arduous for this program of research. Samples typically represented all or most of the youth meeting the criteria for the research phase that we could contact. Additionally, youth and families were recruited through their involvement with our partnering children’s mental health organizations in small to medium-sized cities in south-western Ontario. These sampling procedures cannot guarantee the representativeness of these samples. Nonetheless, looking at agency and sector statistics, there is no doubt that the program of research included youth situations very common for this service sector. Equally important is the strength and consistency of the community adaptation patterns identified across all phases of the research. This program of research does document major challenges facing youth and their caregivers after the youth leave RT, as well as highlighting useful considerations for improving youth community adaptation outcomes. Parent and Youth Demographic Characteristics In our initial exploratory study, we interviewed 29 parents who had a child placed in RT at one of two south-western Ontario children’s

20  Necessary But Not Sufficient

mental health agencies. The 27 mothers and 2 fathers interviewed provided information on 23 male and 6 female children. The average age of interviewed parents was 40.8 years. The marital status of parents was as follows: married (31 per cent), divorced (31 per cent), single (14 per cent), common-law (14 per cent), separated (7 per cent), and widowed (3 per cent). Eighty-three per cent of parents indicated being born in Canada. The average length of children’s mental health service involvement was 1.8 years and may have included other services in addition to the RT stay. At the 1.5–2 years follow-up, we interviewed 106 legal guardians of children involved with children’s mental health RT, of whom 48 were parents and 58 were Children’s Aid Society (CAS) guardians. Thirty-three youth from residential programs were also interviewed. The average age of the 48 parents in this study was 41.0 years. We interviewed 46 mothers and 2 fathers. The marital status of parents was as follows: married (40 per cent), separated (21 per cent), divorced (17 per cent), single (13 per cent), and common-law (10 per cent). Eighty-seven per cent of parents indicated being born in Canada. The average length of stay in RT of the children and youth for whom we had data was 7.8 months. The average length of time between program discharge and the follow-up interview was 21.6 months, with 57 per cent of interviews occurring less than 18 months after program discharge. There were 83 male and 22 female youth, and the average age of youth at this follow-up was 14.1 years. Approximately three to four years after RT, we reconnected with 75 per cent of all legal guardians interviewed in the earlier follow-up study (79 out of 106). Over half of all RT interviews were with CAS guardians at this follow-up (41 out of 79). The average age of the 38 parents interviewed was 42.7 years. Half of these parents were married (50 per cent) followed by divorced (18.4 per cent), separated (13.2 per cent), common-law (10.5 per cent), and single (7.9 per cent). The average length of time between program discharge and this follow-up interview was 41.7 months (about 3.5 years), with 58 per cent occurring less than 42 months post-discharge. There were 61 male and 18 female youth with an average age of 15.6 years. In our transition age study, we interviewed 60 youth (age 18 or older) directly about their life circumstances. Twenty-one youth were those whose legal guardian was interviewed in an earlier phase and 39 youth were newly recruited in this phase. The average age of youth was 19.9 years; 60 per cent were male (36 males, 24 females), and 46.6 per cent were either in care or had been in the care of the CAS with crown ward status. Most youth had been out of RT for approximately five years.

Community Adaptation of Children and Youth  21

In our most recent study examining the first year following treatment, we interviewed 22 youth (age 14 and older), 13 parents and 11 CAS guardians, and 22 primary residential mental health workers. Over a series of interviews occurring approximately 1 month, 6 months, and 12 months following exit from RT, respondents shared in-depth descriptions of youths’ community adaptation processes and outcomes. There were 12 youth (7 females, 5 males) who returned to live with family after RT and 10 youth (6 males, 4 females) who resided in the care of the child welfare authorities. The average age of youth in this study was 15.6 years at our one-month interview. Overview of Research Methods Across our program of research, all youth, parents/guardians, and service providers were interviewed in person either face-to-face or over the telephone. We recruited participants from collaborating children’s mental health organizations in south-western Ontario that provided residential treatment to children and youth ages 5–18. All interviews were audio-recorded (with permission) and transcribed verbatim. Everyone who participated in an interview received a research stipend ranging from $25 to $40 for a single interview. All participants could choose to receive a copy of their interview transcript. We asked youth, parents/guardians, and service providers a series of semi-structured interview questions that addressed outcomes and processes in various life domains relevant to understanding community adaptation following exit from residential treatment. Several standardized measures of child and youth functioning at admission, discharge, and follow-up were also incorporated into the data collection. These included the Brief Child and Family Phone Interview, 3rd version (BCFPI-3) (Cunningham, Pettingill, & Boyle, 2002), which is a descriptive measure of mental health problems, child functioning, and impact on the family completed at program intake. We also included the Child and Adolescent Functional Assessment Scale (CAFAS) (Hodges, 2000), which assesses impairments in day-to-day functioning secondary to behavioural, emotional, psychological, psychiatric, or substance use problems at program admission. In each phase, quantitative data provided descriptive information about participants such as age, length of stay in RT, and demographics. The standardized measures (BCFPI-3 and CAFAS) were analysed using statistical software to generate average scores, frequencies, and patterns of change over time. The qualitative interview transcripts were analysed to decipher common themes important to understanding

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community adaptation following exit from RT. For a detailed description of the research methodology in our program of research, please refer to appendix 2. Research Results: Youth Functioning across Life Domains Research results are organized around several life domains considered important to understanding the long-term community adaptation of youth leaving residential mental health programs. These domains are family, mental health and well-being, school and employment, and social and community conduct. Within each domain, we discuss youth functioning in sequence: prior to admission, during program involvement, and after leaving the program (within the first year, 1.5–2 years, 3–4 years, and beyond 5 years post-treatment). The qualitative data we gathered from each of our follow-up studies offered rich and detailed descriptive information on the long-term daily functioning of children, youth, and young adults with emotional and behavioural challenges. Several youth vignettes from our research are included to illustrate the ongoing community adaptation challenges facing these youth and their families during key developmental periods (latency age, adolescence, and emerging adulthood). The vignettes we chose reflect a spectrum of functioning shared by many youth in this research. Life Domain: Family A key consideration in understanding community adaptation of children and youth involved with residential mental health programs is the assistance that family may offer in sustaining gains made while in RT. In this section we include family descriptive information, information about family relationships, and indicators of family functioning. prior to admission Typically, if a child or youth was still living at home when accepted into RT, the family was experiencing high levels of disruption within the home. Parents told us that they felt worn out and had exhausted all other options at that point. A striking gage of the pressures on family life prior to accessing a children’s residential mental health program was the extent and intensity of violence perpetuated by the child or youth within the home. About half of the parents of children over 12 years of age in our initial exploratory study talked about instances of violence by their child prior to entering care. The most common targets of violence in these accounts

Community Adaptation of Children and Youth  23

were mothers and siblings living in the home. The overt and perilous nature of some of the violence was evident: Last year when [son] was really sick, he became violent too and there was a lot of problems ... That was the first defiance, “I don’t want to go to school, I don’t wanna be in grade 7.” But we kind of kept moving forward, but he pulled a knife on me in the kitchen and I called the police and at that point they said you gotta get some help. He’d break the furniture, put holes in the walls, hurting my animals as to where up until a month ago I had to have one of my animals destroyed because of the child ... How he used to try and hurt the young one ... I would see [son] how he would hurt [his sister] and he had once took her head and banged it up against the table and she lost all her teeth.

Parents of children under 12 in RT described a marginally higher proportion (66 per cent) of their children engaging in overt acts of violence than did the parents of older children. Equally striking was the intensity of the violence given the relatively young ages of the children involved. Parents of younger children talked about this violence in greater length and with more intensity than parents of older children. This may be because more of this violence took place within the home. The dominant impression we were left with was that mothers and other family members did not feel safe in their own homes: No, you’re not going out, yes I am, whatever. And um ... he head butted me, and drove me across the floor, and (Okay), um ... nearly broke my nose ... Everything is going downhill. He can’t stay in school, I mean ... the last ... towards the end. Well, the last time he got suspended was ... he literally demolished the principal’s office, and ripped the blinds off the window, and beat the principal with them. He was endangering his sisters. He was physically attacking them. He was physically attacking me. He would hold us hostage at times. He would gather up things. Whatever he could find. A golf club or whatever, and he would just ... he would hold us hostage. This little boy. If you went anywhere near him to unarm him, he wouldn’t hesitate to throw things.

In our 1.5- to 2-year follow-up study, more than half of the children and youth were not living at home at the time of admission to RT. The most frequently reported places for these youth to live were in child welfare foster homes (32.8 per cent) and group homes (24.1 per cent),

24  Necessary But Not Sufficient

followed by independent living (19.0 per cent) and closed custody (10.3 per cent). Of the youth living at home, more than half (58.8 per cent) were reported to have “a lot” of trouble getting along with their parents at admission. The BCFPI-3 Family Comfort subscale measures the extent to which a child’s behaviour is thought to be a source of conflict and anxiety within the family. A higher score indicates a greater negative impact of a child’s behaviour on the family. The average score for families at admission was 88.8. This was substantially higher than the Ontario children’s mental health outpatient average admission score of 72.2 and well above the level indicating a clinically significant concern (70+ score). during program involvement All 29 caregivers of children in RT we interviewed in our initial exploratory study talked about prolonged and unrelenting stress for the entire family prior to program admission. These parents or caregivers described their relief during the time their child was out of the home. One parent said, “It was like a big weight being lifted off.” Another characterized RT as “taking the burden off” her other son, who was frequently drawn into the fighting in the home. Having their child placed outside of the home decreased tensions and demands on caregivers’ time within the home, enabling them to attend to their own and other family members’ well-being. One parent remarked, “The program ... gave us time to figure out exactly what the issues were and gave us much needed space that we wouldn’t have had [otherwise]” (de Boer, Cameron & Frensch, 2007). Parents connected receiving respite to their improved ability to attend to the needs of the placed child, their other children, and themselves. About half of parents and caregivers described substantial positive changes for other family members after their child was placed. In these families, daily living often became substantially more “functional” soon after the youth entered RT. For example, a mother of an older child said, “Now they [siblings] see that it’s a totally different situation. You don’t have to live fighting all the time ... It’s ... just the burden of ... all that anger ... off my shoulders.” Many parents talked about the benefits of RT for the siblings of the placed child or youth. One mother reported that her other children “are more settled because they don’t have the fear of being hurt anymore.” In addition, about half of the parents talked about positive changes for themselves after their child entered RT. Parents commented that involvement with RT allowed them and their other children to rejuvenate, increasing their energy and optimism. In our study of the first year following RT, many youth and parents said they engaged in family

Community Adaptation of Children and Youth  25

therapy as part of their involvement with treatment and youth home visits during their time in RT. Parents identified the positive impacts of youths’ improved personal functioning, such as newly learned anger management or self-regulation techniques, on family interactions within the home. after leaving the program From our conversations with youth and parents in the early weeks following their exit from RT, we heard tentativeness in the descriptions of life in the home. Youth spoke of being nervous about how they would manage the return to living with their family. Parents described a feeling of “walking on eggshells” around youth and articulated fears of saying or doing something that would undo hard-fought improvements. While youth and parents expressed hopefulness about maintaining gains made while in RT, there was sense of fragility to home life and family relationships in the initial days and weeks following discharge. This seemed to dissipate by our six-month interview and in some cases was replaced by an eventual return to previous patterns of family conflict. Some families were able to better deal with these issues by employing techniques learned through treatment than others were. Over the longer term (1–3 years beyond discharge), in many homes, parent-child conflict and other family pressures were still common, notwithstanding the evidence of less severe difficulties than at program admission. For example, in parent interviews from our initial exploratory study, despite improvements in specific aspects of child functioning in many stories, it was clear to us that parenting their child after RT continued to place substantial pressure on parents of teenage youth and other family members: Then I’m upset, the kids are upset, the kids come to me then I get mad at [son] and he gets mad at me and it’s just one great big roller coaster that doesn’t stop and it’s a constant thing ... He’d come in the house stoned so I can’t have that around little kids. I have four little children to think about. I can’t think about what he needs and wants. When he’s in the state that he’s been in for the last couple of days ... he’s sleeping, like, 15 hours a day ... He needs a lot of sleep, but not 15 hours. And he’s eating very little ... One person can upset the whole house ... It’s when the people leave, and he’s comfortable ... That’s when all the swearing, and the threats, and the humiliating things that are said to me.

For younger children living at home, three-quarters of the stories highlighted some improvements in relationships within the home,

26  Necessary But Not Sufficient

yet in each story, the struggles with parenting their child, while often lessened, continued. Positive changes included clearer expectations between parents and their child, more affection, and less extreme or enduring bouts of temper and conflict. All of the parents with a younger child returning home from RT commented on continuing difficulties in their relationships with this child using expressive language, such as “very frustrating,” “very hard,” “still have our challenges,” “I don’t have a life of my own,” “always a dull roar,” “still has the issues,” and “I’m embarrassed.” Struggles continued for these children and their family relationships at home: I find sometimes depending on the day I’ve had at work, my head can be just be swimming but at the same time I have to stay calm ... in order for me to get a sitter that, and it would have to be a special needs sitter. I always have to be on the go with her. Always finding things to do to keep her mind occupied. So she doesn’t feel alone or isolated or unloved and stuff ... basically, I don’t have a life of my own because all my time and patience goes to her.

About half of all youth living at home were described by their parents as having “a lot” of trouble getting along with their parents after leaving RT, and this did not change much over time (50 per cent at the 1.5- to 2-year follow-up and 40 per cent at the 3- to 4-year follow-up). Levels of disruptive behaviour by youth prior to RT made it difficult for families to maintain their child within the home. While family discomfort eased during the time youth stayed in RT and families were able to maintain some improvements after RT, family pressures and strained relationships at home lasted well beyond program involvement. Approximately 64 per cent of transition-age youth told us they returned to live with family at program exit. Overall 46 per cent of youth in the transition age study were or had been in CAS care as crown wards. About 20 per cent of these youth said that they had lost touch with their family. Now entering young adulthood, 22 per cent reported being married or living with a partner and about one-quarter of youth had one or more of their own children. Conversely, almost half (48 per cent) of youth were living with family members (usually parents) at the time of our interview. In our in-depth study of the first year following exit from treatment, a major storyline consistent with results from our other studies was the central importance of family in supporting youth and providing them with a sense of belonging over time. At the same time, family

Community Adaptation of Children and Youth  27

was also often a source of struggle and instability for youth. Understanding the place of family in many youth stories cannot be done one-dimensionally. While challenges may arise within the family, from marital break-ups to personal problems of other family members (such as addiction) or financial strains, many parents’ long-term commitment to their children and their multiple and persistent efforts in seeking help for their children were evident. There was a sense that a majority of parents were “in it for the long haul” and, whatever happens, their child would not be alone in confronting their challenges. youth who did not return home following exit from rt About 50–60 per cent of youth involved with RT did not return home when they left the program in our initial exploratory study (49 per cent), at 1.5–2 years follow-up (57 per cent), and at 3–4 years post-RT (61 per cent). Nonetheless, contact with family members and the idea of family were important to many of these youth in care: Well, I have a sister and I have a mother and a father. They’re divorced. My father’s whereabouts is somewhere in Toronto or Newfoundland. My mother’s whereabouts is unknown and my sister lives [in a care home]. Well [brother 1] and [brother 2], of like my entire family, [brother 1] is the closest one, [brother 2] is the second closest and me and [brother 1] get into a lot of trouble together because we’re always running away to see each other, because people in CAS really don’t set that up too often so we just want to see each other all the time so we’re always running away to see each other.

The following youth story illustrates a constellation of challenging life circumstances common to youth in our study who were in CAS care for most of their lives. Jamie’s story is marked by residential instability, inadequate parenting, drug addiction, and poor self-esteem. After no longer being able to live with his mother or father, Jamie eventually entered CAS care, spending much of his adolescence moving from group homes to foster homes and spending time in detention. Overall, youth in our research program who grew up in the care of the CAS confronted realities more complex and problematic than youth who returned to live with family members following program exit. Jamie, male, age 20 Until the age of 12, Jamie lived with his mom, but uncontrolled anger, a diagnosis of attention deficit disorder (ADD), and family circumstances led his mom to seek RT for Jamie. In RT, Jamie learned how to control his anger and received

28  Necessary But Not Sufficient counselling to help him get along with his parents. However, it would be many years before Jamie could overcome his resentment towards his mom for putting him in treatment. After RT, Jamie went to live with his dad, who was a heavy drug user. Soon Jamie became addicted to drugs as well and entered into the care of the Children’s Aid Society. During his time in care, Jamie lived many places, including group homes, foster homes, and his own apartment, and spent time in jail for breaking into cars and breaching probationary terms over 20 times in three cities. Jamie remembers his child welfare worker taking him out to bowl, play pool, and “talk about everything.” Jamie never did very well in school. He skipped a lot of class time and described his younger self as a “bad kid,” saying no one really liked him because he was mean. He eventually went to trade school in grade 10, where he earned some independent learning credits and had an apprenticeship in carpentry, which he never finished. During this time, Jamie had many jobs, including construction labourer, dishwasher, waiter, and landscaper. He admits that when he was young and irresponsible he sometimes just wouldn’t show up for work. Between the ages of 16 and 19, Jamie had a few homeless nights, most recently spending a rainy night in a park gazebo along the shores of a lake. Jamie went into detox a few times for methamphetamine addiction but always left to return to the drug. He describes it as one of the toughest addictions for him to battle as it runs in the family. It wasn’t until he and his father left the province that he kicked the habit. Jamie says he has been clean for over a year but still enjoys using weed and alcohol on weekends. Now 20 years old, Jamie has returned to live with his mom, her partner, and two half siblings. Jamie currently pays rent to live at his mom’s and is on an extended care and maintenance agreement with the Children’s Aid Society until his twenty-first birthday.1 Jamie says he doesn’t receive any ongoing financial support from child welfare, but his worker stays in contact with him and will occasionally take him out for lunch. While he no longer sees his dad, they talk on the phone a few times a week. He describes his dad as hard to get along with, and they sometimes argue over the phone. Jamie recently started a new job painting houses. He says the wages aren’t great, but the hours are good and the work is easy. Around the same time as his new job, Jamie began dating someone he met through friends. Jamie describes his girlfriend of four months as a good influence, as she helps him “stay out of trouble” by not going to bars. Jamie wants to be a heavy equipment mechanic but knows the training he needs is expensive, saying that Children’s Aid may only cover some of the tuition cost. He hopes to rent an apartment of his own in the near future.

Despite Jamie’s earlier negative life experiences, including the lack of a stable relationship with a supportive adult, family breakdown, and 1 More recently referred to as a Continued Care and Support for Youth (CCSY).

Community Adaptation of Children and Youth  29

addictions, he has returned to live with his mother now that he is a young adult. Among CAS youth interviewed as part of our transition age study, it was not uncommon for older youth to return to live with someone from their family of origin after they had “aged out” of the child welfare system. Some of the youth in CAS care had been through some very difficult experiences with their families. In the following quotes, youth talked about their complex feelings, including confusion, frustration, and sadness about being in care: We’ve been through a lot. Been through rich times, we had a lot of money. Been through a time when we wouldn’t have barely any food. It’s tough. As long as you have family and love in your family, you can get by it ... I like it just the way it is, besides ... besides my mom with her problem, that’s it ... She had a drug addiction, that’s it. [Q. What was that like for you?] It was hard, being right there. I talked to her, she’s in rehab. [Q. So, what do you like best about your family?] They care for me. Uhhuh. My brother always tell me not to – I don’t know, my brother always tells me to stop stealing cars and stuff. They care about me ... [Q. At what age did you start living away from your family?] I don’t know, I was like, two years old ... I don’t know, I don’t know anything about them ... I don’t know – I don’t barely know anything about them.

Youth expectations for closeness with staff and co-residents in care seemed fairly low, and while several youth mentioned that there were some “good” relationships with staff, even these relationships seemed somewhat distant. I tend to find staff in secure [custody] better than staff in group homes ... I dunno, they’re more looking for your positive rather than just following, like, the rules. Like, they’ll go out of their way on their own time to do something for you, like, when you’re in a group home, it’s work, you just go there, they babysit you and go home. I’m not trying to bash this house whatsoever, but I don’t know, I don’t want to tolerate it anymore. [Q. So, anything you do like about this place?] Um, well, I mean it’s a roof over my head, right? Even if I don’t like it at all, it’s still sometimes available for me. Um, I don’t know. I really don’t. There’s not much that I do enjoy about this house, hence why I’m never here.

A life without family was a reality for about half of the youth following their exit from RT. These youth talked neutrally at best of their

30  Necessary But Not Sufficient

lives in alternative care arrangements (such as a foster home, a group home, or independent living). For many of these youth, feeling that they are loved and that they have a home where they matter is a challenge. Where these children live and how these arrangements nurture them and prepare them for living on their own remain major concerns for the well-being of children involved with RT. Life Domain: Mental Health Children and youth in RT often continue to live with a variety of emotional and behavioural challenges after program involvement. The ongoing management of these challenges and the impact they have in the daily lives of youth and their families are important for understanding how well youth will navigate living in the community. We used several standardized measures of mental health, including the CAFAS (Hodges, 2000) and BCFPI-3 (Cunningham et al., 2002), to assess youth functioning in the life domain of health and well-being prior to entering RT and after leaving it. prior to admission Children and youth in our study struggled with a variety of emotional and behavioural problems prior to entering RT. Problems identified by parents in our initial exploratory study included hyperactivity, anxiety, depression, social withdrawal, delinquent behaviours, running away from home, skipping school, using illegal substances, aggression, and violence: A broken kid, overweight, unhealthy, a high anxiety, stress, afraid to take any risks. It’s just so sad because he didn’t used to be like that. He became a different kid. It’s heartbreaking really. She kept running away. She found the streets, started hanging around the wrong people, started doing drugs, drinking, and partying. He was always a bit hyper more so ... He used to scream a lot whenever he didn’t get his own way ... He screamed for 11 hours ... [Son] used to talk about killing himself because he hated himself.

We assessed youth mental health and personal functioning using several measures commonly administered at the time of this research by children’s mental health centres in Ontario. The CAFAS Moods/ Emotions Subscale assessed levels of anxiety, depression, moodiness,

Community Adaptation of Children and Youth  31

fear, worry, irritability, tenseness, and panic. At RT admission, almost 60 per cent of youth were experiencing “major or persistent disruption” in their lives as a result of these negative emotions. We noticed that the average score of 16.5 on the CAFAS Moods/Emotions Subscale for youth in our study was higher than the 2006 Ontario average score of 14.0, calculated using scores from approximately 18,520 children at admission to children’s mental health services (SickKids, 2006). The BCFPI-3 Managing Mood Subscale measured the extent to which youth have lost interest in their usual activities and relationships. At admission, youth in our 1.5–2 year follow-up study had an average score of 74.1, which was higher than the average score of 65.2 for a comparison sample of over 4,900 children assessed in Ontario children’s mental health centres in 2006 (St. Pierre, 2007). The average score for youth in our study on this measure was also higher than the clinical threshold score (70), indicating these youth were experiencing serious impairment in managing moods. Acting out and engaging in violent behaviour was characteristic of many youth prior to entering RT. Negative externalizing behaviour was measured using the BCFPI-3 Externalizing Behaviour Composite Scale, which consisted of a measure of overactive and impulsive behaviour, a measure of the degree to which youth were engaged in cooperative relationships with others, and a measure of antisocial behaviour. Youth in our study had an average score of 82.5 on this composite scale before entering RT, which suggested these youth were displaying levels of negative externalizing behaviours well above the Ontario provincial average score of 69.9 (St. Pierre, 2007). These high scores supported parents’ stories of youth aggression and violence before entering RT. during program involvement More than two-thirds of all parents in our initial exploratory study identified welcomed and significant improvements in their child’s functioning while the child was in RT. Positive changes included learning new skills and showing improved coping behaviours, improved school performance within the residential school, more control over emotions, and improved self-esteem. Parents also mentioned good weekend visits (though not without periodic challenges), an improved ability to exercise parental control, and less conflict at home. The time he was there, he learned more about how to deal with his feelings. He’s slightly autistic too. Very high-functioning, but um, he just ... he just learned that it was okay to try things. They praise the children there so much that his self-esteem just went soaring.

32  Necessary But Not Sufficient [Daughter] was in there with them for the third or fourth month, I thought, what a big change. This is great, she’s going to come home with her program stuff and she’s going to behave.

Additionally, our review of the discharge information (from treatment files) revealed that many youth had a significant reduction in impairment on the CAFAS Moods/Emotions Subscale. Overall, while most parents were generally hopeful about youth functioning during treatment and at discharge, they did not communicate that they believed their children’s struggles were over. after leaving the program In the first year following exit from RT, there was a noticeable “honeymoon period” when youth appeared to be managing well enough. This period began immediately following discharge and often lasted a few months. During this “honeymoon,” youths’ self-reports and parents’ perceptions of youth well-being suggested that youth were employing with some success various personal coping skills acquired in RT. This effect was seen across multiple life domains, including personal functioning, family relationships, and education. Beyond this initial stage, difficulties for some youth returned to levels of intensity experienced prior to RT. For most youth, even when positive gains were sustained, it was clear that behavioural and emotional challenges continued: He cuts the grass every week, and ... he still sets the table for dinner ... and dries dishes that don’t go in the dishwasher. Like, he still does that on a regular basis ... He never used to be able to control his anger and his emotions, no matter who was around ... Like, he’ll hold it while people are around, but ... unless it’s a real close friend, then I guess he feels comfortable. She thinks ahead, maybe not the way I want her to think ahead which may be some adjustment on my part. You know, like, I want so much more for her ... She doesn’t drink, she doesn’t smoke, she doesn’t do drugs. She just, you know, she doesn’t go to school the way I’d like her to and everything but you know she’s a good kid.

At 1.5–2 years after RT, scores on the standardized measures showed that levels of total mental health problems dropped from admission to follow-up, but scores continued to cluster around the clinical problem concern cut-off of 70. Similarly, despite significant improvement since admission to RT, levels of impulsive, defiant, and antisocial behaviour (as measured by the BCFPI-3 Externalizing Behaviour Composite Scale) were still within the clinical range of symptom severity at follow-up.

Community Adaptation of Children and Youth  33

Many of the young adults in our transition age study talked about the impacts of common mental health concerns in their daily lives.­ Concerns most frequently talked about were anger (73 per cent), anxiety (55 per cent), learning disabilities like ADHD (53 per cent), and depression (50 per cent). About 35 per cent were managing these concerns well enough to avoid major disruptions in their daily lives. A larger proportion (65 per cent) was experiencing serious impacts in multiple life domains (such as loss of a job, isolation from friends and family, or legal charges). Approximately 26 per cent of these young adults reported self-medicating with alcohol or drugs to “manage” their mental health conditions. Strikingly, 64 per cent of these youth reported significant addiction problems with alcohol or drugs in their past (more than a year ago). Many of them talked about overcoming their addictions and, at the time of our interview (approximately five years after RT), marginally fewer than 20 per cent of youth reported serious disruptive impacts of alcohol or drug use in their daily lives. Life Domain: School and Employment Difficulty at school was a pervasive issue for just about all the youth in our program of research. Staying in school and having some success academically were central to the conversations about education. Over and over we heard about trouble with teachers and peers, absenteeism, and poor academic performance. Underlying these concerns is a belief that how youth do in school is pivotal in their community adaptation and for their long-term life trajectories, including finding stable employment. Education undoubtedly plays a crucial role in our thinking about improving community adaptation profiles for youth graduating from RT. prior to admission Before entering RT, the majority of youth in our program of research were experiencing significant challenges with their schooling. Acting out in the classroom, conflict with teachers and peers, frequent absences, suspensions, expulsions, and grade failures were common. We measured school attendance and performance using the CAFAS School/Work Subscale. The average admission score of 22.5 from our 1.5- to 2-year follow-up study was higher than the 2006 Ontario average score of 14.5 for children admitted to mental health services, indicating that youth in RT experienced greater impairment in school performance (SickKids, 2006). Furthermore, 50.6 per cent of youth in this study displayed severe school impairment scores at admission (the proportion of youth with a score of 30 on the CAFAS School/Work Subscale).

34  Necessary But Not Sufficient

Parents’ narratives in our initial exploratory study dramatically emphasized the impact that severe school impairment had not only on the youth but also on their parents and other children in the classroom: He failed grade 7 and I didn’t tell him until about August ’cause I couldn’t. And when his dad came in and we both sat down with him and told him he had to repeat grade 7 and he sat and cried. He was devastated. She’d come home crying because her friends could read and she couldn’t and it took about three years where she could pronounce sentences and stuff. The behaviour is just so disturbing to the class. And they didn’t have a class ... special, for kids with ADD that would be just not distracting the rest of the class. So [son] spent the majority of his time outside of the class by himself.

Parents described being contacted repeatedly by the school. The parents we interviewed suggested that some youth could not be contained within the regular school system. He developed a habit and a pattern of running from school, going AWOL, disrupting things in class or during any programs. He had a lot of difficulty focusing ... It was challenging to try to be a mother and go to work and fulfil your duties there and have a school that’s calling a number of times each day.

Prior to admission, 87.6 per cent of youth in our 1.5- to 2-year follow-up study were in school, but only 78 per cent of these youth attended full-time. Approximately 58 per cent of these youth were reported to have serious school difficulties. during program involvement A significant component of RT delivered by our partnering children’s mental health organizations was the provision of on-site schooling for youth in their programs. The highly structured and increased teacher-to-student ratio classroom was described as a welcomed and effective change by many parents. Some parents reported improved school performance while their child was in residence: At [RT] he started in January, by the time he finished he was doing grade 6 level work and getting As and Bs ... He’s never, ever gotten an A before ever. And he’s doing his homework without me bugging him.

Community Adaptation of Children and Youth  35 It did work ... I don’t know if I can remember any specific things but they just had an influence on the way he acted and he would learn from them.

However, not all youth responded positively to the on-site schooling. When he first went into care, there was the potential for him to come back home ... as we progressed along with it and saw some of the issues developing with him as far as behaviours and his inability to focus at school and his lack of desire to apply himself to school and stuff like that it became more and more apparent that [he] probably wasn’t going to come home and fit into the home environment.

From our review of treatment files, the average score on the CAFAS School/Work subscale at exit from RT (14.4) was lower than the average score at admission (22.5), suggesting improved school functioning while in RT. While the overall trend showed improvement, 47.2 per cent of youth still experienced either moderate or severe impairment scores at discharge. In the next story, Evan’s academic needs exceeded the supports available to him in the regular school system, and after struggling academically for most of his elementary school years, Evan was able to finish grade 7 in RT. Despite the negative social influence of other residents, Evan learned to communicate better and did well in the on-site school. Now entering high school, Evan has joined the football team and knows he will have to work hard to keep his grades up. Evan, male, age 11 Always at least a head taller than his classmates, Evan struggled socially at school. He was intimidating to his same-age peers but also picked on by older kids who were the same size as him. After struggling academically and behaviourally in several schools, Evan left school that year without completing grade 5. He moved to another town with a friend of his mom’s to take a break from the local school system. Things didn’t work out and he soon returned home with no new options. Evan’s mom, a religious woman, got Evan into a Catholic school, where he started to do well with extra support from a resource teacher. Eventually Evan needed more support than the school could provide and he entered the onsite classroom at a RT centre. While in RT, Evan received counselling for anger management and oneto-one help from the classroom teacher. Unfortunately Evan was also easily influenced by other residents with more severe emotional and behavioural issues. He engaged in some fire setting, ran away from the RT school with another resident, and had to be restrained after becoming involved in an altercation among

36  Necessary But Not Sufficient several residents. Despite these challenges, Evan learned to communicate better with people, became more talkative, and gained personal confidence in his abilities. Upon program completion, Evan transitioned back into the regular school system in grade 7. Evan was raised by his mom without any support from his biological father. He and his mother relied on the support of family and friends over the years. Evan remembers his grandparents taking him and his mom out for supper, buying them groceries, and going on short car trips together. An older woman who lived in the apartment next to them also became a source of friendship and support. Evan lived with her for a short while when things between him and his mom were tough. Evan was physically aggressive with his mom a few times. They would often yell at each other, with his mom admitting, “We had some pretty bad fights at home.” When Evan returned home after RT, he was very glad to be back with his mom and she was happy to have him home as well. Now entering high school at 6'3' and 220 pounds, Evan started playing football and enjoys being a part of the team. His coaches are supportive and encourage him to do well academically, but Evan knows he will have to work hard to keep his grades up.

after leaving the program In their first year following RT, a number of youth we spoke to said they continued to attend the on-site RT classroom after discharge. For some, this arrangement lasted up to two years. Youth appreciated the smaller class size and flexibility of lesson content and format. Transitions to other alternative schooling were generally described as difficult. For some, this invariably led to a regression in school progress, including skipping class, not completing the lessons, and dropping out. Very few parents in our initial exploratory study described sustained improvements in how well their child was doing in school after leaving RT. However, 76 per cent of youth were reported still to be in school at 1.5–2 years following RT (partially because of their young age in this research phase). Parents of youth still in school at follow-up reported ongoing and sometimes increasing problems with absenteeism and academic difficulties. He learned to handle himself socially better but his academics dropped further so it seemed like they concentrated mainly on the social stuff and the emotional issues and his education slipped. Once he got in school, in his first semester in the all-nine program, with special ed and behavioural supports, he did fantastic. He did so well that his marks were in the upper 80s. He was like the model

Community Adaptation of Children and Youth  37 student ... Then they said “oh, he’s doing so well, his marks are so high, we’re going to put him in the regular program.” ... It was fatal.

Results from our follow-up studies (1.5–2 years and 3–4 years after RT) confirmed parents’ earlier portraits of increasing academic difficulty over time. The proportion of youth experiencing serious school difficulty increased from 58.2 per cent at RT admission to over 70 per cent in both follow-up studies. We noted that most of these youth were not yet old enough to end their educational involvement legally. Once youth were 16 or older, at that time in Ontario, they could make the decision to leave school. The proportion of youth age 16 or older who were not in school at 1.5– 2 years post-RT was 54.1 per cent. Seventy-one per cent of youth not in school left by their own choice (they chose to leave temporarily or decided to leave school permanently). The remaining youth were not in school as a result of suspensions or expulsions. Of the youth not in school, 75 per cent were also unemployed despite the fact that most of these youth were old enough to be involved in paid employment. At our 3- to 4-year follow-up, the proportion of youth over age 16 not in school remained relatively unchanged at 51.2 per cent. The following two youth described the circumstances leading to their decision to leave school: The reason I left is because of all the stress. All the kids always pickin’ on me, I’m a main centre for bullies, so ... Everybody likes to pick on me and stuff was just not going well, so, my anger would get the best of me so ... Basically, one kid said the wrong thing, I gave it—one time kicked a window in. Instability. Yeah, just basically a lot of drama and crisis and I was just an emotional wreck so that prevented me from continuing to go to school because unfortunately I was in the mind frame that it didn’t matter.

In our transition age study, there were more youth not in school than youth in school. The average age of these youth was around 20 years old. Of the almost 60 per cent of youth not in school or any training program, only about 22 per cent had graduated high school. About 51 per cent of the youth not in school were employed, and of those just over 61 per cent were working full-time. Hopes of returning to school to get a diploma (or equivalency) or returning to further their education were expressed by many young adults. About 77 per cent of youth said that they could use some help achieving their school goals either immediately or in the future.

38  Necessary But Not Sufficient

Life Domain: Social Connections and Community Conduct prior to admission About half of all the youth over the age of 12 in our initial exploratory study were involved with police and the youth justice system prior to entering RT, according to parents and guardians. In many cases, being in contact with the legal system led to their access to RT. Actually we couldn’t find him for an hour and it was probably the worst moment of my life; he did come back to the office and the police were waiting for him and they handcuffed him. That was pretty hard. That was a tough one but I knew it was the right thing to do. Then I started having to go to court for her for truancy, she got charged with truancy. Charged. This day and age charged for truancy because not only did she not go even after she was told, then she was threatened with being charged, then she still didn’t go.

In our 1.5- to 2-year follow-up study, serious rule violations and antisocial behaviour among youth were measured using the BCFPI-3 Conduct subscale. At RT admission, youth (n=75) had an average score of 93.3 on this subscale, which is considered very high, with approximately 98 per cent of the general population having scores below 70. Additionally, the average score on the CAFAS Behaviour Toward Others Subscale at admission was 21.4, far above the average score of 12.4 for the comparison sample (SickKids, 2006). This subscale assessed appropriateness of behaviour towards others including displays of anger, poor judgment, and inappropriate behaviour. Over 80 per cent of youth experienced moderate to severe impairment on this subscale at program entry. during program involvement While in RT, positive changes among youth included improved social relations, increased cooperation with program personnel and generally settling down in the program environment. One parent from our initial exploratory study described her son’s success: He’s been a book buddy to the younger ones, which ... he can be very helpful ... but you’ve got to be very careful, because ... a young child poking him the wrong way ... can set him off ... He’s even been allowed to go on trips ... because he has made great strides, and out of the whole class, he’s been picked as a guide for the younger classes.

From program admission to discharge, youths’ appropriateness of behaviour towards others showed a significant improvement on the

Community Adaptation of Children and Youth  39

CAFAS Behaviour Toward Others Subscale. The average score on this measure dropped to 13.0 from 21.4 at program entry, indicating less impairment. The proportion of youth with moderate to severe impairment in their appropriateness towards others fell to 38.6 per cent at discharge from over 80 per cent at RT admission. Not all youth, however, experienced gains in their social relations and community conduct during RT. One-third of parents/guardians in our 1.5- to 2-year follow-up study with children over 12 talked about their child’s serious behaviour problems while in treatment, including running away from the program, delinquent or criminal actions, and substance abuse. Some of these youth became involved in delinquent activities with other youth they met at the residence. He was the youngest there and yes, he’s going to take on all those bad habits and because of his problem, there wasn’t a whole lot more they could do for him ... They had done everything they could.

after leaving the program Almost half of all youth in our follow-up studies (1.5–2 years and 3–4 years) had contact with police since leaving RT. This proportion was an increase from admission, when fewer of these same youth (29 per cent) were reported by parents/guardians to have trouble with the law. The proportion of youth who were in trouble with the law and consequently received formal charges was 64.7 per cent at 1.5–2 years after treatment and increased to 83.8 per cent at 3–4 years after treatment. These increases were likely due to the older age of youth in our follow-up studies. Some youth spoke candidly about their delinquent activities. We always fight people ... Um, because every time people say stuff, we always fight them. Most of the guys I used to do drugs with, they’re either in jail or they’ve moved, or ... something. [Q. What do you think about that?] How happy that I stopped and I’m here. I’m part of a gang ... if you want to be initiated into it, you get 30 seconds of fame, which is, like three or four people beat you for 30 seconds, because if you can’t handle that or you start crying or fight back, then how are you ever going to handle a gang fight?

In our research, getting in trouble with the law around 1.5 to 2 years after treatment was best predicted by several things, including whether a youth already had contact with the law before entering the program,

40  Necessary But Not Sufficient

greater difficulties in school at admission (as measured by increased impairment on the CAFAS School/Work Subscale), being older (with older youth at greater risk of contact with the law), and being male (with males more likely to experience trouble with the law than females). For an expanded discussion of this regression analysis, see our journal article (Cameron, Frensch, Preyde, & Smit Quosai, 2011). For about one-quarter of the young adults we interviewed in our transition age study, involvement with delinquent peers, antisocial behaviours, and illegal activities were central to their daily lives. These young adults, who were mostly young men, were negatively involved with the law (at least once within the two years prior to our interview) and were also experiencing serious and ongoing challenges in most other areas of their lives. Co-occurring problems included substance abuse, personal functioning issues, and disengagement with the worlds of school and work. Damian’s problems with the law followed a string of academic and behavioural challenges beginning early in his school career. Coupled with a chaotic home life, Damian started associating with a group of youth involved in more serious criminal activity. Damian, male, age 16 In grade 3, Damian was diagnosed with ADD and, during this time, he received a lot of support and encouragement from his principal and teachers. Hyperactive, in constant need of attention, and charming, Damian was well liked by everyone. Things seemed to be going well when Damian and his family moved to a different neighbourhood where Damian would attend a new school. Damian’s behaviours became too disruptive for the classroom and he spent a lot of time outside of class by himself. In high school, his troubles continued and Damian was getting suspended “every other week.” At age 12, Damian brought a pocketknife to school from his grandmother’s house. During a fight, Damian pulled out the knife and threatened to use it. He was charged by police and decided to enter RT rather than face more serious consequences. In RT, Damian was quiet and likable for the first few weeks but soon was defiant and threatened to punch out one of the staff. The police were called on Damian while he was in RT, and eventually he left treatment early. After RT, Damian’s behaviour was “up and down.” He became friends with a younger teen in the neighbourhood and they enjoyed watching movies and playing video games. Encouraged by the changes she saw after RT, Damian’s mother allowed him to spend more time away from the home. Around the same time, he started hanging out with a tougher, older group of friends. Damian’s delinquent behaviours escalated to breaking into houses, and he was charged with robbery and assault along with his new friends.

Community Adaptation of Children and Youth  41 Growing up in a tight-knit immigrant extended family, Damian witnessed the pressure his mother was under to stay married. After his parents divorced, Damian was raised by his grandmother on weekends and would spend weekdays with his mother and her new partner. Over the years Damian received counselling on and off to deal with a tumultuous family life. Eventually, Damian rebelled against his mother and stepfather. At age 15, Damian moved out of his mother’s and stepdad’s home and quit school shortly afterwards. For the first while, he had a place of his own with the support of his dad and then moved in with his grandmother for a short time. When that didn’t work out, Damian went to live with his dad. Damian’s mother tried one last time to help him get back on track by connecting Damian with counselling and school and offering him financial support if he could stay in school. Damian wasn’t able to do this and become physically abusive towards his mother and used drugs. His mother pulled his bond and Damian was re-arrested.

Damian’s story captures the multiple challenges he was struggling with simultaneously across various life domains, including a learning disability (ADD), subsequent school difficulties, a chaotic family life, residential instability, associating with delinquent peers, and poor decision-making around engaging in illegal activities and substance use. patterns across multiple life domains Typically youth entering RT are struggling with difficulties in multiple life domains and are unable to be maintained within their families or in other less structured living arrangements, schools, and communities. Often the relationships among multiple difficulties are complex. For example, youth who disengage with the school system have more opportunity to engage in delinquent behaviours with other disengaged peers. Youth who have trouble at home may be less receptive to learning. Youths’ personal functioning influences their success in multiple life domains. Across our program of research, the majority of youth exiting RT continued to struggle in multiple life domains, and these concerns, while lessening in severity, persisted over time. Overall, school difficulties and dropping out were linked with problems in other life domains (legal, employment, substance abuse). For example, 48 per cent of youth with moderate to severe school difficulties at RT admission were in trouble with the law at 1.5- to 2-year follow-up, compared to only 23 per cent of youth with modest or no school difficulties at admission. Striking differences in community adaptation outcomes were noted between young adults in our transition age study who had a high school education (or equivalent) and those who did not. Of the young adults who did not have a high school education,

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only one-third were employed, 40 per cent were currently involved with the law, and one-third had current substance abuse issues. Of the young adults who had a high school education (or equivalent), half were employed, none were currently involved with the law, and only two young adults (3 per cent) reported current substance abuse issues. In our transition age study, the co-occurrence of substance use and other life domain problems emerged as a key consideration. These young adults were remarkably candid about their past problems with substance use, ongoing use of alcohol and drugs, and its impacts in other domains of living, including employment, trouble with the law, and family relationships. For example, 20 per cent of the young adults revealed persistent and problematic substance abuse, 34 per cent reported moderate usage, and 46 per cent had no or minimal substance use. Only 18 per cent of persistent substance users had a job, compared to 37 per cent of moderate users and 68 per cent of minimal users. About 45 per cent of persistent users had been in trouble with the law within the year prior to our research interview, whereas only 26 per cent of moderate users and 16 per cent of minimal users had. More than half of persistent/problematic users (55 per cent) said that they were using either alcohol or drugs for self-medicating purposes, compared to 26 per cent and 4 per cent of moderate and minimal users respectively. Persistent users had consistently more problematic scores in the areas of regulating attention, impulsivity, conduct, mood, anxiety, and self-harming behaviours. groupings of young adults Our conversations with young adults several years after their involvement with RT created a unique opportunity to explore the experiences of transitioning to adulthood for this particular group of young adults (with an average age of 20). What emerged from this exploration was a rich description of five dominant subgroups of young adults based on their functioning and experiences within key life domains (education, employment, social connections, and personal functioning). We briefly describe these groups below. Young adults in trouble with the law (24 per cent) were mostly male (85 per cent) and over half had been living in state care (57 per cent). These individuals were engaged in ongoing illegal or delinquent activities often with peers who had similar involvements, were disconnected with education and employment environments, experienced difficulties with personal functioning including problematic substance use, and had precarious relationships with family members and, in a small minority, intimate partners.

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Young adults who are socially isolated (24 per cent) consisted of more females (65 per cent) than males, and most did not grow up in state care (57 per cent). These young adults were isolated from social networks and had limited involvement in community or recreational activities, experienced difficulties establishing connections with others and were hesitant or unable to trust others. They also were dealing with personal functioning challenges such as depression, anxiety, and trauma from past abuse. Struggling young adults (17 per cent) were slightly more likely to be female (60 per cent), and 30 per cent had grown up in state care. These individuals were experiencing major difficulties in multiple areas of living, including education, employment, health, and personal functioning. When they were interviewed, they were in crisis or not coping well with daily life. Young adults who are managing well (28 per cent) were divided almost equally between females (53 per cent) and males (47 per cent), as well as between those who had been in state care (47 per cent) and those who were not (53 per cent). Young adults in this group were experiencing some success and enjoyment in several areas of living and were engaged in active coping strategies to manage their personal challenges. They were connected to supportive networks including family, friends, and adult mentors. Young adults who are striving for success (7 per cent) were very few in this study. They were all males who grew up living with their families. These young men were achieving personal, educational, and employment success, and they had supportive family, friends, and social involvements. They were no longer experiencing ongoing mental health issues. In addition to a greater understanding of these functioning group profiles, two other dominant group profiles emerged from this study of young adults: young parents and young adults who grew up in the care of child welfare authorities. Overall, young parents made up 24 per cent of the young adults we spoke to and 57 per cent of these young parents were women. However, from our earlier groupings, 35 per cent of the young males in trouble with the law had fathered one or more children. They often did not live with their children. Young mothers generally lived with their children. Few of these mothers had completed their high school education and all were unemployed while they cared for their children. None of these young adults mentioned using drugs or alcohol at the time of our interview, but 80 per cent of the women said they had struggled with substance use in the past.

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Young adults who grew up in the care of child welfare authorities (47 per cent) were recognizable by the precarious nature of their lives, including highly unstable and insecure living conditions, a difficulty adapting to these changing living circumstances, and continued family relationships coupled with persistent tensions with family members. About 70 per cent of the young adults with a history of CAS care were in one of the previously described more problematic functioning groups, and none of these young adults were in the striving for success group. These young adults often had access to few resources to help them face their personal challenges. Gender and Ethnicity Typically more males access residential treatment than females. A recent review of the characteristics of children in residential mental health treatment reports that the proportion of males in treatment ranges from 59 per cent to 72 per cent (Leloux-Opmeer, Kuiper, Swaab, & Scholte, 2016). Similarly, in our research, the proportion of male children and youth ranged from 60 per cent to 80 per cent across study phases, apart from our young adult group, in which we purposefully recruited equal numbers of males and females. The increased presence of males in residential mental health care may be understood in part by the nature of what precipitates entrance into residential treatment. Other studies have reported males in RT more frequently evidence acting out or externalizing behaviours such as conduct problems, conflict with others, and hyperactivity, while females suffer with relatively more internalizing problems (Knorth, Harder, Zandberg, & Kendrick, 2008; Strijbosch et al., 2015). In our research, at admission males were struggling with higher average levels of externalizing behaviours such as impulsivity and hyperactivity than females (as measured by the parent-reported BCFPI-3). However, these gender differences did not hold steady over our follow-up periods. As mentioned earlier, in our young adult study there were more females who were already young mothers (29 per cent) than males who were young fathers (14 per cent). We also noticed that greater proportions of young women than young men in this study were not living with their family (83 per cent vs 46 per cent), had lost touch with their family (36 per cent vs 15 per cent), and had ever been homeless (50 per cent vs 24 per cent). Conversely, young men appeared to fare worse than young women in their community conduct. Greater proportions of males than females had been in trouble with the law since leaving residential care (65 per cent vs 21 per cent) and were in trouble with the

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law within the year prior to our interview (38 per cent vs 9 per cent). Admittedly, our look at the role gender may play in understanding how youth fare over time beyond program exit remains underdeveloped, as it was not a focus of our research. Consideration should be given to carrying out additional work to explore differential experiences of community adaptation and to thinking about the responsiveness of services offered in the post-discharge period. This book also does not explore the community adaptation experiences of racial, ethnic, or cultural minority children, youth, and young adults following exit from residential mental health programs. Across our research studies, the proportion of respondents who said they were born in Canada ranged from 83 per cent to 98 per cent, with English being their first language spoken. In our young adult study, seven individuals identified themselves as Indigenous persons (12 per cent) and nine identified themselves as a visible minority based on their ethnicity (15 per cent). This homogeneity was undoubtedly a reflection of the region in which our research was carried out (south-western Ontario) and representative of the larger population of service recipients accessing this type of intensive mental health treatment option. Other reviews have reported on the barriers to accessing health and mental health services for Canadian immigrant families (Kalich, Heinemann, & Ghahari, 2016; Thomson, Chaze, George, & Guruge, 2015). Again, an exploration into the community adaptation and service experiences of diverse children, youth, and families accessing residential programs is warranted. Implications for Improving Community Adaptation In our program of research, there was ample reason to be concerned about the long-term community adaptation of both youth in CAS care and those living with their families who have graduated from RT programs. Improvements in youth behaviour on many indicators at program discharge poorly predicted how these youth fared at home and in the community. Existing graduation procedures from RT did not serve these youth particularly well. Many youth continued to struggle beyond program exit; and for most, their challenges tended to be multiple and to co-occur, with particular overlap among school difficulties, trouble with the law, difficulty getting along with parents, unemployment, and substance use. Undoubtedly RT, while helpful for many youth and families in specific areas of functioning, is not sufficient on its own to produce good community adaptation outcomes for many of these youth. A consideration of equal importance is the feelings of isolation

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and heavy caregiving burden experienced by parents of children and youth leaving RT. While specific therapeutic interventions and the passage of time can bring about improvements, many youth will continue to have difficulties in key community adaptation domains of living long after RT. Many will face new challenges as they navigate the transition from adolescence to young adulthood, hoping to secure employment, independent living, and healthy relationships with partners and family members, as well as good mental health. This suggests that helping youth to manage their behaviours and to develop a core set of community adaptation skills is best understood as an ongoing process. Overall, the potential is evident for after-care programming that begins before treatment ends, supports youth and their caregivers, strengthens youth networks, and addresses many of the major factors linked conceptually and empirically with improved community adaptation outcomes. This is the focus of the remainder of this volume.

Chapter Three

Theories and Concepts Relating to Community Adaptation

Research generally indicates that residential children’s mental health treatment can produce positive outcomes for youth and their families, at least in the short term. But what happens in the long term? How do these young people adapt to community life when they begin to make the transition, not just from living in residence, but from childhood to adolescence to young adulthood? What kinds of supports do they need to make these transitions successfully? Before we can answer these questions, we need to consider, first, what successful community adaptation would look like for these individuals. We would also need to consider what kinds of barriers might stand in the way of successful community adaptation and the kinds of resources that are needed to overcome these barriers. A number of theoretical frameworks, mostly within the field of developmental psychology, can help us understand why some young people adapt successfully to their communities (and others do not). An understanding of these frameworks can help us identify some of the circumstances and processes that help or hinder a youth’s transition to community life and guide the development of programs that may help young people adapt successfully. This chapter describes some of the major theories and constructs that have been used to understand community adaptation and the key factors that help to determine whether a young person will be successful or unsuccessful in adapting to community life. We start by describing what successful adaptation to the community looks like for young people and identifying some of the key indicators of successful adaptation. We then discuss several constructs or conceptual frameworks that can be used to help understand why some youth adapt successfully, while others have more difficulty. These constructs and conceptual frameworks draw upon developmental psychopathology, attachment theory, risk and resilience theory, ecological systems theory, and positive youth

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development theory. Elements of these conceptual frameworks are then drawn together in an initial integrated theory to identify the key considerations in helping youth who have graduated from RT adapt to community life. Finally, we discuss how an understanding of these key considerations can be used to guide the development of programs to help young people make the transition to community living. What Is Community Adaptation? In 2004, researchers from the Search Institute, a non-profit research organization devoted to providing “leadership, knowledge, and resources to promote healthy children, youth and communities,” joined with researchers from the University of Washington’s Social Development Research Group to ascertain the key indicators of successful development in young adults (Benson, Scales, Hawkins, Oesterle, & Hill, 2004). Based on thorough review of research and theory in the area of child and youth development, they identified eight general indicators of successful development or adaptation: • Physical health – includes behaviours such as abstinence from abuse of substances, regular exercise, and the avoidance of violence; • Psychological and emotional well-being – indicated by attributes such as having a positive outlook and a sense of purpose; • Life skills – such as the ability to make decisions, regulate emotions, and get along with others; • Ethical behaviour – involves things such as being truthful and avoiding crime; • Healthy family and social relationships – including with parents, intimate partners, and peers, as well as involvement in community activities such as sports teams, cultural organizations, or arts groups; • Educational attainment – exemplified by completing high school, obtaining a degree or diploma, or achieving a professional or skilled trade designation; • Constructive engagement – defined as spending 35 hours a week or more in school, at work, or homemaking; • Civic engagement – involves establishing a presence in the community through activities such as volunteering. Young adults who have these attributes are considered to be thriving and to have adapted successfully to their communities. But how do young people develop these attributes? Why is it that some young

Theories and Concepts Relating to Community Adaptation  49

people develop many of these qualities, while others achieve very few of them? What are the key factors that will determine whether a young person follows a life trajectory that leads towards thriving and healthy adjustment, or one leading towards difficulty and maladaptation? Several theories of development address these questions. Developmental Psychopathology One way of attempting to understand why some young people adapt successfully, while others do not, is to focus on the causes of maladaptation. Developmental psychopathology is the subfield of developmental psychology and child psychiatry that attempts to understand what causes a child or adolescent to deviate from a normal trajectory of development to a more troubled or pathological one. Developmental psychopathology was originally defined by Sroufe and Rutter (1984) as the “study of the origins and course of individual patterns of behavioral maladaptation, whatever the age of onset, whatever the causes, whatever the transformations in behavioral manifestation, and however complex the course of the developmental pattern may be” (p. 18). There has been much discussion of this scientific discipline since that time (e.g., Cicchetti, 1993; Rutter & Sroufe, 2000; Sameroff, 2000). From this theoretical perspective, a major tenet is that knowledge of normal development is essential for understanding maladaptation, since any psychopathology can be conceptualized as a deviation or distortion of normal ontogenetic processes. However, distinguishing normal from abnormal can be quite a difficult task. For example, are certain emotions such as feeling sad on the same continuum as clinical depression or are they qualitatively different? Are different mechanisms involved? Many developmental concepts are analysed within the developmental psychopathology approach, such as the continuity and discontinuity of adaptive or maladaptive behavioural patterns, the notion that different pathways can lead to the same developmental outcomes, the analysis of the mechanisms operating in individuals and their environments across the individuals’ lifespan, the analysis of risk and protective factors, and the identification of pathways to normal development in the face of adversity. For our purpose, this focus will be on high-risk individuals who develop an actual disorder, such as a behavioural problem, and high-risk individuals who do not. There is an appreciation that a particular stressor or other underlying mechanism may lead to different behavioural outcomes at different times in the developmental trajectory and in different contexts. Events

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also are given meaning by each person’s unique cognitive processes such that individuals often experience the same event differently. Maladaptation also is viewed as multiply determined. Another basic tenet is that individuals do not possess either pathological or non-­ pathological forms of functioning; rather, they typically move between these two forms. Furthermore, even when individuals display pathological functioning, they can still demonstrate adaptive coping mechanisms. Developmental psychopathology is more concerned with patterns of adaptation and less concerned with individual characteristics such as personality traits. Furthermore, consistent with ecological theory, a focus of this perspective is the formidable influence of the social context on individual development. One purpose of developmental psychopathology of particular interest for this volume is the identification of the “factors and mechanisms that may deflect an individual out of a particular pathway onto a more or less adaptive course” (Cicchetti, 1993, p. 474). Developmental psychopathology represents an integration of various theoretical approaches such as attachment theory (Bowlby, 1969), including the antecedents and consequences of secure and insecure attachments (Ainsworth, Blehar, Waters, & Wall, 1978; Bowlby, 1980), ­developmental theories (such as Piaget’s [1977] theory on cognitive development and Bandura’s [1977] social learning theory), and environmental t­heories (e.g., Bronfenbrenner’s [1977, 1979] ecological systems theory). Developmental psychopathology shares common risk and protective factors related to community adaptation with these theories. Attachment Theory One of the key factors that will determine whether a young person does or does not adapt successfully to community life is the individual’s ability to form stable, healthy relationships with others. Attachment theory is a prominent theory about how individuals develop relationships with others and how these relationships affect their lives. Research shows that the very first relationship that individuals have – those between infants and their primary caregivers – are critical determinants of their later development. Social development begins with the establishment of an emotional attachment between infants and their caregivers (Bowlby, 1969). Emotional attachment refers to the affectional ties that one feels for special people (e.g., a caregiver). As infants develop, their attachments extend to others within and outside the family. These attachment ­figures become models guiding the acquisition of ways of thinking

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and behaving. Internal working models of social relationships (Bowlby, 1980) are the cognitive representations that youth form during infancy of themselves, other people, and ideas about relationships. Youth rely on these internal working models to guide their social interactions in various contexts, and these models have considerable implications for community adaptation. Moreover, attachment patterns develop within particular cultural contexts (Morelli & Rothbaum, 2007). For example, people in Western cultures are thought to value personal qualities such as autonomy, while some non-Western cultures may consider relational qualities such as interdependence more important than autonomy. It is important to note that the family culture or the culture to which the primary caregiver subscribes can have an enormous influence on attachment. The quality of the attachment during infancy has implications for the later development of a youth’s sense of security and competence (Ainsworth et al., 1978; Benoit, 2004). The concept of organized attachments refers to the notion that when infants are distressed and their caregiver comforts them, they know how to respond to this familiar behaviour. There are three types of organized attachments: one is secure and two are insecure (resistant and avoidant). Insecure attachments are associated with an increased risk of developing problems in social and emotional adaptation. The concept of disorganized attachment refers to the notion that when infants are distressed, they do not know what to do in response to their caregiver. Many factors influence attachment. Reciprocal relationships indicate that caregivers influence children, and children influence caregivers to think and behave in certain ways. Goodness-of-fit refers to the match between the characteristics of the parent and family environment and the characteristics of the child. The quality of attachment is influenced by variations in caregivers’ ability to create warm and sensitive relationships, child temperamental factors, and issues not attributed to caregiver or infant characteristics. Youth who have developed a secure attachment are more likely to demonstrate better sociability and relationships with siblings. They also tend to have higher self-esteem, greater empathy, and better problem-solving abilities. Youth with secure attachments have been shown to have fewer behavioural problems and demonstrate less aggressive or disruptive behaviour. Children whose primary attachments are insecure are more likely to become hostile and aggressive in later years, to be socially or emotionally withdrawn, and to exhibit clinically relevant psychological difficulties (Enns, Cox, & Clara, 2002). They are more likely to experience

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poor peer relations and few close relationships, and to display ­deviant behaviours such as disobedience throughout childhood and adolescence (Allen, Weissberg, & Hawkins, 1998; Schneider, Atkinson,  & Tardiff, 2001). Disorganized attachment is recognized as a strong ­predictor of maladjustment and emotional and behavioural problems in youth (Benoit, 2004; Green & Goldwyn, 2002). Risk and Resilience Some of the most prominent theories used to explain why some young people are able to adapt centre on the concepts of risk and resilience. Risk factors are circumstances that result in young people having a greater likelihood than normal of developing problems. There are many kinds of circumstances that result in a child or youth being at greater risk for developing serious emotional or behaviour problems. Poverty is one of these circumstances (Bradley & Corwyn, 2002). Exposure to maltreatment, such as physical or sexual abuse, is another (Maniglio, 2010). Witnessing violence either inside or outside the home is yet another factor that increases a young person’s likelihood of developing problems (Margolin & Gordis, 2000). For example, a recent study using a nationally representative sample of Danish grade 9 youth found that boys who witnessed severe violence at home were more than three times as likely to develop emotional problems as boys not witnessing violence (Helweg-Larsen, Frederiksen, & Larsen, 2011). Other factors associated with higher risk for the development of emotional and behaviour problems in young people include parental conflict and divorce (Amato, 2001; Bradford, Vaughn, & Barber, 2008), parental alcoholism or substance abuse (Vidal et al., 2012), and physical illness of either the child or a parent (Barkmann, Romer, Watson, & Schulte-Markwort, 2007; Hysing, Elgen, Gillberg, Lie, & Lundervold, 2007). Parents who experienced trauma and maltreatment as children often have difficulty providing a nurturing environment for their children (Amos, Furber, & Segal, 2011). In addition, for many youth, the act of being removed from family and placed in state care is traumatic even if unavoidable. The impact of risk factors appears to be cumulative; young people who experience multiple risk factors are more likely to have mental health problems (Forehand et al., 1991). Repeated exposure to risk factors is associated with a greater likelihood of more severe youth problems (Hickman et al., 2013; Nilsson, Gustafsson, & Svedin, 2012; Thakar, Coffino & Lieberman, 2013). Repeated exposure to potentially traumatic events also has variable consequences at different stages of youth development and can lead to a progression of psychological disorder

Theories and Concepts Relating to Community Adaptation  53

diagnoses as youth age (Carrion & Wong, 2012; De Bellis, 2001; Schmid, Petermann, & Fegert, 2013). Changes in the developing brain from exposure to severe early stress and maltreatment suggest an increased risk for disorders in adulthood, including ADHD, borderline personality disorder, depression, and post-traumatic stress disorder, or PTSD (Teicher, Andersen, Polcari, Anderson, & Navalta, 2002). Furthermore, memory processing and executive functioning can be affected, leaving youth with increased risk of impaired learning (Carrion & Wong, 2012). However, there are many young people who experience considerable adversity but never develop notable problems. These young people are deemed “resilient” (Fergus & Zimmerman, 2005). According to resilience theory, resilience is the presence of promotive or protective factors that allow a young person to overcome the negative outcomes associated with exposure to negative circumstances. There are two kinds of promotive factors: assets and resources. Assets are those skills and capacities, such as self-efficacy and coping ability, that reside within the individual. Resources are positive factors, such as adult mentoring or family support, that are external to the individual and can also reduce the impact of negative environmental circumstances. These promotive factors can operate in different ways. According to the “compensatory” model of resilience, promotive factors have a direct, positive effect on well-being that compensates for the independent, negative impact of risk factors. For example, having athletic skills, which can enhance feelings of selfworth, may compensate for the negative impact that learning difficulties can have on self-esteem. According to this model, the promotive factors would have a positive impact on the young person whether the person is at risk or not. Another model – the “protective” model – suggests that promotive factors buffer the impact of risk factors on well-being. According to this model, the promotive factors would have their greatest impact on youth who are at risk and would have little impact on youth who are not at risk. For example, having the support of an adult mentor may reduce the effects of risk associated with living in poverty, but it would have little effect on young people who do not experience poverty. Ecological Systems Theory Risk and promotive factors derive from many different sources; for example, they can come from the family, school, or neighbourhood environments experienced by the young person. Bronfenbrenner (1977, 1979) proposed what he referred to as an “ecological” approach for understanding human development, which focused on the progressive accommodation between people and their changing environments.

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According to this theory, the environment consists of a series of interrelated layers ranging from the immediate to larger social settings. The microsystem is most immediate and consists of individuals and their family and the relationships formed within this system. The mesosystem consists of the interrelationships among the microsystems, such as the relationship between the family and the school. The exosystem refers to broader social systems, such as government, that affect individuals. Macrosystems refer to general prototypes that exist in the culture. These can be formal, as in laws or regulations, or informal, such as ideology made manifest through customs and practices. An important assumption of this theory is that individuals continue to grow throughout their lives and environments continue to change. Understanding community adaptation requires an examination of the unique characteristics of individuals, such as personality and social skills, and their interaction with the environment. In ecological systems theory, the notion is advanced that problems in social or emotional functioning can arise from dysfunctions in the ecosystem around individuals, as well as residing within the individual. For example, risk factors can occur at the level of the individual (e.g., having a learning disability), the family (e.g., ineffective parenting), the school (e.g., poor-quality teaching), the community (e.g., high levels of violence in the community), or society (e.g., ineffective social policies). Germain (1979) adapted ecological systems theory to inform social intervention because it lent support to the view that the “lack of a good fit between the coping capacities of the person and the qualities of the impinging environment” (Swenson, 1979, p. 233) may be central to understanding community maladaptation and efforts to foster positive youth development. Numerous factors are related to difficulties in youth community adaptation; accordingly, most community adaptation outcomes are multiply determined. It is also noteworthy that many common factors such as poverty (Conradt, Measelle, & Ablow, 2013), punitive parenting styles with low warmth and responsivity (Stormshak, Bierman, McMahon, & Lengua, 2000), and youth attachment history (Raudino, Fergusson, & Horwood, 2013) are modifiable and, if addressed, may foster youth community adaptation. A comprehensive approach to developing interventions, according to ecological systems theory, would be to provide or enhance promotive factors at several different ecological levels. Such an intervention might involve helping the child (e.g., with social skills training), improving family dynamics (e.g., through parenting programs), and enhancing school programs (e.g., by providing more supports for individuals with learning problems).

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Transition to Adulthood It is also important to look at youth community adaptation in its developmental context. Transition from adolescence to adulthood involves making a complex journey from one stage of development to another. Such developmental transitions are periods of life characterized by ­discontinuity, in which many changes occur within a short period. These changes present many challenges requiring a fundamental reorganization in the way an individual relates to his or her environment (Connell & Furman, 1984; Schlossberg, 1981). They can also have a profound impact on mental health: “Developmental transitions, representing major life changes within individuals and in social roles and contexts, can contribute to alterations in the course of mental health and psychopathology” (Schulenberg, Sameroff, & Cicchetti, 2004, p. 799). Several changes typically occur during the transition from adolescence to adulthood. During this period, the young person may complete education or training, take on employment, form long-term romantic attachments, become individuated from parents and family, and even begin a family of their own. Arnett (2000) argues that this period of development, during which the young person explores options with regard to things such as careers and romantic partnerships, merits being considered its own developmental stage, separate from adolescence and adulthood, one which he refers to as emerging adulthood. One of the most widely cited and most comprehensive theories of transition is that proposed by Schlossberg (1981). According to her model, three major factors will determine the extent to which an individual adapts successfully to a transition. The first of these is the nature of the transition. For example, transitions may entail a change in roles, and these role changes can be considered to represent gains (e.g., getting a job) or losses (e.g., severing a relationship). Transitions can also be the result of a decision made by the individual (an “internal” change), or they can be necessitated by external events or circumstances (an “external” change). Other aspects of the transition’s nature include whether the change is gradual or sudden, the duration of the transition (permanent, temporary, or uncertain), and the degree of stress that accompanies the transition. Difficult transitions are those that involve losses, are the result of external forces, and are sudden and stressful. A second factor has to do with what Schlossberg refers to as pre-transition and post-transition environments. These have to do with the kinds of supports the individual has from intimate relations, family, and friends, as well as from institutions such as school or religious

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organizations. Schlossberg suggests that the physical environment is also an important part of the pre- and post-transition environment. For example, poor housing can add considerably to the amount of stress that accompanies the transition. The final major factor influencing an individual’s adaptation to transition has to do with the characteristics of the individual. These characteristics include things such as the person’s psychosocial competence, socio-economic status, age, and health. Youth transition to adulthood occurs within a sociocultural context; however, there is a “profound lack of institutional structure to facilitate the transition to young adulthood” (Hurrelmann, 1990, p. 236). The main institutional structures for transitioning youth concern education, employment, and housing. Less institutional structure may allow some youth greater latitude and choices as they self-select their paths and activities. Although the lack of institutional and cultural structures may be desirable for some youth, for other youth the lack of structure can be devastating. Developmental processes of change and accomplishing developmental tasks are the main focuses of transition to adulthood for youth (Schulenberg et al., 2004). The lack of institutional structure can negatively affect such transitions. For example, youth involved with intensive mental health services often have difficulty remaining connected to the education system and finding employment (Frensch et al., 2009). In January 2017 in Canada, youth (15 to 24 years of age) had the highest unemployment rate (13.3 per cent, compared to 6.8 per cent for people 25 to 54 years of age; Statistics Canada, 2017). Theoretically, interventions to lead youth to successful transitions to adulthood would provide supports for productive processes and accomplishments in education and employment. Positive Youth Development Many theories relating to the problems that youth experience, such as those in the area of child psychopathology, focus on negative and maladaptive behaviours and processes. Even those theories that look into some of the broader determinants of youths’ difficulties, such as home, school, and neighbourhood environments, tend to focus on the negative aspects of these environments. Looking beyond the way developmental theory views young people to the way society views young people, we find attitudes towards young people that are similarly negative and disapproving. Adolescence is seen as a period of “storm and stress,” in which young people fight with their parents, are frequently

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sullen and uncommunicative, and engage in risky behaviour such as taking drugs (Arnett, 2000). The idea of positive youth development arose in reaction to this negative view of young people. Rather than seeing young people as being “troubled,” proponents of positive youth development view youth as resources that can make a positive contribution to society if they are provided with a supportive and caring environment. Instead of focusing on problems and maladaptive behaviours, positive youth development focuses on young people’s strengths and how these strengths can be nurtured and enhanced. This new perspective on youth development has been adopted by a number of developmental theories (e.g., Larson, 2000; Lerner, Fisher, & Weinberg, 2000). Lerner and his colleagues, for example, identified five capacities that they considered critical for healthy adolescent development (Lerner et al., 2000). These capacities are referred to as the “five Cs”: Competence (e.g., social skills, ability to make decisions); Confidence (e.g., high self-esteem); Connection (e.g., good relations with family members, attachment to one’s school and community); Character (e.g., knowledge of right and wrong); and Caring (e.g., feeling empathy and sympathy for others). Young people who have these capacities will develop into thriving individuals, and possession of these capacities will lead to a sixth C – Contribution – in that young people will come to contribute to their family, friend groups, community, and society. In order to develop these capacities, young people need to be provided with key resources, such as a safe, loving, and caring environment, an education that provides them with marketable skills, encouragement, an opportunity to make constructive use of their time and give back to their communities, and freedom from prejudice and discrimination. Youth Assets Central to the positive youth development approach is the idea that young people have strengths and assets that need to be nurtured for them to adapt successfully to community life and to develop into healthy, contributing members of society (Benson, Scales, & Syvertsen, 2011). Researchers associated with the Search Institute – a non-profit American organization devoted to discovering what children and adolescents need to succeed in their families, schools, and communities – have, through their own investigations and extensive review of the research literature, identified forty assets that are critical for healthy adolescent de­velopment (www.search-institute.org/our-research/development-assets /developmental-assets-framework). These assets are divided into two groups: internal assets are those capacities within the individual that

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promote positive development, while external assets are characteristics of the young person’s external environment that produce successful development. Each group comprises four categories. The four categories of internal assets are commitment to learning (e.g., being motivated to do well at school), positive values (e.g., being honest and responsible), social competencies (e.g., being able to plan ahead and make choices, the ability to resist negative peer pressures), and positive identity (e.g., having high self-esteem and a positive view of the future). The four categories of external assets are support (e.g., family support, a caring neighbourhood), empowerment (e.g., being given the opportunity to serve a useful role in the community by helping others), boundaries and expectations (e.g., being in a family or school that provides clear rules and consequences), and constructive use of time (e.g., being involved in youth programs such as sports or clubs). A large body of research shows a strong relationship between the possession of these assets and positive adolescent development. For example, Leffert et al. (1998) conducted a survey in which they assessed developmental assets in a sample of nearly 100,000 students in grades 6–12 in over 200 cities across the United States. Included in their survey were items assessing involvement in high-risk behaviours such as substance abuse and antisocial behaviour. The results indicated that the more assets youth had, the less likely they were to be involved in a wide range of risky behaviours, including drug abuse, violence, and even suicide attempts. Results such as these suggest that programs aimed at helping young people graduating from residential mental health programs should seek to build both internal and external assets to assist these youth in making the transition to independent community living. Thriving A more recent theory deriving from positive youth development and youth assets theory has to do with the construct of thriving (Scales, Benson, & Roehlkepartain, 2011). Thriving, according to Benson and Scales (2009), is more than just avoiding problems and difficulties; it involves having a sense of direction and purpose and embracing life, rather than just coping with it. A key element of thriving involves the young person identifying a “spark” – an interest, skill, talent, or capacity – that energizes and excites the youth, and that she or he follows and develops purely out of intrinsic interest. It could be something like an interest or talent in music, building car engines, or volunteer work with children. When this spark is combined with an environment that supports and encourages expression of the spark, the young person is on their way

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to becoming a thriving, contributing member of society. Environmental support can come from adults who encourage and celebrate the young person’s spark, help provide opportunities for its expression, and provide pressure, when necessary, to move to the next step in developing the spark. A thriving young person, according to the theory, is one who can identify something in life that they are passionate about and that gives life a sense of purpose and meaning. Recent research by Scales et al. (2011) lends empirical support to thriving theory. Youth responding to an online survey of over 1,800 American 15-year-olds were asked if they had a spark in their life – something that they are passionate about, that gives them joy and energy, and that gives them real purpose. They were also asked several questions about relational opportunities that supported their interests (e.g., “What kinds of easy-to-get-to resources are there in your neighbourhood/community for pursuing your talents, interests, or hobbies?”), and how much empowerment or voice they had in making things better for themselves or their community (e.g., “When things don’t go well for me, I am good at finding a way to make things better.”). In addition, respondents completed several measures of academic, psychological, social, and behavioural thriving. Results showed that young people who had all three elements of thriving – a spark, relational opportunities, and a feeling of empowerment – showed a greater degree of thriving than did young people who possessed only one or two of these elements. An Integrated Theory Each of the theories described above highlights important considerations in designing programs to help youth in residential mental health programs adapt to community life. Several of these – such as notions of risk and resilience, the consideration of ecological systems or environments, and the promotion of strengths and capacities – are common to a number of the theories advanced. Taken together, these theories suggest some key factors that influence the adaptation to community life among youth that would need to be addressed by programs designed to help these young people make a successful transition from care to community living: • Risk factors – These are things that would place the young ­person at greater risk for developing problems as they move from childhood to adolescence to young adulthood. These risk factors can be present at every ecological level. For example, at an individual level, a youth may have poor impulse control or emotional

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regulation skills that would need to be addressed. At a more ­systemic level, the youth may experience difficulties stemming from factors such as a problematic family environment (e.g., limited parenting skills) or a harsh neighbourhood environment (e.g., high levels of violence and crime). • Promotive factors and assets – These are things that counteract the influence of risk factors and that promote thriving and healthy adaptation. These can also be present at different ecological levels. At the individual level, promotive factors and assets can be things like sparks or talents, or the ability to plan and make decisions. At a more systemic level, the youth may have assets such as family support or opportunities to engage in creative activities or get involved in youth organizations. • Relationships – A number of the theories, particularly attachment theory, suggest that relationships are a critical element of successful adaptation to community life. Attachment theory focuses on relationships, initially with the primary caregiver but, as the person develops, with other members of the family, peers, adults outside the family, romantic partners, teachers, employers, and others. ­Asset-based theories also suggest that relationships are of primary importance to healthy adaptation. For example, one of the categories of developmental assets outlined by the Search Institute is support, which includes family support and the support of non-parent adults. • Engagement or involvement – Theories that fall within the general area of positive youth development (such as asset theory, the five Cs, and theories about thriving) suggest that, in order to develop into successful adults, young people must be given a voice in what happens to them and an opportunity to be involved in activities that stimulate their interests, at school, at work, and in the community. According to asset theory, they also need to be involved full-time in school, work, or homemaking. • Transition, continuity, and discontinuity – Developmental theories, as their name implies, focus on the way the individual develops through the course of their life. Many of these theories posit that individual development proceeds through various stages. The transitions between these stages are accompanied by many changes and discontinuities that necessitate adjustment and the development of new skills for the individual to adapt successfully. In addition to helping young people who have been in residential mental health programs sustain the gains they have made, it is necessary to provide support that allows them to deal with the changes they encounter as they move from childhood into adolescence and then

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into young adulthood. Different factors are likely to come into play at different times during these transitions. • Multiple determination – A premise of many theories is the notion that adaptation and maladaptation are multiply determined; that is, many factors are experienced in combination, resulting in good or poor adjustment to community life. Young people who are having difficulties adjusting are often experiencing multiple risk factors. In contrast, individuals who are adjusting well have several assets and promotive or protective factors in their favour. These theoretical formulations, then, suggest that services and programs designed to help young people who have been in RT make the transition to young community living should: • Attempt to reduce the intensity and severity of risk factors present at all ecological levels; • Build strengths and capacities in young people; • Build promotive and protective factors, both within the youth and in family, school, work, and neighbourhood environments; • Provide youth with environments that are supportive and empowering, in which they are able to make constructive use of their time; • Help youth make connections by getting involved in activities that spark their interests; • Foster healthy, stable relationships with family members and individuals outside the family; • Deal with several of the attributes of healthy development, including physical health, psychological and emotional well-being, ethical behaviour, educational attainment, and community engagement; • Give the young person a prominent voice in the kinds of services they need and in deciding on future goals; • Recognize that young people proceeding through major life transitions often need considerable support through times of discontinuity. Young people who have been in RT have often experienced many significant difficulties, usually in the context of difficult family, school, and community environments. While they may have improved through treatment, they are still vulnerable. The theories we have reviewed suggest that helping these young people adjust successfully to community life will require complex, multifaceted interventions that teach them to address the many challenges they will face. This will include simultaneously building the skills they will need and working with them to create the most nurturing environments possible.

Chapter Four

Pathways and Programs to Improve Youth Educational Processes and Outcomes

Throughout our program of research, education was one of the most consistently identified life domains with persistent and significant challenges for youth accessing residential mental health programs. Youth and families described a plethora of tribulations, including academic deficits, learning disabilities, trouble getting along with teachers, bullying, lack of motivation, and attendance issues. To build on this work, we conducted a synthesis of research to describe the pathways to school trouble and success and to identify promising programs to improve educational outcomes. Main Patterns • Our program of research documented the pervasiveness of school problems among youth accessing residential treatment. • Pathways to school dropout are a complex combination of ­influences across different life domains. Some ­prominent risk ­factors ­include academic and social disengagement, ­delinquency, living with emotional and behavioural problems, and family challenges. • Protective factors include academic successes, positive relationships between students and teachers, participation in extracurricular ­activities, and positive social and family engagements. • Programming to improve students’ academic performance and connections with school and to improve parents’ involvement with youth education emerged as two key areas for interventions. • Adult mentors/advocates who supported vocationally relevant ­curricula, life skills development, and engagements with families have demonstrated success at improving educational outcomes.

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We present a number of short stories throughout this chapter to ­illustrate youth experiences primarily with education. Each story is a reflection of one youth’s experience reported by parents/guardians or youth included in our program of research. Overall, our research shows that the majority of youth were struggling with school, and their educational prospects were not good. Scott’s story is typical of the school experiences of many youth we interviewed. Scott, male, age 23 Reflecting on his childhood, Scott said his early years were marked by abuse in the home from his stepfather and bullying by students and teachers at school. He technically completed grade 8 but really stopped attending school on a full-time basis when he was in grade 6. Scott was frequently absent for sickness and experienced very high levels of anxiety and isolation. Scott spent time in two different RT programs, each for about one year. Scott remembered meeting so many people – doctors, psychiatrists, nurses, teachers, and special education people – during his first stay at RT that he got confused. After his second stay at RT, he participated in some specialized school programs and remembered having a person who would come to his house to make sure he was awake and to drive him to school. Scott found this very helpful, but he did not make significant advances in schooling. Overall, Scott continues to struggle. He hopes to attend university one day but is unsure how university works. He feels that he has the ability to succeed but wonders whether he has the motivation. Scott struggles with a variety of mental health issues: anxiety (especially around formal school situations), panic attacks, and prolonged periods of depression. He said he is tentatively looking for a job, preferably one involving physical labour. While he has received supports over the years to build his skills such as looking for a job or doing an interview, Scott said he does not understand the human element, which he called the games that people play.

Profile of Youth I hated it ... I couldn’t stand – well, I hate it, I didn’t like anything about it, I never went to school.

In our program of research, almost across the board, youth who graduated from RT struggled with school. At the 3- to 4-year follow-up, over half (51.2 per cent) of those 16 or older (the legal age to leave school at that time) were not in school. The single largest reason for not being in school was their decision to drop out (47.6 per cent), followed by

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a temporary absence of their own choice (23.8 per cent), and being permanently expelled (19.0 per cent). Less than 1 in 20 of those age 18 or older had graduated high school. When youth were still in school, many of their parents reported continued problems with absenteeism (30.0 per cent) and poor grades (45.5 per cent). Close to half attended programs such as special section schools, special education classes, and behavioural support programs. Almost 20 per cent of youth age 16 and up had been permanently expelled. The primary reasons included truancy and verbal or physical confrontations. Over half of youth reported interpersonal conflicts at school. The conflicts were often severe and frequently directed at authority figures. Well, for me, I have an issue with being told what to do or whatever or being pushed so I have, like, bad anger issues, but I’ve been working on them, so it’s not as bad as it used to be, but for me I don’t like being told what to do by, like, people I don’t have to be listened to, or whatever. And I don’t like being pushed around and I don’t like being hit or anything, so if somebody hits me, I can defensive and fight back or I’ll get all like ... um, I don’t know, what’s a good word to describe, all up in their face and like, start talking back to them. Let them know I don’t like it and they keep going and I usually push them back or whatever.

Overall, youth who were not in school did not speak positively about being out of school. They typically did not describe alternative prosocial engagements. Because I’m bored. It’s so boring, it’s just like, sitting here all day, and like, knowing that all my friends are in school, like, my boyfriend’s going back to school.

Some youth explicitly linked their school difficulties to other problems in their lives, such as learning disabilities, mental health issues, substance abuse, and family problems, while many other simply described their difficulties. Mainly, just getting up and going to it ... Um, I don’t know, like, I’m not very good at getting up in the morning. It seems no matter how, like, early I get up ... it takes me a while to get to sleep. And so, uh, that’s probably the biggest problem, actually, I’m usually a lot of times late for school because I have trouble getting up.

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Many of the youth who were having difficulty at school described unfavourable attitudes and lack of motivation. They reported that school was boring or not relevant, or that they were apathetic about it. Discussions were notable for youths’ lack of focus on their academic or employment futures. A lack of realism about what might be required to obtain their objectives was common. Hope to get all my credits, pass high school, to do a little bit of college so I can get a good job. [Q. What kind of job would you want to have?] Be a vet [veterinarian].

Youth attitudes towards teachers varied considerably. For some, teachers and administrators suggested conflict with authority. Others described positive relationships with teachers who spent extra time with them and respected them. [Q. What makes a teacher nice and okay?] Just, um, the nicest ones are there to like help you and not just because they have to be there. [Q. So the ones who care kind of?] Yeah, not the ones who are just there because that’s their job.

For youth who were reasonably successful at school, things that helped engage these students included extracurricular activities, social ties, and strong relationships with their teachers. Most youth reported that friends were the best part of school. I’ve made a lot of friends, made a lot of things, just happened, made a lot of things change, made my marks improve, with a lot of work, pulled it off. After everyone told me I wasn’t going to be able to do it, I just ... to look at them and laugh and be like, I made it. Nah. I don’t know what you guys were talking about, and it felt really good.

Special schools or programs were reported to be beneficial for some students, particularly because of smaller classes, more help from teachers, the ability to work at their own pace, and alternatives such as vocational programs. You don’t get credits, but you get paid for the time that you’re there and basically you learn communication skills, life skills, social skills, um, reasons to y’know, actually take the initiative to get a job and reasons for some kids who want to go back to school.

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The pathways that lead to school trouble for youth are complex. Megan’s story shows how internal and external influences can derail educational aspirations. Megan, female, age 16 Megan had a very difficult summer the year she completed grade 8. Shortly before her class was to graduate one of Megan’s close friends died in a car crash; not long after, another friend committed suicide. Counselling was offered to all of the youth in the small, rural community but Megan appeared to take it harder than most; she made links to her own father’s death, which occurred before her birth. At the same time, her mother was separating from Megan’s stepfather. At the beginning of her grade 9 year, Megan began to see a counsellor on a regular basis and was making progress until the counsellor left for a maternity leave. Megan began to lose weight, stopped taking an interest in her ­appearance, and stopped going to school. Megan did not earn any credits in the fall ­semester and continued to skip school through the winter semester. Conflicts escalated with her mother about missing school, resulting in physical altercations, ­frequent running away, and a trip to the police station, along with the involvement of Children’s Aid. After a short-term admission to a mental health facility, a truancy officer helped Megan’s mother connect with RT, where Megan stayed for three months. Because of her anger with her mother, Megan spent the weekends with an aunt and uncle rather than returning to her own home. Megan began to look and feel better; her mother felt that her daughter was coming back to her. When she c­ ompleted her time at RT, Megan enrolled in a different high school in an attempt to make a fresh start. The school offered a small class program with one consistent teacher for youth who had attendance problems. On the second day, the teacher was absent and Megan began to skip class again. Once again, the absences led to a confrontation with the principal and Megan left the new high school ­permanently. Megan now lives with her boyfriend’s family and is ­attempting to complete homeschooling.

Pathways to School Success and Trouble Dropping out of school is a process of disengagement that often begins in early childhood (Dynarski et al., 2008). This process of fading out of school is most often the result of a combination of factors across different life domains (Audas & Willms, 2001; Hammond, Linton, Smink, & Drew, 2007). In interviews, student dropouts described a tug-of-war between forces keeping them in school and those moving them out of school (Lessard et al., 2008). Aspects of school life that alienate students help push them out of school (e.g., school policies such as frequent use

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of suspensions and expulsions, or assigning a failing grade based on number of absences). Influences outside of school pull students away from school (parenthood, employment, peer influences, family needs). School Characteristics Rumberger and Lim (2008) suggest that over and above student and family characteristics, school differences can account for 20 per cent of variations in youth dropout rates. There is evidence that clustering more at-risk students in a given school leads to higher dropout rates (Audas & Willms, 2001). School policies such as zero tolerance for misbehaviour or inflexible academic standards may force youth out of school (Hammond et al., 2007). Based on the 1988 National Education Longitudinal Survey, a frequent reason given by youth for dropping out was that the “curriculum was not relevant to their lives or work” (Hammond et al., 2007). They said that they would stay in school if the work was interesting, with more “real-world” teaching. Youth who dropped out reported that they did not feel that their teachers were interested in them and thought that the school discipline was ineffective and unfair (Audas & Willms, 2001; Hammond et al., 2007). In contrast, positive relationships between students and teachers correlate with lower dropout rates especially (Rumberger, 2004b). This effect was described by youth who reported feeling like they were glowing when they were acknowledged, cared for, and appreciated by teachers and said that if more teachers had made them feel like that, they would still have been in school (Lessard et al., 2008). Grade retention or being “held back” is a powerful predictor of future dropout and being held back more than once dramatically increases the effect (Hammond et al., 2007; Lessard et al., 2008; Rumberger, 2004b). Repeating a grade in elementary or middle school has a stronger relationship with youth dropping out than repeating a grade in high school (Rumberger & Lim, 2008). Being retained for more than one grade increases youth dropout dramatically – for example, in one study 80 per cent of youth who had been kept back for two or more years before grade 9 left without graduating, and 94 per cent who were retained in both elementary and middle school dropped out (Hammond et al., 2007). Another consistent predictor of dropping out is poor academic performance, whether in early or later grades (Hammond et al., 2007; Rumberger & Lim, 2008). Major reasons that participants in the National Education Longitudinal Survey (1988) gave for leaving school included “poor grades,” “failing at school,” or “couldn’t keep up with schoolwork” (Hammond et al., 2007). In interviews, many youth

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described poor school performance leading to them losing friends or being rejected (Lessard et al., 2008). Also, youth who dropped out of school tended to have lower academic and occupational aspirations (Hammond et al., 2007; Rumberger, 2004b; Rumberger & Lim, 2008). Academic and Social Engagement Conceptually, academic and social engagement at school is often considered the most important precursor to dropping out (Rumberger & Lim, 2008). Students with undiagnosed learning disabilities may be at particular risk for academic disengagement, following a cycle of poor performance leading to low self-esteem, potentially poor behaviour that distracts from learning, and eventually blaming and rejecting the school system (Audas & Willms, 2001). The evidence is fairly strong that higher academic engagement corresponds to reduced likelihood of dropping out and an increased likelihood of graduating (Rumberger, 2004b; Rumberger & Lim, 2008). Some studies supported that involvement in extracurricular activities in high school reduced the likelihood of not finishing high school, but others failed to find a relationship (Hammond et al., 2007; Rumberger & Lim, 2008). Interviews with youth who dropped out shed light on the different avoidance strategies used by students (Lessard et al., 2008). Some lived invisibly, withdrawing from social aspects of school, skipping school, using drugs, or spacing out; this strategy was more prevalent among girls. Other students who struggled with learning or school difficulties described walking in the dark, where school was not valued and they did not see the point. Other forms of academic disengagement include cutting classes, truancy, not finishing homework, and coming to class unprepared (Hammond et al., 2007). High levels of school absences as early as grade 1 have been associated with future dropping out (Audas & Willms, 2001; Hammond et al., 2007; Rumberger & Lim, 2008). In addition, 43 per cent of youth in the 1988 National Education Longitudinal Survey said they left school because they had missed too many school days (Rumberger, 2004b). Having friends who have dropped out may increase perceived acceptability of dropping out and a norm of lower expectations. Having friends who are involved in antisocial behaviour may reduce social links to the school and increase the chance of engaging in behaviours that would result in expulsion. Being rejected by school peers may result in feelings of alienation and withdrawal from the school environment and lead youth to engagements with antisocial peers (Audas & Willms, 2001; Lessard et al., 2008; Rumberger, 2004b; Rumberger & Lim, 2008). In his 2011 review, Rumberger updates his earlier work with a review of 389 analyses in 203 studies published between 1982 and 2007

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(Rumberger, 2011). Aspects of educational performance – in particular failed courses, retention, poor grades and test scores, and student mobility – were all linked to increased school dropout. Conversely, higher levels of student engagement such as participation in extracurricular activities and solid attendance reduced the likelihood of ­dropout in 24 of 35 studies of student engagement in high school. Community Influences Overall, coming from a disadvantaged neighbourhood characterized by social disorganization, high levels of poverty, many s­ ingle-parent households, lower levels of adult education and employment, ­violence, and crime contributes to higher levels of dropout (Audas & Willms, 2001; Hammond et al., 2007; Rumberger, 2004b). Audas and Willms (2001) reported on a study which showed that when fewer than 5 per cent of the adults in the neighbourhood had managerial or professional jobs, youth from the community were many times more likely to drop out of school. There is some evidence that youth who work more than 20 hours per week, especially if they are working to help their family, are more likely to drop out regardless of gender, race, or socio-economic status (Hammond et al., 2007; Rumberger, 2004b). Youth Characteristics Having a learning disability or psychological problems increases the risk of dropping out. Studies suggest that having a learning disability increases the chance of dropping out two to three times (Hammond et al., 2007; McWhirter, McWhirter, McWhirter, & McWhirter, 2007; Rumberger & Lim, 2008). In addition, studies have shown that half of seriously emotionally disturbed students drop out, compared to 15 per cent of students without disturbances (Rumberger & Lim, 2008). Youth who have poor social skills and difficulty getting along with peers at school tend to disengage from school environments while being drawn to alliances outside of school that are often not positive (Hammond et al., 2007). Feelings of isolation and alienation can lead to psychological disengagement from school (Wessendorf, Lehr, Covington-Smith, & Ohlund, 2008). A more recent review of the relationship between mental health difficulties and educational attainment (Esch et al., 2014) identifies additional considerations. Internalizing disorders such as depression, suicidal ideation, social phobia, and broader anxiety disorders were modestly linked with increased probabilities of dropping out. Externalizing ­disorders, such as conduct disorder, oppositional defiance disorder,

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and antisocial personality, were linked with a substantially greater likelihood of dropping out. For example, in one study reviewed, students with ADHD were 2.7 times more likely to drop out of high school than peers with no disorders. Problem behaviours identified as early as grade 1 have been linked to eventually dropping out of school (Audas & Willms, 2001; Hammond et al., 2007; Lessard et al., 2008; Rumberger, 2004b). Students who were aggressive in grade 1 and those who had more cumulative negative comments from teachers were more likely to drop out once they reached high school (Audas & Willms, 2001). Similarly, early antisocial behaviours including violence, substance use, trouble with the law, and having antisocial peers has been shown to increase the chance of leaving school even when academic failure or difficulty were not present (McWhirter et al., 2007). Hammond et al. (2007) identified youth misbehaviour as the strongest predictor of dropping out in high school. Dropping out of school tends to coincide with increased delinquency and substance use (Audas & Willms, 2001; Rumberger & Lim, 2008). Overall, McWhirter et al. (2007) concluded that youth who have been sentenced were less likely to graduate from high school; two-thirds did not even return to school after release from legal custody. In Rumberger (2011), in 11 of the 19 analyses, delinquent youth were more likely to drop out of school. Being arrested doubled the odds and having a court appearance almost quadrupled the odds of youth dropping out of school. Higher dropout rates in high school were linked with substance use in 17 of 23 analyses. Pregnancy often coincides with girls dropping out, and it is possible that a common root is responsible for both events (Audas & Willms, 2001; Rumberger, 2004b). The dropout rate for students with children was the highest rate for any single risk factor (Hammond et al., 2007; Rumberger & Lim, 2008). In Rumberger’s more recent review, teen parenting and pregnancy was a dropout predictor in 50 out of 62 studies (Rumberger, 2011). Family Rumberger and Lim (2008) reported that 15 of 25 studies that measured parental expectations in middle or high school showed significant effects on high school completion. Hammond et al. (2007) linked low parent educational expectations to youth high school dropout. Audas and Willms (2001) concluded that parental expectations were particularly important for low-achieving students. In Rumberger (2011), lower levels of dropout were associated with higher parental educational expectations in 33 out of 41 studies in high schools.

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Of 102 studies identified by Rumberger and Lim (2008), two-thirds (67) found that higher levels of parental education corresponded to lower levels of dropout. Almost three-quarters of studies showed that having parents who had not completed high school increased the likelihood of dropping out. Assessments of positive and negative caregiving as early as 12 months and the presence or absence of various early life disruptions have been linked to future high school completion (Hammond et al., 2007; McWhirter et al., 2007; Rumberger, 2004b; Rumberger & Lim, 2008). Dropping out has also been linked to high levels of stress in the home stemming from conflict, substance use, financial and health problems, frequent moves, and family disruptions such as divorce or death (Hammond et al., 2007; Kearney, 2008). Among the young dropouts interviewed by Lessard et al. (2008), 25 per cent told stories of family turmoil including abuse, neglect, parent criminality, death, and placement in foster care. Parental involvement in schools has been shown to influence whether low-achieving students stay in school (Audas & Willms, 2001; Rumberger, 2004b). Hammond et al. (2007) presented evidence that children of parents who had no contact with the school throughout their grade 8 year were more likely to drop out, and children of parents who never talked about school in the home were six times as likely to drop out as children of parents who talked about school regularly. Low levels of monitoring of everyday youth activities and no schoolnight curfews have been associated with higher dropout rates; however, so were excessively high levels of regulation (Hammond et al., 2007). Rumberger (2004a) suggested that parents can lower the odds of children dropping out through monitoring, providing emotional support, and encouraging independent decision-making. Kearney (2008) reported that parental involvement was linked to both academic achievement and attendance. Programs to Improve School Outcomes Understanding the pathways to school success and trouble for youth at risk suggests emphases for programs to improve education processes and outcomes for youth leaving RT. In addition, there was broad agreement among reviewers about two general programming guidelines: 1. Use available data and evidence to guide interventions and ­program fidelity. Overall researchers point to the lack of convincing evaluations of programs to improve academic outcomes. In spite of this, most agree on the importance of using the available

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evidence to guide the selection of interventions (Abrami et al., 2008; Dynarski et al., 2008; Franklin, Kim, & Tripodi, 2009; Hammond et al., 2007; ­Hoagwood et al., 2007; Olin, Saka, Crowe, Forman, & Hoagwood, 2009). S ­ pecifically, programs should be delivered in the manner in which they were designed, including appropriate staff training and supervision, duration of the program, and monitoring for program fidelity (Hammond et al., 2007; Hoagwood et al., 2007). 2. Address multiple risk and protective factors and use a combination of strategies to address educational and non-education needs. It is clear from the preceding section that a constellation of risk and protective factors contribute to youth success or trouble at school. A substantial majority of the reviews endorsed p ­ rograms d ­ irected at multiple risk and protective factors (Dynarski et al., 2008; H ­ ammond et al., 2007; Hoagwood et al., 2007; Olin et al., 2009; ­Prevatt & Kelly, 2003; Rumberger, 2004a; Test, Fowler, White, ­Richter, & Walker, 2009; Wessendorf et al., 2008; Wilson, ­Gottfredson, & Najaka, 2001). Some concluded that the positive effects of educational interventions were more evident when p ­ rograms began earlier in children’s lives (Abrami et al., 2008; ­Rumberger, 2004a; Wessendorf et al., 2008). However, Wilson et al. (2001) found good evidence that interventions can have positive effects with youth in middle and high school, particularly when ­focused on high-risk youth rather than general student populations. Two key areas for interventions emerged from the research reviews: (1) programming to improve students’ connections with the school and (2) programming to improve parents’ involvement with the school. A number of specific program approaches that were supported by research evidence, professional judgment of researchers, and logical links to risk and protective factors were identified in each area. These are discussed below, followed by examples of established programs that incorporate combinations of suggested program strategies. Improving Student Connections to School monitoring, mentoring, and advocacy Despite what is known about indicators of school trouble, many students who drop out do not receive any encouragements or supports to stay in school. In one study, 60 per cent of dropouts said no one on school staff encouraged them to stay, and less than 25 per cent saw a counsellor to discuss school trouble or plans to drop out in spite of evidence that they were having difficulty at school (McWhirter et al., 2007).

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It has been suggested that effective intervention programs can use data from student records and personal information to identify and monitor students at risk based on histories of academic problems, truancy, grade retention, and behaviour problems and where possible include additional information about motivation, academic potential, social skills, and teaching approaches (Dynarski et al., 2008; Wessendorf et al., 2008). Monitoring and responding to youth as they progress may be best accomplished by a supportive adult who has a trusting relationship with the student. There is evidence that linking at-risk youth with a caring adult who monitors, supports, and advocates for the student can reduce the likelihood of dropping out. Such adult mentors or advocates were important elements of many of the identified successful programs (Abrami et al., 2008; Dynarski et al., 2008; Klima, Miller, & Nunlist, 2009; Knesting & Waldron, 2006; Olin et al., 2009; Prevatt & Kelly, 2003). Positive adult relationships can contribute to decreased risky behaviours, better attendance and grades, and improved communication and social skills, and can promote better school engagement (Dynarski et al., 2008). Mentoring programs may be particularly useful for ­students with emotional or behavioural challenges (Test et al., 2009). Adult advocates potentially can play a role in contacting community agencies and helping students and their families access supports. It has been suggested that the adult advocate could be a resource teacher, a community/agency member, or a social worker who plays a role in the youth’s daily life and acts as a case manager (Dynarski et al., 2008). The adult should become a trusted person in the student’s life who can offer direction in all aspects of the student’s life, helping them to access resources and to address barriers to school success. The match between the adult and student is critical. The adult should be able to talk to the student about their life situations. Their demeanour, including eye contact, body language, and tone, can affect potential relationships (Knesting & Waldron, 2006). academic enrichment Because low academic achievement, absenteeism, and grade retention are all associated with higher levels of dropout, tutoring or enrichment programs that build skills, reduce frustration, and engage students were thought to be effective interventions. Overall, the evidence on the effectiveness of programs to improve academic success was mixed but suggested that building academic skills can reduce dropout for at-risk youth, particularly if provided by concerned adults in flexible formats. A number of reviewers identified academic supports as important components of intervention programs (Abrami et al., 2008; Dynarski et al.,

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2008; Hammond et al., 2007; Klima et al., 2009; Lehr, Hansen, Sinclair, & Christenson, 2003; Prevatt & Kelly, 2003). These reviews provided tentative support for the hypothesis that academic remediation on its own may not be sufficient to improve school outcomes for youth at risk. On the other hand, they supported the hypothesis that they can be an important element of broader program strategies. academic engagement More recently, there has been a shift to focus on promoting students’ engagement and enthusiasm for school and supporting students in meeting academic, social, and behavioural standards. Research about supporting youth academic engagement is more limited and the strategies are diverse. Two strategies that have received some attention are making clear connections between high school learning and post-school experiences (often through work experience) and providing individualized educational programming. Many educational support programs include a vocational training or work-based learning strategy, and there is great diversity in the approaches used. Abrami et al. (2008) concluded that vocational work placements without youth supports and links to post–high school goals were less effective than programs that provided content that was relevant to youth post-school goals. This may account for the mixed results that some researchers have found for community-based learning interventions (Lehr et al., 2003). Others have found evidence that interventions such as career development advising, college campus visits, and information about financial aid had positive effects on high school completion (Dynarski et al., 2008). For youth with emotional or behavioural difficulties, clarifying the link between school and future work may be particularly important. One study reported that the odds of males or females with emotional and behavioural disorders (EBD) dropping out of school if they attended no vocational classes was 132:1 compared to non-disordered youth. These odds fell to 73:1 if youth attended one year of generic vocational education, and to 32:1 if they participated in three different forms of vocational education (Test et al., 2009). Personalized learning environments and instructional processes are particularly important for students with various disabilities, but they can be beneficial for any at-risk student (Test et al., 2009). Test et al. (2009) found two studies in which student-centred planning and individualized services were identified as key factors in preventing dropout. They argued that it was important to engage youth in their own learning plan beginning in middle school. Dynarski et al. (2008) thought that personalized learning environments presented

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opportunities to encourage better school relationships and greater innovation in educational strategies. social engagement Social engagement refers to the degree to which students feel connected to their school and to other students and participate in extracurricular activities. Low levels of youth social bonding to school have been associated with dropping out (Audas & Willms, 2001; Hammond et al., 2007; Rumberger & Lim, 2008). Students with emotional and behavioural problems may face greater challenges with social engagements at school. Many programs intended to reduce dropout address social competencies and life skills (Abrami et al., 2008; Dynarski et al., 2008; Franklin et al., 2009; Hammond et al., 2007; Hoagwood et al., 2007; Prevatt & Kelly, 2003; Test et al., 2009; Wessendorf et al., 2008; Wilson et al., 2001; Zins, Bloodworth, Weissberg, & Walberg, 2004). It is difficult to find strong evidence of the success of these programs in reducing dropout rates. Nonetheless, based on existing evidence and expert opinion, Dynarski et al. (2008) recommended programs to improve students’ classroom behaviour and social skills. Typically social engagement programs focus on improving youth social competencies and skills in order to promote better relationships at school. Programs with evidence of effectiveness included components such as life skills development (communication, critical thinking, peer resistance, conflict resolution, and social skills building), behavioural interventions (cognitive behavioural therapy and variants), and education regarding group norms (Hammond et al., 2007). A large proportion of programs (83 per cent) used a cognitive behavioural approach (Olin et al., 2009). Cognitive behavioural programs developed students’ problem-solving skills or provided rewards or punishments for behaviour (Klima et al., 2009). These programs were found to promote ­self-control and social competence and to reduce the likelihood of dropping out in a metaanalysis of 165 studies (Wilson et al., 2001). Other researchers reported mixed results of studies of interventions to build students’ behaviour and social skills (Dynarski et al., 2008; Lehr et al., 2003). Improving Parent Involvement in Youth Education Two main family focuses have been found relevant to influencing the likelihood of youth graduation: interactions within the home and interactions between the home and the school. Researchers have identified the presence of study aids, high educational expectations and aspirations, parental monitoring, and parent communication and involvement with

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the school as statistically significant correlates of school completion (Audas & Willms, 2001; Hammond et al., 2007; Kearney, 2008; Lehr et al., 2003; Rumberger 2004a). Little evidence of impacts on educational outcomes was found for programming that focused specifically on families. Interventions with families were typically a smaller part of a program that had youth behaviour management as its focus (Hoagwood et al., 2007). However, family strengthening was a component of many successful programs. Interventions included focuses on parenting training, family management, communication skills, how to help children with academics, and improving home-school coordination (Hammond et al., 2007; Olin et al., 2009). In some cases, family strengthening programs contributed to positive effects on youth behaviours like delinquency and substance abuse, but not as clearly on youth academic achievement (Hammond et al., 2007). Programs that empowered and supported families and included a designated adult who maintained contacts with the family were found to be successful (Cooper, Chavira, & Mena, 2005; Test et al., 2009). General Programming Considerations Two recent systematic reviews (Freeman & Simonsen, 2015; Wilson & Tanner-Smith, 2013) of the literature on increasing school completion echo some of our earlier conclusions. Freeman and Simonsen (2015) identified 20 intervention studies that reported some positive effects on high school completion with a view to synthesizing common elements of effective interventions. In 45 per cent of these studies, programs with some positive effect were multi-component in design and included at least two of the following interventions: academic strategies, behavioural strategies, attendance strategies, study skills strategies, and school organizational or structural changes (e.g., smaller class sizes). Overall, more practice interventions reported positive outcomes (76 per cent) than policy-based interventions (36 per cent). In their systematic review of 152 dropout prevention programs, Wilson and Tanner-Smith (2013) examined the comparative effectiveness of programs by considering differential effects for program types, fidelity, program setting, and various student group characteristics. Programs delivered in school-based settings or mixed settings were more effective than those delivered in exclusively community-based settings. Implementation fidelity was significantly positively associated with better program outcomes. There was little difference in effects of programs based on participant characteristics such as gender, ethnicity, or age. Most of the programs they reviewed were intensive in nature

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and involved considerable time and changes in the education setting. Consequently, regardless of program (with the exception of attendance monitoring programs), all programs had statistically significant odds ratios indicating they demonstrated lower dropout rates than students in the comparison groups. The weighted mean odds ratio for dropout programs was 1.72, which was converted into an estimate of a 13 per cent dropout rate for program students in comparison to a 21 per cent dropout rate for students in comparison groups. Program Examples Two programs that incorporate the best-practice principles to address known risks and pathways to school trouble and to improve school outcomes are described here. The first, Check & Connect, closely links a highly involved adult to the youth at risk. The adult advocate monitors the student’s progress; works with the school, teachers, and community agencies; and provides consistent support for the youth and their family. The second program, Pathways to Education, targets youth in known high-risk areas and provides comprehensive support on an individual and group basis. This program originated in Canada, and preliminary results are promising. What these programs have in common is a multifaceted approach centred on providing a consistent and supportive relationship with an involved adult, addressing academic and social needs, advocating for appropriate interventions, and guiding educational planning.

Check & Connect Check & Connect is a strengths-based model of student engagement for students at risk of not completing school. The program draws on resilience research that supports the importance of a positive and caring adult in a child’s life and the importance of fostering strong family, community, and school connections. Program strategies include mentoring, monitoring, case management, academic support, behavioural intervention and problem-solving, and family strengthening (Hammond et al., 2007). The program guidelines stress relationship-building, problem-solving, and persistence in working with students. The adult mentor monitors the different indicators of student educational performance and engagement. The mentor provides feedback to youth and families and, depending on the youth’s circumstances, ­provides or facilitates youth training in cognitive behavioural problem-

78  Necessary But Not Sufficient solving, tutoring, and home-school meetings and offers links to community resources. Relationships with families are strengthened through phone calls, meetings, and home visits (Hammond et al., 2007). Wessendorf et al. (2008) reported that the adult mentor works closely with the youth and family for at least two years, regularly monitors school adjustment and progress, and intervenes in a timely manner to maintain and ­re-establish the student’s connection to the school. Prevatt and Kelly (2003) identified Check & Connect as a promising approach. Experimental studies have shown that students with emotional or behavioural challenges in this program were more likely to be enrolled in school, less likely to have interrupted school, and more likely to be on track to graduate. Check & Connect students were also more likely to access services than were students in control groups. Longitudinal studies have shown reduced rates of truancy, out-ofschool suspensions, course failures, and dropout, along with increased attendance and five-year school completion rates (Wessendorf et al., 2008). Four longitudinal studies provided evidence that students in the Check & Connect program had lower truancy and absenteeism, had lower dropout rates, accrued more credits, and were more likely to finish high school (Hammond et al., 2007). Another study showed that participating in Check & Connect over three years resulted in better assignment completion and fewer grade 9 dropouts when compared to those who had participated for only two years (Prevatt & Kelly, 2003). In a more recent effectiveness study, Maynard, Kjellstrand, and Thompson (2014) demonstrated that the Check & Connect program had significant effects on improvements in academic performance and ­reductions in disciplinary referrals. For more information on effectiveness studies of the Check & Connect program, see the US I­nstitute of Education Sciences’ What Works Clearinghouse at https://ies .ed.gov/ncee/wwc/Docs/InterventionReports/wwc_checkconnect _050515.pdf.

Pathways to Education The Pathways to Education program is an intense, multifaceted, and long-term support that strives to work in partnership with parents, community agencies, volunteers, local school boards, and secondary schools to promote school attendance, academic achievement, and credit accumulation.

Youth Educational Processes and Outcomes  79 The program model has four main components: 1. Academic tutoring offered by volunteers four nights per week in core subjects (students must attend at least twice per week if their grades fall below a certain level); 2. Social supports through group mentoring for grade 9 and 10 students – there is also specialty and career mentoring for grade 11 and 12 students; 3. Advocacy through a student-parent support worker who monitors attendance, academic progress, and program participation and who helps students build good relationships with parents, school, and peers; and 4. Provision of bus tickets for transportation to school, vouchers for school lunches, and a financial incentive to participate through a bursary towards post-secondary education. Initial results of the program were promising. In the first community served (Regent Park), 93 per cent of eligible youth participated. Dropout rates in the community declined from 56 per cent to 12 per cent, and the rate of students going to post-secondary school increased from 20 per cent to 80 per cent. For more information refer to www.pathwaystoeducation.ca.

Cody’s story describes the incremental improvements that can occur through RT. The principles and promising programs described previously suggest strategies to change the school trajectory of school for youth with multiple educational risk factors after they leave RT. Cody, male, age 12 Throughout his early childhood, Cody witnessed occasional emotional and physical abuse from his father directed at his mother. When he was nine years old, his parents separated and he spent seven months living in a women’s shelter with his mother and sister. Cody had difficulties at school; he could not read and had difficulty controlling his anger, often lashing out with ­violence. By the time Cody was 11, he had been suspended from school 14 times. He had frequent angry outbursts, and the last time that he was suspended he had ­demolished the principal’s office, tearing the blinds from the window and ­hitting the principal with them. His mother knew that she had to take action when a small argument caused Cody to head butt her, forcing her across the room and almost breaking her nose. His mother called an emergency support line that had been provided by the

80  Necessary But Not Sufficient school and asked for help. Cody was charged with assault and admitted to RT. Once he was in RT both Cody and his mother received counselling; Cody began taking Ritalin and was encouraged to participate in activities like Scouting and sports. The agency worked with Cody’s mother, helping her learn how to set and enforce limits with him. Cody spent six months in RT. He often went home on weekends, and the RT staff supported Cody’s mother’s rules in RT; for example, if he returned home an hour after his curfew on Sunday night, he would have to go to bed an hour earlier on Monday night. Now at age 12, Cody is back living at home and doing much better. He has learned different ways to deal with his anger, like removing himself to play with Lego or with video games. Because of his previous difficulties at mainstream school, he was allowed to continue to attend school at RT. He now reads well enough to enjoy the Harry Potter books, and his report card shows mostly As and Bs.

Implications The pathways analyses suggest that a very high proportion of youth leaving RT will be at high risk of school failure. Our prior research indicates that many of these youth will leave high school as soon as it is legally possible for them to do so. Many will be struggling with emotional and behavioural challenges, one of the major correlates of school failure. Access to adult mentors and family support for educational success will be limited for most. Of extra concern is that youth leaving RT to live in out-of-home state care are extremely likely to face significant barriers to success at school. It seems sensible that improving educational outcomes for these youth should be a central focus of any programming designed to improve their long-term community adaptation outcomes. Some programming elements with demonstrated success at improving educational outcomes for youth at risk of school failures appear particularly promising for youth leaving RT: adult mentors and advocates, supported vocationally relevant curricula, life skills development, and engagement with families. However, we know that these youth also will have community adaptation challenges in life domains besides education. Practically, it will not be feasible to implement credible separate programming strategies to bring improvements in each life domain. To best serve these youth, it becomes essential to look for program approaches with the potential to bring improvements in more than one life domain and to consider how different program approaches might feasibly be packaged together to augment youth community adaptation outcomes.

Chapter Five

Delinquency Pathways and Programs

Understanding the pathways to delinquency and exploring promising program responses are important considerations in addressing the multifaceted adaptation challenges of youth returning to the community following residential treatment. Findings from our longitudinal program of research indicated that up to half of all youth exiting RT will get in trouble with the law at one point or another. Main Patterns • Delinquent behaviours and trouble with the law were concerns for increasing proportions of children and youth in our program of research. Negative contact with police peaked at almost half of all youth in our research around 1.5–2 years and 3–4 years following residential treatment. • About one-quarter of all young adults interviewed in our transition age study continued to have a lifestyle characterized by ongoing delinquent behaviours, association with delinquent peer groups, and problems in multiple domains of well-being, including substance use and unstable employment, housing, and relationships. • Youth criminal history, youth behaviour problems (such as hyperactivity and aggression), family dysfunction, and negative peer associations are considered some of the strongest predictors of future involvement in the justice system. • The pathways to delinquency are complex and multilevelled and demand that program responses consider the interplay of multiple risk and protective factors. • Key principles of promising programming to reduce youth delinquency and offending include focusing on high-risk youth,

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targeting well-established predictors of youth criminal behaviours, matching responses to developmental stages and youth characteristics, and respecting program fidelity. • Skills development for youth, parent training and supports for family functioning, and positive peer and adult social connections are compelling program strategies for reducing youth offending behaviours. Sean exemplifies one-quarter of young adults in our transition age study who had a lifestyle characterized by delinquent activities and trouble with the law. Sean’s story illustrates the complex relationships between early experiences and future delinquency. Sean, male, age 22 When Sean was young, his mother was addicted to drugs and spent a lot of time “passed out,” leaving Sean and his older brother to their own devices. Sean and his brother fought frequently. Sean commented that his frictions at home made it difficult for him to focus on his schoolwork and to stay motivated at school. Sean did not finish high school. He reported being angry at the world at that time, not wanting to listen to anybody or to do anything properly. Sean’s mother died when he was 12 years old. Within a year of her death, Sean entered RT. He spent nearly three years living in residence, during which time he was frequently in trouble. He destroyed property in the residence and got into conflicts with staff. He describes himself at that time as being a “snap case,” who would get angry very quickly and start breaking things. He disliked almost all of the RT staff, feeling that they were only working there to get a pay cheque and had no real concern for the youth. However, he did develop a close relationship with his primary worker and maintains contact with her to this day. After the group home, Sean went into foster care, and then spent a brief time back with his father, who had married his late wife’s sister. It didn’t work out and Sean moved onto a series of foster homes. Sean was heavily involved in gangs during his mid-teens and was arrested frequently, mostly for property crimes. Shortly after he graduated from foster care, at the age of 18, he started selling drugs to make a living. He was arrested within a year for aggravated assault after he stabbed someone. He spent six months in custody followed by 15 months of probation. Sean felt that he didn’t get the help he needed to turn his life around, particularly after he left RT and foster care. He feels he would have benefitted particularly from skills training in anger management and general life skills. Sean currently lives in an apartment with his wife of four years. They have two boys, a younger son of their own and an older son from his wife’s previous

Delinquency Pathways and Programs  83 relationship. Sean is working in construction and landscaping and likes his supervisor, who praises his work when he does a good job. The amount of work is variable; sometimes he works every day, but other times there may be no work for several days. He requires occasional social assistance for things like dental bills. For a long time, he had almost no contact with his father, but he has re-established that relationship and sees his father regularly. He is currently making up some of his high school credits and would like to get his licence to become a heavy equipment operator.

This chapter focuses on youth from residential mental health treatment programs involved with the juvenile justice system. It is shaped by two broad research questions: 1. What are the pathways to delinquency for youth with emotional or behavioural difficulties after leaving juvenile justice custody? 2. What programs for children and youth have been shown to reduce delinquent behaviour, reduce involvement with the justice system, and improve community adaptation for youth leaving juvenile justice custody? This chapter begins with a brief overview of the youth in our program of research who described delinquent lifestyles that sometimes included formal involvements with the juvenile justice system. Brief Profile of Delinquent Youth Approximately 35 per cent of all youth had been in contact with the law at admission to RT. This was a much higher percentage than the 6 per cent of Canadian youth between the ages of 12 and 17 who have been accused of committing a crime (National Crime Prevention Centre, 2012) and within the range (24 per cent to 66 per cent) reported in other studies of youth with mental health challenges (Barth et al., 2007; Greenbaum, Foster-Johnson, & Petrila, 1996). The proportion of RT youth in trouble with the law increased to 49 per cent at our 1.5- to 2-year follow-up study. Our interpretation was that this increase was likely due to older youth being more likely to come into contact with the formal justice system. Nonetheless, it does point to a priority community adaptation focus for youth graduating from RT. In addition, as discussed below, this difficulty may be particularly prevalent among male youth graduating from RT into long-term care of the child welfare authorities (Cameron et al., 2011; Frensch et al., 2009). Many of the delinquent youth in our program of research rated quite high on conduct disorder measures (Preyde, Frensch, et al., 2011).

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Average mean scores on caregiver-rated scales indicated that the greatest problem scores for youth at RT admission were for conduct problems. While significantly improved, these scores for conduct problems were still in the range for clinical concern at 1.5–2 years post-treatment. Many youth leaving RT were having trouble in more than one community adaptation domain. For example, a large majority of youth in trouble with the law also had serious school difficulties after graduating from these programs. Youth leaving RT to live in the care of child welfare authorities often experienced serious difficulties in most life domains. Generally, it was not possible to draw clear boundaries between having school problems, being in trouble with the law, struggling with their parents, having personal functioning difficulties, and experiencing other community adaptation problems. As mentioned, challenges in areas of living such as education, employment, and trouble with the law became more serious as youth became older. In our transition age study (approximately five years beyond RT), a subgroup of about one-quarter of young adults continued to exhibit delinquent behaviours and experience negative involvement with the law. This group was predominantly male (86 per cent) and had grown up in the care of the child welfare authorities (71 per cent). Many had been involved with delinquent activities over the long term and had faced a variety of legal charges. One young adult was in jail and some were on probation at the time of our interviews. These young adults described a multitude of daily living challenges, including problems with substance abuse, suboptimal personal well-being, limited education and employment, and problematic relationships. As one youth described, I’ve needed to steal to survive ... I’ve had drug issues ... My adult record is two theft ... and my youth record was ... a theft under and a possession of stolen property ... My [most recent] assault with intent of robbery is due to the fact that I took ... a variety of drugs that night and I decided ... to go rob it ... That was a mix of acid, coke, crack.

Pathways to Delinquency Youth with diagnoses of attention deficit hyperactivity disorder (ADHD), conduct disorder, and substance use are particularly at risk of delinquent involvement (Langley et al., 2010; Pyle, Flower, Fall, & Williams, 2016; Young, Moss, Sedgwick, Fridman, & Hodgkins, 2014). However, mental health issues are one piece of the complex situation that can lead youth towards or away from criminal behaviour.

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Researchers agree that risk and protective factors for delinquency do not come from a single source (Welsh & Farrington, 2012). Ecological systems theory (Bronfenbrenner, 1979) has been used to justify looking at risk and protective factors at the levels of individuals, families, schools, peer groups, and communities (Howell, 2003; Savignac, 2009; Wasserman et al., 2003). However, generally, research focused on risk factors is more prevalent than research examining protective factors. Some argue that the appropriate risk and protective focuses may change as children age. For young children, efforts may be best focused on improving parenting practices and family resources. For adolescents, reducing negative peer associations and improving positive social ties become more appropriate, along with reducing aggressive and violent youth behaviours, improving relationships with parents, and addressing mental health issues. Offending behaviours have many highly interrelated determinants that are cumulative. In addition, many youth experience a cluster of problems such as delinquency, drug use, school difficulties, and early parenthood (Howell, 2003; Savignac, 2009; Sigfusdottir, Kristjansson, & Agnew, 2012). Consequently, addressing delinquency risk and protective factors will be relevant to other community adaptation domains as well. A number of risk and protective factors for delinquency and reoffending consistently appeared across the meta-analyses and narrative reviews considered for this chapter. These can be grouped into individual, family, and community/peer characteristics. Individual Characteristics Numerous researchers have associated a wide variety of individual youth characteristics with higher or lower likelihood of initial or reoffending delinquent activities (Barth et al., 2007; Day & Wanklyn, 2012; Fergusson, Horwood, & Ridder, 2005; Greenbaum et al., 1996; Hodges & Kim, 2000; Jolliffe & Farrington, 2004; Leve, Chamberlain, & Kim, 2015; Pyle et al., 2016; Stams et al., 2006). The following are two such characteristics. youth behaviour problems In narrative reviews, youth behavioural issues linked to criminal offending included early and persistent antisocial behaviour and aggression (Day & Wanklyn, 2012; Howell, 2003), beliefs or attitudes favourable to criminal behaviour (Hawkins et al., 2010), and ADHD (Young et al., 2014). In a meta-analysis, Leschied et al. (2008) found that behavioural difficulties including hyperactivity, aggression, and conduct disorders

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predicted adult criminality. They also connected lack of age-appropriate social skills to offending behaviours. Other meta-analyses found that criminal behaviour was related to antisocial personality for mentally disordered adults (Bonta et al., 1998) and to aggression (Lipsey & Derzon, 1998). One meta-analysis found that externalizing behaviour problems in adolescence appear to be better predictors of adult criminality than such problems noted at a younger age (Leschied et al., 2008). prior offending behaviour The likelihood of future criminal activity becomes much higher once a youth has already committed a crime. Across studies, prior criminal history has been shown to be the best predictor of future involvement in the juvenile justice system (Day & Wanklyn, 2012; Lipsey & Derzon, 1998; Robst, Armstrong, Dollard, & Rohrer, 2013). Meta-analyses of risk factors have shown that criminal history predicts both general and violent reoffending among mentally disordered offenders (Bonta, Law, & Hanson, 1998), among adolescents (Leschied, Chiodo, Nowicki, & Rodger, 2008), and for early offending behaviour (Lipsey & Derzon, 1998). Repeat offending behaviour appears to follow the same path, so that youth with violent histories are more likely to reoffend violently and those with non-violent histories are more likely to have general recidivism (Lipsey & Derzon, 1998). In a narrative review, Hawkins, Welsh, and Utting (2010) found evidence that almost 40 per cent of children who were involved in serious crimes between the ages of 4 and 10 were also involved in serious or violent crimes in adolescence or adulthood, compared to between 20 per cent and 23 per cent for those whose first offence occurred between ages 11 and 14. In narrative reviews, Bonta et al. (1998) found that substance use predicted general and violent recidivism among mentally disordered adults, and Hawkins et al. (2010) suggested that drug involvement triples the risk of violent behaviour. Family Factors parenting practices A relationship between poor parenting practices and future criminal behaviour has been identified in both meta-analyses and narrative reviews (Bonta et al., 1998; Day & Wanklyn, 2012; Hawkins et al., 2010; Howell, 2003; Leschied et al., 2008; Lipsey & Derzon, 1998; Murray & Farrington, 2010; Savignac, 2009). Savignac (2009) found that parenting problems contributing to delinquency included parents’ inability to foster self-control in children,

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inconsistent and coercive parenting, lack of supervision, and harsh punishment. Hawkins et al. (2010) presented evidence that poor family management at age 10 did not significantly increase the risk of violence, but at age 14 it doubled the risk. In a meta-analysis, Leschied et al. (2008) found that for children ages 7 to 11, coercive, inconsistent parenting that was lacking in supervision was a strong predictor of future criminality. In another meta-analysis, Lipsey and Derzon (1998) found that parent-child relationship problems including discipline difficulties measured at ages 12 to 14 had a small to moderate effect on future offending. family environment Narrative reviews suggest that youth who grew up in families where attitudes were favourable to criminal behaviour and parents were criminally involved with the justice system were more likely to commit offences (Day & Wanklyn, 2012; Hawkins et al., 2010; Howell, 2003; Leve et al., 2015; Savignac, 2009). Hawkins et al. (2010) reported that parent criminality, measured when youth were 14, doubled the risk of future youth violence; and living in a family with favourable attitudes towards violence, measured when youth were age 10, also doubled the risk of future violence. Savignac (2009) reported on a study where 63 per cent of boys with criminal fathers participated in criminal behaviours themselves, compared to 30 per cent of other boys. Leve et al.’s (2015) narrative review of risks for juvenile justice involvement for females presented evidence of a link between maltreatment during childhood, in particular physical and sexual abuse, and increased risk for involvement in crime. In addition, females exposed to child abuse or family violence were more likely to commit a violent act and rates of abuse among incarcerated females far exceeded those among males. In meta-analyses, youth criminal behaviour has been linked to having antisocial parents (Lipsey & Derzon, 1998), witnessing or being the target of family violence, and living in an adverse family environment (Leschied et al., 2008). Narrative reviews have identified several family factors postulated to protect youth from engaging in criminal activity, including positive parenting practices, good relationships with parents, good communication with parents, parental supervision of youths’ activities, and overall support to youth from their families (Howell, 2003; Savignac, 2009). Community Context and Peers In his narrative review, Howell (2003) concluded that association with delinquent peers was a strong and stable predictor of delinquent

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behaviour and that there was evidence that aggressive and antisocial youths gravitate to one another. He also concluded that early peer rejection may constitute a risk for future delinquency, especially for aggressive children who, when rejected by prosocial peers, may gravitate towards deviant peer groups. However, affiliating with prosocial peers and staying away from antisocial peers protected youth against offending behaviour. In another narrative review, Hawkins et al. (2010) reported that having delinquent friends at ages 10, 14, and 16 all increased risks of later violence and that gang membership at age 14 tripled the risk of offending, while gang membership at age 16 quadrupled the risk. The effects of delinquent peer associations are better documented for males, with studies of females having mixed results (Day & Wanklyn, 2012). Lipsey and Derzon (1998) reported that social factors became increasingly stronger throughout late childhood and into adolescence. For example, youth who lacked social ties were more than 18 times more likely to offend and those with antisocial peers were 15 times more likely to offend than youth with prosocial peer relationships (Lipsey & Derzon, 1998). There was limited evidence from narrative reviews that communities with high availability of drugs and adults involved in crime increased the risk of youth delinquency. Some evidence also showed that youth from poorer neighbourhoods and neighbourhoods with higher civic disorganization, unemployment, physical deterioration, and resident mobility were more likely to participate in criminal acts (Hawkins et al., 2010; Leve et al., 2015; Murray & Farrington, 2010; Savignac, 2009). Howell (2003) linked youth offending to low commitment to school, low educational aspirations, and multiple changes in schools. He also found that early and persistent academic difficulties had been connected to the onset of delinquency, particularly for males. On the other hand, he identified factors such as higher motivation and commitment to school, higher educational expectations and aspirations, and educational support from teachers and mentors as reducing the risk of youth offending. School environments with a more cohesive school culture and higher degrees of trust between teachers and students, and where rules and procedures are consistently followed, have been associated with lower rates of delinquency (Gottfredson, Cook, & Na, 2012). Overview of Pathways There is solid agreement among delinquency researchers that the pathways to delinquency are complex and function on many levels. A fair

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amount of agreement exists that the effects of different risk and protective factors are cumulative for youth. Researchers also agree that many offending youth are coping with multiple challenges in their lives. Overall, in both the meta-analyses and the narrative reviews, the risk factors for delinquency that had the strongest predictive power and most agreement among reviewers included prior involvement in criminal or delinquent activity; negative peer and other social ties; externalizing youth behaviour problems; poor or limited parenting capacity; and criminal or antisocial parents. The meta-analyses reviewed suggested that the primary predictors of youth offending (with medium to strong effect sizes) can be usefully grouped under four broad categories: youth criminal history (including substance abuse), youth behaviour problems, family dysfunction, and negative peer involvements and social ties. None of these reviews suggested that any single risk or protective factor was the most important consideration in preventing delinquency. There also does not seem to be any reason to believe from this analysis of pathways that positive change in one area (e.g., youth behaviour or family functioning) would likely be the catalyst for positive change in other areas. Rather, the implicit and sometimes explicit suggestion in these reviews was that often for individual youth, and certainly for groups of youth, attention to multiple risk and protective factors will be needed. Cindy, female, age 18 Cindy is an 18-year-old woman who grew up off-reserve with her mother. Her mother had mental health problems (she was bipolar) and abused drugs and alcohol. She has an older brother and a sister but has not had any contact with her mother or brother since she was 14. Sporadic attempts to reconnect with her sister have not been successful. Her biological father has been in and out of jail since she was two years old; she has never met him. Cindy was abused both physically and sexually when she lived at home. She reports that her mother would frequently beat her and her siblings. She also describes her mother as neglectful and lacking in parenting skills. She went into residence in a children’s mental health centre when she was in her early teens. When she left the centre, she came home to live with her mother but was thrown out a day later. She subsequently lived in a variety of settings. She was in several group homes, from which she ran away frequently. She spent time in both open and closed youth custody facilities. She stayed with friends for brief periods of time. And she sometimes lived on the street for short intervals when she had run away from some of these other settings. Cindy had difficulties in school. She claimed to have ADD but was only treated for this (with medication) briefly. Consequently, she had difficulty

90  Necessary But Not Sufficient concentrating in school. Her difficulties also derived from her times in a custody facility and the fact that she changed schools whenever she moved to a different group home. She was expelled from school at the age of 15. Cindy describes her school life as one in which she had no friends and was bullied frequently. She says that this bullying has had long-lasting effects on her self-esteem and resulted in her current abuse of alcohol. Cindy has a long history of involvement with the criminal justice system. She has had 56 charges laid against her, though many of these were for breach of the conditions of probation. Her most recent charge was for armed robbery. As mentioned earlier, she has served time in both open and closed youth detention centres. She is currently in a special Indigenous diversion program, which involves a healing circle and a healing plan, for an offence she committed while she was a minor. If she does not complete this plan, she will be charged as an adult. Cindy used a variety of drugs – marijuana, MDMA, oxycodone, and others – when she was younger but at present only smokes marijuana. She also drinks heavily at times. Cindy has been a sex worker since the age of 16. She is involved with an organization that she describes as a “syndicate” involved in prostitution and the drug trade, which provides “enforcement” services for its associates. Cindy initiates young women (some of whom are underage) into prostitution for the syndicate and instructs them in “how to be safe.” Cindy claims to have no friends and distrusts most people, feeling that people are “just going to end up backstabbing me, abandoning me, talking shit behind my back or try and steal from me.” She has a casual male friend with whom she has sex, but no boyfriend. She has no hobbies except for “making money [through sex work]” and “drinking myself to sleep.” She hates the Children’s Aid Society and claims she’s had little help from almost all the services with which she’s been in contact, feeling that “all the social workers I’ve had just throw you around.” She has never had a worker last more than a year. Cindy currently lives in a main-floor apartment that is subsidized and receives $1,000 a month for accommodation and living expenses from CAS. She describes her neighbourhood as rundown and dirty, populated mostly by drug addicts and individuals on welfare or disability. Cindy is currently a full-time student, working to complete the five credits she needs for her grade 12 high school diploma. She has been on an Individual Education Plan that provides her support in completing her diploma requirements. Cindy would like to attend college to become a pharmacy technician, and then go to university to become a pharmacist.

Programs to Reduce Delinquency: Lessons Learned Careful review of meta-analyses and narrative reviews about interventions to prevent initial or reoffending youth delinquency suggested some

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overarching lessons. While few review articles made definitive statements about the superiority of particular interventions, there were key principles that could be cautiously extracted. By integrating these key principles with evidence about pathways and interventions, a beginning framework emerges that might assist with making decisions in different contexts about which specific interventions to improve youth community adaptation merit further exploration. The following summary shows the nature and extent of the agreement among reviewers about some general programming principles to reduce youth offending or reoffending: 1. Four reviewers highlighted that programs to prevent or reduce youth reoffending are more likely to be effective when focused on high-risk youth (Howell, 2003; Lipsey, 2009; Lipsey & Wilson, 1998; James, Stams, Asscher, De Roo, & van der Lann, 2013). 2. Six reviewers stressed that programs should focus on the known predictors of crime and recidivism (Ashford, Sales, & LeCroy, 2007; Bonta et al., 1998; Howell, 2003; Kurtz, 2002; Leschied et al., 2008; Lipsey & Cullen, 2007). Howell (2003) suggested that the most salient risk factors and therefore the most useful to target are antisocial personality characteristics like low self-control and antisocial peer connections combined with a lack of prosocial connections. Bonta et al. (1998) concluded that, if criminal behaviour is considered a learned behaviour, then pro-criminal attitudes, associates, and lifestyles are promising targets for interventions. 3. Three reviewers explicitly stressed the importance of matching the temperament and circumstances of the youth with programmatic responses. Howell (2003) highlighted the importance of taking into account differences in offenders’ motivations, personalities, and abilities. Lipsey and Cullen (2007) argued for the importance of differential program responses depending on the characteristics of young offenders. Koehler, Lösel, Akoensi, and Humphreys (2013) posited that treatment must correspond to the risk level of reoffending, consider dynamic risk factors, and match the capabilities of the offender. 4. Three reviewers commented on the importance of matching program responses to youth development stages. Loeber and Farrington (2001) stressed the importance of expanding the focus of programming to include school, peers, and community connections when youth are ready to leave elementary school. Leschied et al. (2008) also saw the usefulness of shifting programming focuses for youth in middle childhood and adolescence. Lipsey and Derzon (1998) saw a need for a broader range of programming focuses as youth entered adolescence.

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5. Six of these reviewers stressed the need to respect program fidelity requirements to improve adaptation outcomes for youth (Hawkins et al., 2010; Howell, 2003; Koehler et al., 2013; Lipsey, 2009; Lipsey & Cullen, 2007; Trupin, 2007). In his meta-analysis, Lipsey (2009) concluded that, after youth risk, the largest contributor to effect size was quality or fidelity of program implementation. In another meta-analysis, Lipsey and Cullen (2007) found that the quality of program implementation was almost as important as the type of treatment provided. Hawkins et al. (2010) highlighted the fidelity difficulties in transferring program models across settings and in scaling up from demonstration projects to broader implementation. Trupin (2007) stressed the importance of detailed manuals and intensive treatment to maintain good outcomes in the replication of many program models. Koehler et al. (2013) stressed that programs adhering to risk-need-responsivity (RNR) principles (Andrews et al., 1990) had the strongest mean effect, indicating a 16 per cent reduction in reoffending. 6. Four reviewers (Hawkins et al., 2010; Howell, 2003; Lipsey, 2009; Underwood & Knight, 2006) concluded that programs to reduce youth reoffending should use a combination of strategies to address multiple risk factors in diverse domains of living. Howell (2003) also stressed that youth program involvement should continue for several years to produce the greatest impacts. The strongest area of agreement about guidelines for programming across this consideration of the reviews was that programs need to respect what is known about pathways to youth delinquency and youth reoffending. The clearest consensus was that effective programs must focus on known and important predictors of youth delinquent behaviours. There was somewhat less agreement that the most promising programs would incorporate diverse intervention strategies to address multiple risk factors. Finally, there was quite broad agreement that, when a program model is known to produce good outcomes, respecting its program rationale and service delivery requirements (program fidelity) is essential to reproducing these good outcomes in other settings. While mentioned less often, it is likely that appropriate programming to reduce delinquency and youth reoffending will differ in important ways for younger children and adolescent youth. Interventions to Reduce Reoffending Considerable effort has been made to determine the capacity of different program approaches to reduce youth reoffending and recidivism. Two

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types of sources provided information about interventions: meta-analyses and narrative reviews. Each presented some challenges to interpretation. Narrative reviews typically provided less extensive evidence to support program effectiveness claims but were more likely to describe a broader range of programs and incorporate the author’s expert opinion. Meta-analyses potentially provide more rigorous evidence. However, quite a few different program models were usually included within any particular program category in available analyses. In addition, there was little consistency among the categories in which interventions were placed across the meta-analyses reviewed. Consequently, it is difficult to draw conclusions about specific program approaches. In this discussion, we reserve the term “multi-component” for programs that incorporate a variety of intervention strategies (e.g., youth skill training, family therapy, peer groups, academic supports) usually focused on different aspects of the youths’ lives. In addition, many of the meta-analyses report the program impacts in terms of a percentage reduction in youth reoffending. These analyses drew on the work of Lipsey and Wilson (1998), who calculated an overall recidivism rate of 50 per cent based on the average for the control groups in studies of programming for youth on probation. For our purposes, a recidivism rate of 43 per cent is reported as being 7 per cent lower than a recidivism rate of 50 per cent. Social and cognitive behavioural skills programs operate on the premise that personal beliefs about violence and aggression and a lack of social skills contribute to youth offending behaviour. Participants learn to identify psychological and situational factors that may trigger unwanted behaviour and to adopt strategies for coping effectively. Skills-building programs provide instruction and practise opportunities to develop skills that help youth control behaviours and foster their ability to participate in normative prosocial functions (Lipsey, 2009). The most common skills-building programs are cognitive behavioural interventions such as cognitive behavioural therapy (CBT). Common cognitive components include problem-solving, communication skills, and situational self-awareness. In addition to positive reinforcement, behavioural components may also include token economies and behavioural contracting. Other types of skills-building programs teach the ability to cope effectively with relationships; problem-solving/ decision-making; critical thinking; assertiveness; peer selection; lowrisk choice making; self-improvement; stress reduction; peer resistance; recognizing and appropriately responding to risky or potentially harmful situations; conflict resolution; and leadership skills/training (Hammond et al., 2007).

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Overall, there was good evidence from the narrative and meta-analytic reviews that skill development programs in general, and cognitive behavioural programs in particular, had significantly lower rates of youth reoffending. These approaches also were connected to beneficial changes in youth behaviours and other psychosocial outcomes. Part of the attractiveness of this general program model is that it is usually short-term, sometimes provides specific service delivery guidelines (manuals), and is relatively easy for agencies to implement. On the other hand, it is less evident that skill development programs would be sufficient on their own if enduring changes are sought in several domains of youth community living (Ashford et al., 2007; Foley, 2008; Hawkins et al., 2010; Koehler et al., 2013; Kurtz, 2002; Lipsey, 2009; Lipsey & Cullen, 2007; Lipsey & Wilson, 1998; MacKenzie & Farrington, 2015; Tennyson, 2009; Townsend et al., 2010; Trupin, 2007; Underwood & Knight, 2006). Coping Power (Lochman & Wells, 2004) is an example of a skillsbuilding program aimed at reducing delinquency, substance use, and school-based problem behaviours among youth with aggressive behaviour.

Coping Power Coping Power is a multi-component selective prevention/intervention program for middle-school-aged boys with aggressive behaviour. Coping Power addresses key risk factors associated with substance ­ use and delinquency by fostering social competence, self-regulation, and positive parental involvement. Delivered in a school-based setting, ­Coping Power has also been adapted for delivery in mental health settings. The program has a child component and a parent component. The child component is delivered in groups of five to six boys for 34 one-hour sessions over 15 months. The child group sessions are co-led by a program specialist and a school guidance counsellor. Child teachings include “behavioural and personal goal setting, awareness of feelings and associated physiological arousal, use of coping self-statements, distraction techniques and relaxation methods when provoked and made angry, organizational and study skills, perspective taking and attribution retraining, social problem-solving skills, and dealing with peer pressure and neighbourhood-based problems by using refusal skills” (Lochman & Wells, 2004, p. 573). The parent component is delivered in 16 parent group sessions (four to six parents) over the same 15 months. Groups are held at the boys’ school

Delinquency Pathways and Programs  95 and are co-led by two program staff. The parent component is a parent training program based on social learning theory, which incorporates various parenting skills like rewarding appropriate child behaviour, giving effective instruction, and establishing ongoing family communication. Parents also learn to support their child’s social cognitive skills acquired through the Coping Power program. Several evaluation studies (Cowell, Horstmann, Linebarger, Meaker, & Aligne, 2008; Lochman & Wells, 2004) have shown that Coping Power is effective in reducing delinquent behaviour and substance use and improving social competence and behaviours in the classroom at a one-year follow-up. See www.copingpower.com.

Peer support groups manifested large variations in how they were understood in these reviews. Typically, a group of youth at risk of delinquency or of reoffending would meet with facilitator, who may or may not be a therapist. Different groups focused on different issues such as self-esteem, drug abuse, sexuality, culture, and life skills. There was no clarity in the reviews about the theoretical or service delivery frameworks used by these groups. In addition, relatively few of the program model studies covered in these reviews focused clearly in whole or in part on the use of peer groups to reduce youth delinquency or reoffending. It is not possible to draw any conclusions about the potential of peer support groups to reduce reoffending or delinquent behaviours based upon the research reviewed. Equally important, in light of the importance placed on negative peer and social involvements as risk factors for delinquent youth, and of the importance of prosocial involvements as protective factors, is the relative lack of attention to peer involvements in the research about programming for these youth (Foley, 2008; Hawkins et al., 2010; Lipsey, 2009; Lipsey & Wilson, 1998). Mentoring programs have generally focused on youth who have been identified as at risk because of socio-economic, geographic, and demographic factors. These programs ideally involved matching youth with carefully screened, supportive adults who met regularly with the youth usually for at least one year. While the research base is limited, information from two meta-analyses suggested that mentoring programs can have a modest impact on lowering youth delinquency and reoffending rates. Two narrative reviews concluded that well-run mentoring programs can have positive impacts on youth attitudes and behaviours that put them at risk of involvement in criminal activities. These narrative reviews also indicated that successful implementation of youth mentorship programs depends on the availability and

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commitment of high-quality volunteers for an extended period. They also suggested that mentoring success is enhanced with high levels of mentor commitment and good youth-mentor matches, including gender and ethnicity, as well as early intervention before long-term habits are entrenched, and when mentorship programs are combined with other supports (Hawkins et al., 2010; Jolliffe & Farrington, 2008; Lipsey, 2009; Underwood & Knight, 2006). Parenting development programs address problems with parental management in the home. Programs teach consistent use of rewards, punishments, and monitoring typically in guided group meetings with parents using role playing and modelling exercises. While the number of reviews including this option were limited, there does appear to be good evidence for the usefulness of parenting training, especially for children between 6 and 12 (Hawkins et al., 2010; Savignac, 2009). Family therapy programs involve counsellors who work with the youth and the family to improve communication and positive interactions within the family and to reduce negative patterns of behaviour. Programs are typically of a finite length (e.g., 10 weeks). Two meta-analyses showed inconsistent evidence for reducing reoffending in youth who participated in these programs (Lipsey, 2009; Lipsey & Wilson, 1998). However, two specific family-based approaches have received considerable positive attention in the narrative literature. Functional family therapy (FFT) is a prevention/intervention program targeting youth, aged 11–18, at risk of or involved with delinquent acts, violence, and substance use, and youth with conduct disorders. FFT ideally includes flexible delivery of service to families in various home and community settings and is available when youth leave institutional placements. It averages 12 home visits per family. In their narrative review, Hawkins et al. (2010) concluded that research evidence supports the effectiveness of FFT in reducing youth reoffending; for example, youth aged 11–18 had a recidivism rate 16 per cent lower than a control group receiving another treatment in one study. In his narrative review, Savignac (2009) identified FFT as effective at reducing reoffending based on evidence from many “rigorous” evaluations. Multisystemic therapy (MST) is an intensive family- and communitybased treatment for youths at risk for out-of-home placements. MST ideally includes family and cognitive behavioural therapies along with other supports specific to family needs, with the goal of reducing delinquent behaviour and keeping youth at home. Drawing on family systems theory and social ecology theory, MST focuses on how the youth’s environment may contribute to well-being, and treatment includes the individual, family, school, and community. Treatment usually takes

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place in the family home and community, and involvement generally lasts for three to five months. A trained therapist is typically available at flexible times to a small number of families. Goals are developed collaboratively with families and the program builds on family strengths. MST has received considerable attention across both narrative reviews and meta-analyses (Henggeler, 2016). Narrative reviews provided strong evidence that MST reduced youth antisocial and criminal behaviours across juvenile samples and in youth with severe emotional disturbance (Hawkins et al., 2010; Painter, 2010; Savignac, 2009; Trupin, 2007; Underwood & Knight, 2006). In studies using randomized controlled trials, youth who received MST were less likely to be re-arrested than those who had individual counselling, and when they did reoffend it was less frequently for violent crimes and drug offences. Furthermore, MST decreased aggression with peers, promoted family cohesion, and reduced rates of criminal activity and institutionalization (Trupin, 2007; Underwood & Knight, 2006). In Tennyson’s (2009) meta-analysis of 10 studies, MST reduced criminality for up to four years after treatment. In a more recent meta-analysis (van der Stouwe, Asscher, Stams, Deković, & van der Laan, 2014), small but significant effect sizes were noted for MST on general delinquency, substance use, and specific family factors such as parental mental health and parenting. Greater effect sizes were found for younger and non-ethnic study samples, as well as studies carried out in the United States, suggesting that effect sizes were moderated by study population, treatment conditions, and outcomes measured (van der Stouwe et al., 2014). The success of MST is attributed to multimodal, multilevel interventions and good program integrity because of high levels of supervision and support (Kurtz, 2002). SNAP Under 12 Outreach Project is a Canadian program exemplar of the MST model.

SNAP Under 12 Outreach Project SNAP Under 12 Outreach Project is a multisystemic intervention aimed at boys ages 6–11 with aggressive and antisocial behaviours. The program objective is to keep at-risk young males in school and out of trouble. Program components are tailored to the child’s and family’s assessed level of risk and need. Components can include SNAP Boys Group (teaching CBT and problem-solving skills), SNAP Parent Group (teaching child management strategies), Individual Befriending/Mentoring, Stop Now

98  Necessary But Not Sufficient and Plan Parenting (SNAPP; individualized family counselling), SNAP School Advocacy/Teacher Support, and SNAP Long-Term Connections/ Continued Care. The SNAP program has demonstrated effectiveness for lowering delinquency, offending behaviours, and aggression scores across studies with juvenile populations. Augimeri, Farrington, Koegl, and Day (2007) reported significant differences in scale scores on the Child Behavior Checklist (CBCL) between the group receiving the SNAP program and the control group. These group differences remained significant over time. By their eighteenth birthday, a greater proportion of youth in the control group had at least one criminal conviction than the proportion of youth who had participated in the SNAP program (57 per cent vs 31 per cent). This difference, while large enough to have practical implications, was not statistically significant in this investigation (Augimeri et al., 2007). Similarly, Lipman et al. (2008) reported improved scores on the CBCL over a six-month follow-up that favoured the group receiving the SNAP program over the comparison group (children on the waitlist for program involvement). This included a reduction in rule-breaking, aggression, conduct problems, and total problems as measured by the CBCL (Lipman et al., 2008). The SNAP program model has been adapted to other groups and contexts, including SNAP Girls, SNAP Schools, and SNAP for Indigenous Communities. As of January 2017, the program was administered both within Canada and internationally at over 35 affiliate sites. A national expansion strategy is in progress to target 120 new SNAP sites in Canada by 2019–20. See https://childdevelop.ca/snap.

Resource coordination programs such as case management services and agency coalitions are intended to help youth gain access to appropriate community services. Ideally, case management programs take a proactive role in helping people navigate fragmented service and support networks. Agency coalitions bring together various stakeholders such as schools, law enforcement, health and human service agencies, local government, business, and religious groups, as well as youth, parents, and other neighbourhood residents, to help troubled youth. There was not convincing evidence from these reviews that generic case management services or agency coalitions were likely to reduce substantially youth delinquency or recidivism rates. There was limited evidence that the Wraparound model – a resource coordination program that creates a tailored network for a youth involving informal helpers

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(family members, friends, volunteers) as well as formal services – might reduce youth reoffending (Ashford et al., 2007; DeGusti, MacRae, Vallée, Caputo, & Hornick, 2009; Foley, 2008; Hawkins et al., 2010; Lipsey & Wilson, 1998; Savignac, 2009; Underwood & Knight, 2006). Employment problems have been associated with higher incidence of physical and mental illness as well as antisocial behaviour (Ashford et al., 2007). However, there was little research in these reviews connecting youth employment programs with reduced youth delinquency or recidivism. Housing access has been correlated with other measures of successful community adaptation (Ashford et al., 2007). However, no studies appeared in these reviews on the impacts of access to housing supports on delinquency. Alternative school programs provide education and training options for youth outside of the mainstream classroom. Two meta-analyses showed small or mixed effects of academic programs on recidivism (Lipsey, 2009; Lipsey & Wilson, 1998). Two narrative reviews provided some evidence that specific alternative program models (i.e., Southern Oaks, Status) result in less criminal involvements and other benefits for participating youth (Foley, 2008; Hawkins et al., 2010). On the other hand, in his narrative review, Kurtz (2002) suggested that there is no clear causal link between school trouble and subsequent delinquency. He suggested that youth behaviour problems often co-occur and contribute to poor school outcomes. Multidimensional treatment foster care (MTFC) has the underlying philosophy that the best treatment for youth with serious emotional or behavioural problems takes place in a structured family environment. MTFC places youth in short-term foster homes while therapy involves them and their families. Duration of foster care is typically 6–9 months with 12 months of intensive parental training. Lipsey and Wilson’s (1998) meta-analysis showed that teaching family homes – a type of MTFC in which 4–8 children live in residence with a teaching-parent couple – were effective in reducing reoffending for incarcerated youth. Five narrative reviews supported MTFC’s capacity to reduce criminal behaviour, reoffending, and youth violence (Hawkins et al., 2010; Henggeler, 2015; Kurtz, 2002; Savignac, 2009; Underwood & Knight, 2006). Multiple-component programs (MCP) refer to programs that incorporate various strategies to meet youths’ needs in various life domains. Most of the reviewers emphasized the need for complex interventions (Ashford et al., 2007; Hawkins et al., 2010; Howell, 2003; Kurtz, 2002; Lipsey, 1999; Spencer & Jones-Walker, 2004; Tennyson, 2009; Trupin, 2007; Unruh, Povenmire-Kirk, & Yamamoto, 2009). For example,

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“Interventions that are explicitly based on a causal model and address a range of possible causal factors have been shown to be more successful than those that do not” (Kurtz, 2002, p. 687). Spencer and Jones-Walker (2004) concluded that simple solutions aimed at “fixing” young offenders are not generally successful because they do not address the myriad of personal, family, and contextual influences affecting outcomes. Hawkins et al. (2010) added, “Multiple prevention strategies crossing multiple domains that are mutually reinforcing and that are maintained for several years produce the greatest impact” (p. 234). Implications for Improving Youth Community Adaptation One implication from this review is that there is not likely to be a simple, short-term program approach that will produce substantial and enduring reductions in youth offending. A second implication is that there are probable benefits to thinking about what combination(s) of programming strategies would be feasible and sensible to reduce offending among these youth. This review suggests several broad program strategies worthy of closer consideration: skill development for youth, parent training and supports for family functioning, and positive peer and adult social connections for youth. It also seems likely that promising programming strategies will have to differ somewhat for younger and older youth populations. Unfortunately, this review provided no guidance for how to respond with different cultural and ethnic groupings of youth and families. It is also important to stress that other community adaptation challenges are facing youth leaving RT (e.g., school, family living, transitioning to independent living). It would be impossible to identify one of these challenges as the most important. Nor would it be credible to expect change in any one area of living to be the key to promoting change in the other areas. Yet it is not possible to do everything. Therefore, from our perspective, it will be important to look for commonalities across programming in different life domains, to think about whether the same strategies could be relevant to several community adaptation challenges for these youth, and to consider what packages of programming focuses and strategies seem both feasible and promising.

Chapter Six

Family

Following residential mental health programs (RT), many youth return to their families and potentially benefit from support from their parents and other family members well into early adulthood. However, youth leaving RT cannot always count on useful or consistent support from their families. Developing ways to foster successful family reunification with youth and to enhance family functioning and stability has particular relevance for these youth and their caregivers. The following list provides a brief overview of major patterns from this chapter’s reviews. Kenneth’s story illustrates common family realities among these youth. Main Patterns • For youth who return home, increased risk of reunification ­breakdown following residential treatment has been linked to negative youth behaviours (e.g., substance use, running away), poor family and parental functioning, and a history of out-of-home placements. • The stability of youth returning home following residential treatment is positively affected by the family’s engagement in treatment, longer lengths of stay, and use of after-care services. • Social and cognitive skills training showed positive effects on youth behaviours and relationships with others. Improvements in these areas can help to stabilize reuniting families and to maintain youth in their homes. • Parent training and support programs also held promising benefits to family reunification and stability by way of increasing caregiver confidence, capacities, and feelings of support in their efforts.

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Kenneth was unable to live safely with his family and entered residential treatment in grade 6 following an intense period of conflict with his parents. Kenneth returned to his mother’s care after living in out-of-home care for about two years. They still sometimes have trouble getting along, but Kenneth now uses some of the skills he learned in treatment to manage his behaviours. Kenneth, male, age 16 Kenneth entered residential treatment when he was in grade 6. He was involved in many fights with his mother and with his father and stepmother. He had trouble dealing with his anger. These problems made it difficult for Kenneth to live at home, maintain friendships, and engage in scholastic activities. One of his fights with his father became physical and the police were called. He has not seen his father since that day. Kenneth spent approximately two years in either RT or a group home. Kenneth now lives with his mother. At first, they lived in a noisy apartment complex. He felt very unsafe in this neighbourhood and did not feel like he had a refuge where he could go to escape. Kenneth and his mother moved to a different neighbourhood and feel safer in this apartment complex. He and his mother do not always get along. During these times, Kenneth tries to practise the skills in reducing his anger that he learned in RT. Kenneth attends a vocational school where he tries to engage in the classroom activities. He especially likes the class on cars and auto mechanics. Kenneth was being bullied at school and at first, he yelled back; but now he ignores the bullying and it happens less frequently and less intensely. He gets along well with the teachers and feels respected by them but still has challenges with friends on occasion. Kenneth really likes this school and the opportunities it provides for engaging with teachers. He has lunch with the same two friends every day at school. He finds the breaks from school such as holidays too long. He would someday like to be a mechanic and own a Mustang.

This chapter focuses on the subset of youth who return home after accessing RT. Family environment and family involvement are examined for their implications for youth well-being. Family environments present both risk and protections for youth well-being. Engaging and strengthening families is one strategy for developing youth assets, resources, and resilience. Consequently, programs to enhance family capabilities and stability are reviewed. Youth Returning Home after Residential Mental Health Treatment Less than half of youth discharged from residential treatment were living with family in our 1.5- to 2-year follow-up study (43 per cent) and in our 3- to 4-year follow-up study (39 per cent). Many of these youth

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showed improved personal functioning, and many reported less troublesome relations with family members: I can tell her [Mom] everything. I can talk to her about everything; she’s ­always there for me when I need something. So she gets me out of trouble and she’s always sticking up for me and just showing me the right way to go.

For intact families, residential treatment provided a unique opportunity for de-escalation and for mental health specialists to engage with youth and caregivers. For example, this youth talked about the benefits of parental support coupled with learning strategies for managing his anger: Well, I did a couple of anger management courses a couple of years back and I kind of used steps from that and my mom kind of helps me out with that too. [Q: And what sorts of steps did you learn?] Pretty much just to, like, walk away, which is pretty tough for me because I don’t like people thinking they’re better than me so they can walk all over me. I was told to, like, deep breathe or whatever or just think in your head who it’s coming from or whatever. My mom taught me that before you get in a fight, there’s, like, battles worth fighting and there’s ones that are not worth fighting, so choose your battles wisely.

At the same time, for over half of the youth who returned home, the levels of parent-child conflict and conflict between parents about youth behaviours continued to be high. Many families still reported clinical levels of disruption in daily activities such as going out shopping or visiting and having friends or relatives into the home. Approximately 58 per cent of parents reported that they were having significant problems in getting along with the youth living in the home, and many of these youth were also struggling with relationships in the community. One youth spoke about contributing to the problems in the family and placing family members and loved ones at risk: Um ... let’s just say I’ve been charged a lot. I’m not proud of it ... Um, okay, like, if I could maybe one time, actually, I ... one night, take all that back, if I could stop myself, I would stop myself, it was stupid. I put my sister, my family in jeopardy, I almost put my family in a gang war, I almost risked my girlfriend being killed, I risked a lot of things happening, from drugs to crime, if I had a chance to stop all of that I would. I would erase all of that. So ... all you kids out there, this is no joke, all you kids out there, if you hear this, do not do drugs, do not do crack, it’s bad.

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Parents of youth in conflict at home described their perceptions of lower parenting competence, personal quality of life, and increased stress. In addition, some of these families were coping with scarce financial resources: Um, like, my mom kinda stressed out about not being about to pay the – like, she can pay the rent, but she wants to have money to be able to like, to like, buy stuff for the girls and stuff, and she doesn’t have that all the time so it kind of stresses her out.

Some parents were themselves dealing with addictions and other mental health problems: She’s a big drug addict. Uh, she’s always in jail ... I can’t really say she doesn’t care ’cause I don’t really know but that looks like she doesn’t really care about any of her kids that she has because she just ends up giving them away or they just end up doing their own thing, going on the street so.

Pathways to Stability The percentages of youth returning home after RT varies. Farmer, Southerland, Mustillo, and Burns (2009) revealed that 61 per cent return home, Lakin et al. (2004) reported 37 per cent, Preyde, Cameron, Frensch, and Adams (2011) reported 43 per cent, and Teare et al. (1999) indicated that 62 per cent returned home. After RT, some youth are placed in foster family or group home care; some are admitted to hospital; and a few youth are placed with extended family or live independently. Several variables appear to be related to the stability of family reunification following RT (Farmer et al., 2009; Teare et al., 1999). Reunification instability has been linked to running away, substance abuse, and negative youth behaviours while in RT. A history of previous youth placements in out-of-home settings was also predictive of reunification instability. Youth with high externalizing problems manifested in struggles at school or at home were found to be at increased risk for reunification breakdown in separate studies (Fontanella, 2008; Teare et al., 1999; Xue, Hodges, & Wotring, 2004). In two studies, identified risk factors included past or recent youth violent episodes, youth being victims of abuse, and youth with a history of suicide attempts or suicide ideation (Farmer et al., 2009; Fontanella, 2008). Youth from families characterized by a history of parental mental illness, parental alcohol or drug abuse, or family violence were identified as about twice as likely to experience a reunification disruption

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(Fontanella, 2008; Teare et al., 1999). Youth presenting higher burdens of care for parents were more likely to re-enter inpatient treatment (Foster, 1999; Xue et al., 2004). Family member engagement in RT and use of after-care services positively influenced the stability of youth returning home (Lakin et al., 2004). Engagement refers to an active partnership between service providers and family members where the family members are involved in a two-way communication and are allies in the decision-making (Dostaler & Cannon, 2011). Identified barriers to family member involvement include limited financial resources, transportation difficulties, other parental responsibilities, conflict within the home, high levels of parental stress, and parental personal problems (Armbruster & Fallon, 1994; Baker, Arnold, & Meagher, 2011; McKay & Bannon, 2004; Nickerson, Brooks, Colby, Rickert, & Salamone, 2006). Engaging families in programs has been associated with successful reunification of families and improved youth development. Programs designed to actively partner with families in the delivery of care have provided evidence of: reducing the duration of stays in residential care by almost 50 per cent (Martone, Kemp, & Pearson, 1989); improving child functioning (Anderson, Wright, Kooreman, Mohr, & Russell, 2003; Leichtman, Leichtman, Barber, & Neese, 2001; Lieberman, 2004); decreasing length of stay in treatment for youth living in less restrictive settings (Anderson et al., 2003; Blau et al., 2010; Byalin, 1990; Knecht & Hargrave, 2002; Landsman, Groza, Tyler, & Malone, 2001; Lieberman, 2004); and improving family functioning (Lakin et al., 2004). Programs to Increase Family Stability and Reunification Interventions are needed to improve youths’ evolving capacities and relationships within one of their principal environments, the home. Youth with emotional and behavioural challenges often have conflictual family relationships. Interventions to enhance the ability of youth to function in a family environment can be crucial for successful reintegration into family and community living. Interventions also need to focus on supporting caregivers and parenting practices. Intensive Family Preservation Services Intensive family preservation services (IFPS) originally were designed as short-term crisis intervention programs to reduce the need for out-of-home placements in child welfare. A core service provider was supposed to actively reach out to families in their homes, be available

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on very flexible schedules, provide a diverse array of assistance, and help families access tangible educational and emotional supports (Tracy, 2017; Frankel, 1988; Rivera & Kutash, 1994). Early evaluations of these programs without control groups showed promising results (Nelson, Walters, Schweitzer, Blythe, & Pecora, 2009). Later reviews have highlighted difficulties with definitions of what constitutes IFPS and with implementation fidelity to the original program model (Schweitzer, Pecora, Nelson, Walters, & Blythe, 2015). These reviews also pointed to the generally poor quality of IFPS evaluations and to the narrow focus of most evaluations on prevention of out-of-home placements (Nelson et al., 2009; Tully, 2008). In one investigation, families who received intensive casework services, parenting and life skills education, family-focused treatment, and help with accessing community resources had reunification rates three times that of a comparison group, and families stayed together at a higher rate seven years later (Lewis, Walton, & Fraser, 1995;). MacLeod and Nelson (2000) conducted a meta-analysis of 56 studies, including 10 IFPS program studies, and reported medium program impacts at program discharge and at follow-up (effect sizes of 0.50 and 0.35 respectively), though the aforementioned poor methodological quality may dilute confidence in these effect sizes.2 Several reviewers suggested that IFPS programs designed to adhere to the principles of the original Homebuilders model (www.institute family.org/programs_IFPS.asp) had the most robust results (Nelson et al., 2009; Tully, 2008). A meta-analysis of 14 IFPS with rigorous experimental designs found that programs that adhered to at least 13 of the 16 components of the Homebuilders program reduced out-ofhome placements by 31 per cent (Washington State Institute for Public Policy, 2006, cited in Nelson et al., 2009). Tully (2008) argued that four elements differentiated IFPS that followed the Homebuilders model from other IFPS programs: 1) focusing on youth at imminent risk of out-of-home placement; 2) having small service provider caseloads; 3) maintaining intensity of service; and 4) having around-the-clock availability for families. From their meta-analysis, MacLeod and Nelson (2000) concluded that IFPS programs that focused on empowerment 2 Effect size is a quantitative measure of the magnitude of the experimenter effect. The larger the effect size the stronger the relationship between two variables. Effect sizes can be used to quantitatively compare the results of studies done in different settings. They are widely used in meta-analysis. S.A. McLeod (2019, July 10), What does effect size tell you? Simply Psychology, https://www.simplypsychology.org/effect-size .html.

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and strengths were more effective than those that were expert-driven and deficit-focused. Dagenais, Begin, Bouchard, and Fortin (2004) conducted a meta-analysis of 38 reports on 16 IFPS where the program was assessed for impacts on rates of placement. Of these, nine reported significantly better placement rates and seven reported no significant difference. Overall, these investigators reported positive effects on general family functioning, family support networks, and child functioning at home. They also found a small number of studies with evidence of positive effects on conjugal relations, youth delinquent behaviours, and peer relationships. Other reviewers cautioned that, while some evidence exists that IFPS has some success in family reunification, it is not clear that there is reduced risk of re-entry into care, and longer-term interventions may be required (Tully, 2008; Wulczyn, Chen, Collins, & Ernst, 2011). Parent Training Parent training is another common component of services trying to keep families together or to reunite them. These initiatives aim to change parenting behaviour to manage or to ameliorate child behavioural or emotional problems. Parent training programs often are combined with other supports and services for parents and youth (Hoagwood et al., 2010). Some reviewers have raised concerns about parent training as a stand-alone approach and about its long-term impacts (Cameron, O’Reilly, Laurendeau, & Chamberland, 2001; Johnson, Kent, & Leather, 2005). In addition, Hoagwood et al. (2010) concluded that parent training programs have shown strong evidence of success with the general population, but more limited positive and enduring results with more vulnerable populations. Assessments of parent training programs in this review were typically focused on youth behaviours and well-being and on parenting behaviours. Some evaluations included measures of family functioning. None focused on the impact of parent training on youth reunification with families or youth out-of-home placements. Kaminski, Valle, Filene, and Boyle (2008) conducted a meta-analysis of 77 parent training programs intended to enhance behaviour in young children (from birth to age seven). They found that overall programs changed parents’ behaviours and reduced behaviour problems in children. The effect size for parents was 0.43, and for children it was 0.30. Overall, their analysis suggested that the most effective strategies were to (1) help parents create positive interactions with their child; (2) teach emotional communication skills to parents; (3) teach parents how to use

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time-outs and the importance of parenting consistency; and (4) require parents to practise new skills with their children during training sessions. They also found that using a standardized curriculum increased program effect size. Johnson et al. (2005) concluded that parent training is the treatment of choice for mild to moderate behaviour disorders. They argued that parent training following well-established behavioural training protocols was more effective than non-behavioural training. Buchanan-Pascall, Gray, Gordon, and Melvin (2018) concluded that parent training interventions are an effective treatment for reducing externalizing problems in children aged 4–12 years. In MacLeod and Nelson’s (2000) meta-analysis, the pooled effect of five parent training programs was medium at post-test (0.36) and modest at follow-up (0.25) and overall (0.34). In Piquero et al.’s (2016) update of their earlier meta-analysis of family/parent training studies, they reported an overall mean effect size of 0.37 across 78 individual studies. There are several popular parent training programs with modest to medium evidence of intervention effectiveness. The Incredible Years Parenting Program (www.incredibleyears.com) is sometimes presented as the treatment of choice in parent training programs; however, evidence for its positive impacts is only modest (mean effect size of 0.31) (Piquero et al., 2016). Littell, Campbell, Green, and Toews (2005) reported that the Incredible Years showed similar improvements to other interventions for youth with social, emotional, and behavioural problems. The Triple P – Positive Parenting Program has shown short-term medium effect sizes (Piquero et al., 2016) and long-term small to medium effect sizes on child behaviours and parent practices, satisfaction, and efficacy (Sanders, Kirby, Tellegen, & Day, 2014).

Triple P – Positive Parenting Program Triple P – Positive Parenting Program is an international parent training program with applicability for a wide range of families, including those with complex issues such as depression, marital discord, highly distressed parents, and involvement with child welfare services. Triple P is a behavioural family intervention intended to promote ­positive relationships between parents and their children (ages 2–16). Using a variety of sources (multimedia, self-directed, or professional consultations), parents access information on parenting and behaviour management strategies. Triple P uses didactic presentations, individual

Family 109 or group activities, and homework to assist parents in identifying causes and goals for behaviour change. Other teachings include communication skills, planned activity scheduling, differential reinforcement, and effective consequences for misbehaviour. Triple P is offered in multiple formats and can be tailored to various target populations: Standard (with single families), Group (in group sessions), Enhanced (additional parent-focused modules), Self-Directed (using a workbook), Media (12 teaching video episodes), and Stepping Stones (for parents of children with a disability). In the Enhanced Triple P, additional modules focus on practice, coping skills, and partner support. Five levels of family support ranging in intensity and duration are offered. Most relevant to families with children and youth leaving residential treatment, levels 4 and 5 address the needs of families whose children have serious problems and families with multiple risk factors for increased family dysfunction. Level 4 provides intensive parent training over 8–10 sessions. Level 5 offers an individualized intensive program for families with more serious difficulties and includes practice opportunities for parents to manage their stress and improve parenting skills. The universal goals of Triple P are to provide support to parents, reinforce parenting skills, promote good family functioning and non-violent behaviours, reduce the risk of child abuse, and increase resources available to parents. Triple P has been found effective as a family support method. Across various formats, Triple P had on average medium effect sizes on child behaviours. Parents reported improvements in child behaviours. Mothers and fathers reported improvements in negative parenting behaviours. Medium positive effect sizes were found on parenting behaviours. However, clinical observations showed minimal improvements in negative parenting behaviours. See www.triplep.net for more detailed information. (Additional sources: Savignac, 2009; Tellegen & Sanders, 2013; and Thomas & Zimmer-Gembeck, 2007).

In general, parent training may be indicated with younger children, while other treatments such as cognitive behavioural therapy have been shown to have greater effectiveness with older adolescents (McCart, Priester, Davies, & Azen, 2006). Additionally, parent training on its own has been shown to be less effective with economically disadvantaged families (Lundahl, Risser, & Lovejoy, 2006). Parenting training programs based on social learning, cognitive behavioural, and ecological

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theories show promise in addressing the complex interaction of youth characteristics and family environments. Family Therapy There were no assessments of the impacts of family therapy or parent-child relationship therapy on youth reunification with their families or on maintaining youth in their homes in this review. A broader review of the effectiveness of family therapy and parent-child relationship therapy with disadvantaged populations or with youth with serious emotional or behavioural problems was beyond the scope of our review. While difficulties between parents and youth leaving residential mental health facilities is an important concern and a major contributor to family breakdown, no conclusions can be drawn from this review about the potential of family therapy or parent-child relationship therapy to improve these situations. Parent Support Parent support programs usually provide different types of information, advocacy, and educational and emotional support to parents of youth (Hoagwood et al., 2010). However, in this review, there was little consistency in how parent support programs operated. They also were often offered in combination with other programming. Many support programs included parent-to-parent relationships such as Parent Connectors (Kutash, Duchnowski, Green, & Ferron, 2011) and Parent Connections (Ireys & Sakwa, 2006). Peer advocates sometimes helped parents negotiate court and services systems and helped to normalize parent experiences (Child Welfare Information Gateway, 2011). Hoagwood et al. (2010) found relatively few formal evaluations of programs with these characteristics. Parent Connections Parent Connections is a family-to-family support program for parents with children who have emotional and behavioural difficulties. The program links a “veteran” parent, known as a parent support partner (PSP), with up to eight parents who have a school-aged child. The PSP offers support in the form of weekly telephone calls to build a relationship with each parent. Parents and their PSPs also meet at a series of educational workshops facilitated collaboratively by professionals and parent advocates. In addition to their educational merit, the workshops provide an opportunity for

Family 111 parents to share experiences and receive informational, affirmational, and emotional support. Informational support involves PSPs helping parents identify difficulties and find ways to address their needs and concerns. PSPs provide affirmational support by identifying opportunities for parents to build parenting competencies, confidence, and positive self-evaluations. Parents receive emotional support by their PSPs listening to their concerns, communicating an understanding of their feelings, and supporting parents to cultivate other emotionally supportive relationships with key people (relatives, friends, faith community members, etc.). Parent Connections was built on five primary principles: • A strong support network can improve parents’ responses to the challenges of raising a child with emotional and behavioural difficulties. • Support can help parents deal more effectively with their own worries and doubts. • Support can diminish feelings of stigma. • Support may allow professional treatment to work more effectively (i.e., stay engaged with treatment, make use of resources). • Building parents’ knowledge and skills can produce an increased sense of efficacy. Results from an evaluation using data from 257 families revealed positive program impacts on maternal mental health and perceived support. Parents involved in the program, compared to a control group, reported greater breadth of support. Maternal mental health was also positively impacted by program involvement. About 22 per cent of mothers in the program moved from high to low levels of anxiety 12 months into the program. Only 9 per cent of mothers in the control group had lower levels of anxiety after 12 months. Source: Ireys & Sakwa, 2006

In MacLeod and Nelson’s (2000) meta-analysis of 56 studies of programs developed to promote family well-being and prevent maltreatment, two programs were based on a social support model. The effect sizes of all social support/mutual aid interventions were medium to large at post-test (0.75), medium at follow-up (0.61), and medium overall (0.61). Social support and mutual aid interventions had the highest effect size of all program approaches, but this conclusion was based on only two studies. Hoagwood et al. (2010) reviewed 50 family-based programs for children’s mental health. Programs that focused mainly on supporting

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parents were associated with increased satisfaction by caregivers. The Maternal Stress Coping Group taught coping skills to parents of youth with ADHD in situations where the parents were themselves at risk for depression. Participating parents had significantly reduced depression, improved self-esteem, fewer negative cognitions about their child, less impairment, and greater satisfaction than a waitlist control group (Chronis et al., 2006, cited in Hoagwood et al., 2010). Similarly, a parent stress-management program for caregivers of youth with ADHD provided information, instruction in coping skills, emotional support, and advocacy. It was associated with reduced stress and improved parenting for mothers and increased satisfaction compared to a waitlist control group (Treacy et al., 2005, cited in Hoagwood et al., 2010). Singer et al. (1999) (as cited in Affronti & Levison-Johnson, 2009) concluded that, in parenting programs that used parents as mentors, parents had significantly better acceptance of family circumstances, better perceived their ability to cope, and felt better able to move forward with problems. In another study, Roman et al. (1995) found that parent mentors were associated with better mother-child interaction scores, better parental responsiveness, higher quality of home environment, and lower parent anxiety (as cited in Affronti & LevisonJohnson, 2009). While most studies reported high levels of parental satisfaction, parent support programs had little direct effect on child/youth outcomes. However, Woolacott, Orton, Beynon, Myers, and Forbes (2006) identified two random-control trials in which lower rates of re-hospitalization and increased patient psychosocial functioning were associated with support group involvement of caregivers of individuals with various chronic conditions. Kutash et al. (2013) reported improved emotional functioning in children of families who received family education and support services up to 18 months earlier. Cognitive Behavioural Therapy/Social Cognitive Skill Development for Youth Youth behaviour problems have been associated with difficulty in reuniting families and reduced stability when youth return home. Reviews of social and cognitive skill interventions have shown consistently positive effects on youth behaviours and relationships (Koehler et al., 2013; Thomas et al., 2008; Weisz et al., 2017). In Hoagwood et al.’s (2010) review, 10 cognitive behavioural treatment (CBT) programs in children’s mental health provided evidence of youth having reduced symptoms

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of obsessive-compulsive disorder, decreased oppositional behaviours, reduced anxiety, and decreased post-traumatic stress. Lundahl et al. (2006) reported small to moderate effects immediately following treatment for both behavioural and non-behavioural programs, no lasting effects for non-behavioural programs, and small effects for behavioural programs at follow-up. While reviewers did not specifically examine these program approaches for impacts on family reunification or maintaining youth at home, conceptually, improved youth behaviours and relationship skills should be linked to improvements in family reunification and stability. Multi-component Programs There were no multi-component programs in this review that had a primary focus on family reunification or improving youth-parent relationships within the home. Cameron et al.’s (2001) narrative review, focused on programming to prevent child welfare out-of-home placements, suggested that the clearest consensus in the literature was that, for many adolescents at risk, one-shot, single-dimensional interventions will not suffice to prevent out-of-home placements. However, despite this consensus across reviews in the literature, these authors also uncovered relatively few multi-component programs. While many of the comprehensive programs they reviewed did not include outcome evidence, for those that did, they found evidence of significant youth benefits in domains such as school engagement and performance, sexual risk-taking, teen pregnancy, trouble with the law, and reducing out-of-home placements. Youth functioning in the home was typically not included as an outcome measure in these assessments. In MacLeod and Nelson’s (2000) meta-analysis of 56 programs to promote family well-being and reduce maltreatment, there were five multi-component programs. Effect sizes of all multi-component programs were medium at post-test (0.41), small at follow-up (0.22), and medium overall (0.37). Little detail was provided on the five multicomponent programs. In the following vignette, Stan’s profile exemplifies the continued reliance on family for emotional and tangible support by many young adults living with emotional and behavioural challenges. Early behaviour problems (substance use, trouble with the law) and conflict with his parents led to Stan’s involvement with residential treatment. In RT, Stan received help with addressing difficulties in school, managing his

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personal well-being, and improving relationships with others, which may have contributed to the stability of his return home. Stan, male, age 20 Stan was in RT as a young boy and reflected that he found the experience quite helpful in learning to manage his anger and get along better with others. He was diagnosed with ADHD and was put on medication. He said that the medication made him feel worse, so he has stopped taking it. During RT, Stan received a lot of help with his school work, including tutoring, and he found hands-on learning particularly helpful. While Stan managed to successfully complete high school, he continues to have great difficulty finding a job. He expressed frustration and disappointment at this. He would like to go to college and possibly train to become an electrician but the cost is prohibitive. During his adolescence, Stan had some trouble with the law and had a problem with recreational drugs. He said he has learned that he wants a better life – one without these troubles – and he has succeeded. Stan presently lives with his parents and younger brother. Conflict was a major occurrence that led to his initial referral to RT. At present, there is no conflict, and family members get along well. His mother has helped him prepare résumés, and he finds her generally supportive. Stan has a few long-term friends, though he is otherwise not connected to any community or group. His main concerns now are financial strain, a lack of employment, and no means to further his education. Stan would like to be more independent as he feels he is imposing on his family.

Implications for Improving Youth Community Adaptation Youth behaviour problems are associated with difficulties in reuniting families and reducing family stability. Reviews of social and cognitive skill training consistently showed positive effects on youth behaviours and relationships with others. These benefits of youth social and cognitive skill development programs are consistent with the findings in other sections of this volume. Improved youth behaviours and relationship skills should help to increase reuniting families and maintaining youth within their homes. While less evidence was available, parent training and support programs also promised some family reunification and stability benefits through increasing caregiver confidence, capacities, and feelings of support in their efforts. However, for each of these approaches, it was less clear that on its own it would be sufficient to produce enduring improvements in youth community adaptation outcomes. Most reviewers believed that the value of these education and support programs are best realized as part of broader packages of

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service and supports. Nonetheless, the limited amount of studies and the poor methodological quality of the primary research on which these multi-component program reviews (e.g., Littell et al., 2005; Shepperd et al., 2009) were based means that this conclusion is grounded mostly in pathways analyses and reviewer rationales. The family can have major positive and negative influences on the development, well-being, and life opportunities of youth with emotional and behavioural disorders. The findings from our program of research indicate that many youth leaving RT, despite the gains they made in care, will still confront serious conflicts within their families. The review in this chapter indicates the value after RT of improving parent-child relationships, youth interpersonal skills, and augmenting parents’ caregiving and confidence as part of broader strategies to improve community adaptation outcomes for youth and families.

Chapter Seven

Youth Transitions from Substitute Care: Outcomes, Pathways, and Programs

Early research by the Partnerships for Children and Families Project underlined the crossover in youth populations served by both child welfare and children’s mental health systems. In particular, approximately half of youth involved with RT in the participating service organizations were in the care of Children’s Aid Societies (CAS) at the time. Main Patterns • In our research, youth accessing RT who were also in the care of child welfare authorities experienced compounded vulnerability for negative community adaptation outcomes following exit from RT. • For youth transitioning out of care, negative outcomes in all life domains (education, employment, housing, delinquency, mental health) were linked with having emotional and behavioural difficulties. Substance abuse in particular was a concern for older youth and had notable negative associations with employment and personal well-being. • Independent living programs (ILPs) are a widely used approach to supporting youth transitioning out of substitute care. The Transition to Independence Process (TIP) model is primarily used in assisting youth with emotional and behavioural challenges in the transition to adulthood. Both are touted as ways of working with young adults that can have a positive impact on improving outcomes in various domains of living. • Two integral components of successful programming for youth leaving care are to build a unique network of support around youth and to position youth as decision makers in their transition process. Youth transition conferencing, a variation of the family group

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decision-making model, is a strategy for working with youth that embodies these principles. Older youth leaving CAS care face two important and coinciding transitions: from foster care to community living and from adolescence to young adulthood. These life-changing transitions are often navigated earlier than other youth and without support from family. This leaves many of these youth vulnerable to poor adaptation outcomes, including in education, employment, delinquency, housing, and mental health. The Midwest Evaluation of Adult Functioning of Former Foster Youth (hereafter Midwest Study; Courtney et al., 2007) and the Northwest Foster Care Alumni Study (hereafter Northwest Study; Pecora et al., 2010) suggest youth “aging out” of the child welfare system fare worse than youth in general in securing employment, obtaining a high school diploma, finding a safe place to live, and maintaining health and happiness. Transition-age youth with emotional and behavioural difficulties exiting the children’s mental health system face similar community adaptation challenges (Fagan, Davis, Denietolis, & Sondheimer, 2014). Understanding the pathways to poor and improved after-care outcomes helps to inform programming for both youth populations. From our transition age study, 46 per cent of young adults we spoke to reported growing up in substitute care provided by child welfare authorities. Their stories echoed themes of compounded vulnerability found in other studies. They • experienced multiple living environments and had difficulty adapting to changing living circumstances; • confronted complex patterns of past and current circumstances that contributed to insecurity in their lives; • continued to see their family as important in their lives despite often persistent difficulties and tensions with family members; • often continued to be involved with child welfare (in the Continued Care and Support for Youth Program, which replaced the previous Extended Care and Maintenance Agreement in 2013), and the majority identified a service provider as an important adult in their current lives. As an illustration, Kyle lived in substitute care most of his adolescence and described feelings of abandonment and thoughts of suicide. Now 21 years old, he is struggling with no education, no job, a physical injury, and lingering issues of anger and depression.

118  Necessary But Not Sufficient Kyle, male, age 21 Until the age of 18, Kyle lived mostly in group homes where he was bullied by other residents. His mother was addicted to drugs while Kyle was growing up, and he only saw his father occasionally. For a short while, Kyle lived with his grandmother but returned to CAS care due to his uncontrollable anger. Kyle said that he feels like his parents abandoned him. He experienced serious depression in the past and has considered suicide. Around age 11, Kyle entered special education, eventually leaving high school after grade 10. He is currently working on obtaining his GED (general equivalency diploma) part-time but admits to playing video games for up to 20 hours a day. Before recently hurting his ankle, Kyle worked at a bakery for over two years. He is now on social assistance. Kyle has been living with a family member for the past six months, previously having been kicked out of a place he had rented. He hopes to move out on his own again and live with his girlfriend. Kyle has a small but strong support network and credits his two close friends with pulling him out of a deep depression. Despite an up-and-down relationship with his girlfriend, he said she is someone who makes his life worth living. Kyle has had a few supportive adult male figures who helped him along over the years, including a chef who taught him how to cook, a group home staff member whom he still sees occasionally, and a weekend staff member in RT who Kyle said was the first adult male with whom he connected. Despite his current challenges, Kyle has hopes of finishing his high school equivalency degree and attending a culinary arts program at the local college.

Community Adaptation Outcomes for Youth Transitioning from Substitute Care In our program of research, youth who had been in RT who were in CAS care had consistently more problematic community adaptation profiles, on average, than youth in the care of their families. This was true at admission and at discharge from these residential programs. It was also true in the follow-up years, whether youth were of primary school age, in their preteen or early and middle teenage years, or entering young adulthood (Cameron, de Boer, Frensch, & Adams, 2003; Cameron & Frensch, 2015). While most youth leaving RT in our longitudinal program of research encountered serious and ongoing difficulties adapting to community life, and many of the challenges were similar for youth returning to family or to CAS care, the young adults who had graduated from CAS care talked about several relatively unique experiences. While a few youth returning home confronted difficulties that were somewhat comparable (e.g., extreme residential instability or very little access to support

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from family members), these experiences were common among young adults from CAS care. About 90 per cent of the young adults from CAS care talked about moving from home to home during their time in care. Troubles adapting to different living circumstances, conflict and violence when they were in these homes, running away, and feeling as if they did not belong were common themes in the narratives of these young adults. Most of these youth had lived in a group home (often several) during their time in care, and many recounted unpleasant memories about these times. Some made connections between their time in group homes and becoming more deeply involved with substance abuse and delinquent activities. A few of these youth had a long-term placement with a single foster family, but this was not common. Said one 22-year-old female who was in care from age 13 to 21, If there was one thing that I guess I never had, it was any sort of stability ... I’m going to all these different places, all these different people, all these different staff, all these different ... kids in and out, in and out. Like, no. That’s one thing that if I had a little bit of sadness or resentment to life, it would be the fact that I have no [support] ... I don’t have anybody. Not even my parents, you know. Not even family ... it sucks but turned out great, so [laughter].

Most of these young adults came from families of origin that were confronting severe difficulties when they entered care. During their time in care, youth typically received very little consistent support from family members. After leaving care, most had contact with some members of their families. However, compared to the young adults who had not been in CAS care for an extended period, they described receiving less material and emotional support from family members. About a quarter said that they had very little or no contact with family members. Nonetheless, despite often persistent tensions, most of these young adults continued to see their family as important in their lives and some continued to hope for improved relations. A 21-year-old female previously in care said, I was 15 when I moved out [of RT] ... I moved to [a big city] with [mom], and that only ended up working out for ... a month ... before my grandpa died and my mom just ... just pretty much gave the world the finger ... Me and my mom got in a fight and she kicked me out, and I called my Grandma ... she picked me up and she called Children’s Aid ... It was more to get me off the streets and get me away from my mom ... my foster

120  Necessary But Not Sufficient parents got me into school and they really helped me, motivate me. My foster mum is the reason I’m in a college and I’m where I am today ... I have a better relationship with my mom now than I’ve ever had. We’re kind of more like friends than we are mother and daughter.

Perhaps because of their relations with their families, and the amount of time they have spent in the care of child welfare authorities, many of these young adults continued to have relatively frequent involvements with child welfare and other social service providers. About two-thirds of these young adults were or had been on Extended Care and Maintenance (ECM) Agreements after they left CAS care. In 2013, these agreements were replaced by the Continued Care and Support for Youth Program. At the time, ECM Agreements provided financial support for these young adults (provided they were in school or were employed) and included regular contacts with a child welfare service provider. More striking was that about 90 per cent of these young men and about 70 per cent of these young women identified a service provider from child welfare or, less frequently, from children’s mental health residential programs as important adults in their lives (e.g., primary child welfare service providers, group home personnel, foster parents). These service providers provided advice and emotional support that, when it was available, was most commonly provided by parents, extended family members, and family friends to other young adults in this research. One 19-year-old male previously in CAS care shared this experience. [Q. Are you still getting assistance help from Child Welfare?] Extended Care and Maintenance ... I’m going to school, I’m participating in programs and stuff ... It helps me with my schooling. They’re helping me find a job again ... how to get into the pre-apprenticeship program at [college] ... [Q. So how’s (ECM worker) helped you with your schooling over the past couple of years?] She sits down with me twice a week for five hours a day to help me with my school work ... Anything I’ve asked her to help me get into, she’s helped me ... [Q. How long have you known her?] Since I was first in group homes ... She worked at [facility] when I was living there, and she became an ECM worker ... I asked her if she wanted to be my ECM worker and she said yeah ... She’s like a mum, but a friend at the same time. It’s kind of weird ...

A scan of the literature on outcomes for youth leaving substitute care revealed ongoing challenges in the areas of education, employment, delinquency, housing, and mental health.

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Education Poor educational outcomes for youth leaving substitute care have been well documented. Rates of high school completion among youth exiting substitute care are consistently lower than completion rates among the general student population (White, O’Brien, Pecora, & Buher, 2015). Reported rates vary across studies from 49.5 per cent at age of emancipation from care to 84.8 per cent when longitudinal studies are considered. Obtaining a GED instead of obtaining a high school diploma is more common among foster youth than among the general population (Pecora et al., 2010). Youth in care tend to drop out of school early (Smithgall, Gladden, Howard, Goerge, & Courtney, 2004). Grade failures, multiple school changes, and overrepresentation in special education characterize academic careers of youth in substitute care (Pecora et al., 2010; Pecora, Williams, et al., 2006; Scherr, 2007). While many youth hold aspirations to attend future vocational or college training, few youth enrol in post-secondary education and even fewer actually graduate (White et al., 2015). Employment Reported rates of employment among former youth in care vary widely between 40 per cent and 80 per cent for the two years after care (Dworsky, 2005; Goerge et al., 2002; Hook & Courtney, 2010). Research agrees, however, that the population is both underemployed and earning less than their counterparts in the general population. Among employed former youth in care, annual earnings are low, with anywhere from 17 per cent to 64 per cent reported to be living below the poverty line and/or receiving some type of social assistance (Dworsky, 2005; Goerge et al., 2002; Hook & Courtney, 2010; Pecora, Kessler, et al., 2006). In some cases, low rates of employment and earnings have been reported to persist into young adulthood (Dworsky, 2005; Stewart, Kum, Barth, & Duncan, 2014). Delinquency The majority of youth in care are non-offenders or low offenders, with proportions of these youth ranging from 34 per cent to 69 per cent (Cusick, Courtney, Havlicek, & Hess, 2011; Vaughn, Shook, & McMillen, 2008). Youth in care have higher rates of delinquency than youth in the general population (16–18 per cent vs 4–6 per cent). However, life course patterns of delinquency for substitute-care youth are similar to patterns

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in the general youth population, albeit with higher levels of delinquent behaviours and arrests peaking in mid- to late adolescence and then dropping off by age 21 (Cusick et al., 2011). Rates of delinquency vary widely depending upon the outcome being measured, from selfreported arrests, to less serious legal involvement like theft under $50, to the most serious of crimes involving the use of a weapon. For example, self-reported rates of arrest for youth in care by age 19 vary from 18.2 per cent (Vaughn et al., 2008) to 57 per cent for males and 34.4 per cent for females in the Midwest Study (Cusick et al., 2011). Additionally rates and subtypes of criminal behaviour can vary by youth characteristics including age, gender, race, school status, and patterns of substance use (McMahon & Fields, 2015; Ryan & Testa, 2005). Housing A basic need for youth exiting substitute care is to find a safe and stable place to live. This task does not come easy to youth with limited financial resources and familial supports. Without the safety net of family to fall back on, former youth in care experience rates of homelessness higher than other youth in the general population. Approximately 14 per cent of former youth in care from the Midwest Study were homeless at least once following exit from care (Dworsky & Courtney, 2009). In the year following emancipation from care, 22.2 per cent of the Northwest Foster Care Alumni youth experienced one or more nights of homelessness (Pecora et al., 2010). Additionally, housing instability including multiple and frequent moves is characteristic of living arrangements of former youth in care in the months after discharge (Jones, 2011). Mental Health Our research and others’ have highlighted the sizeable overlap in populations served by both child welfare and children’s mental health (Greger, Myhre, Lydersen, & Jozefiak, 2015; Klein, Damiani-Taraba, Koster, Campbell, & Scholz, 2015; Leloux-Opmeer et al., 2016). Mental health challenges among youth in substitute care are common, with estimates of up to 60 per cent of youth in care (or three in five children) ever having a mental health disorder and 37 per cent of older youth in care reporting a psychiatric disorder within the past year (McMillen et al., 2005). Greater mental health needs among youth in care are often placed within the context of deleterious pre-care experiences of neglect or abuse and the trauma of placement itself. In the Midwest Study rates

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of mental health diagnoses varied by type, with 16.2 per cent of youth diagnosed with PTSD and 10.1 per cent diagnosed with major depressive episode (Keller, Cusick, & Courtney, 2007). Substance use disorders are also higher among youth exiting care than in the general youth population. Rates of alcohol dependency ranged from 11.3 per cent for “lifetime” use among Northwest Study alumni (White et al., 2008) to 14 per cent for Midwest Study former foster youth (Keller et al., 2007). Drug dependency within the last 12 months was 8 per cent for former foster youth in the Northwest Study (vs 0.7 per cent for general population) while alcohol dependency within the last 12 months was 3.6 per cent for former foster youth, which was not that dissimilar from the general youth population (2.3 per cent). Pathways to Community Adaptation Outcomes Jenna’s story illustrates complex circumstances with impacts on her transition to young adulthood. Jenna went into care at an early age and experienced much instability in her life. Jenna, female, age 20 Jenna graduated with a high school diploma from a small alternative school that she described as the “best school ever.” This was after attending at least six previous schools at which she would refuse to do homework, get into conflicts with the teachers, and often come to school either drunk or high. During her teenage years, Jenna drank a lot and used a variety of drugs. She received drug counselling but did not find it helpful. It wasn’t until her friends started having children that she (and her friends) cut back on their use. Jenna still smokes marijuana, regularly saying that she does not consider it a drug. Jenna has had no legal troubles since leaving RT but describes her younger self as a rebel. She recalls being depressed and cutting herself but doesn’t know what her diagnoses were, despite being on multiple psychotropic medications at the time. She describes her current emotional state as good and has weaned herself off all medications. While Jenna sees her parents now, she says she does not really know them and has only recently become closer to her father, who is a recovering alcoholic. Jenna did not live with her family from a very early age and has a history of residential instability. After RT, Jenna lived in transitional housing for youth at risk of homelessness and later accessed a job training program at the YMCA. It was through this program that she got her first job at a grocery store. She has been working there full-time for two years and is now a supervisor. She currently lives in a subsidized apartment with her cat.

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To organize our discussion of pathways to community adaptation outcomes for youth leaving CAS care, we constructed a matrix of types of risk and protective factors (individual, in-care experiences, and precare experiences) by domains (education, employment, delinquency, housing, and mental health). Table 7.1 presents this matrix. It suggests that community adaptation outcomes for youth transitioning from substitute care are influenced by a few key risk and protective factors that are common to more than one domain: Individual Risk Factors • Having emotional and behavioural difficulties was identified as a risk factor for negative outcomes in all domains for youth transitioning out of substitute care. Substance abuse was also a risk factor in the domains of employment and mental health. • Involvement in the criminal justice system and an association with deviant peers were linked to negative outcomes in the areas of employment and delinquency. • Older youth in the child welfare system were at greater risk for negative mental health outcomes, particularly substance abuse. In-Care Experiences • In four out of five life domains (excluding housing), instability of child welfare placement was linked to poorer later community adaptation outcomes for youth transitioning from substitute care to independence. • Living in group care had negative consequences in the domains of housing, delinquency, and mental health. • Running away from substitute care was linked to poor housing and mental health outcomes. Pre-care Experiences • Experiencing abuse or neglect was linked to poor community adaptation outcomes in four out of five life domains (excluding employment). • Dysfunctional family patterns including parent-child conflict, family violence, low family cohesion, and strained or no relationship with the mother were risk factors for negative outcomes in housing, delinquency, and mental health.

7.1  Overview of Factors Associated with Negative Life Domain Outcomes Education

Employment

Individual

Special education classification (e.g., EBD or learning disability) (Smithgall et al., 2004; Snow, 2009) Academic deficits (Scherr, 2007; Smithgall et al., 2004; Snow, 2009)

In-Care Experiences

Placement instability and school changes (Pecora, Kessler, et al., 2006; Pecora, Williams, et al., 2006; Smithgall et al., 2004; Snow, 2009)

Housing

Delinquency

Mental Health

Mental health diagnosis Externalizing (Naccarato, Brophy, & behaviours Courtney, 2010) including Involvement in criminal delinquency justice system (Hook & and substance Courtney, 2010) use (Dworsky & Race (Hook & Courtney, 2009; Courtney, 2010) Jones, 2011; Nesmith, 2006; Robert, Pauze, & Fournier, 2005)

Externalizing behaviours (Vaughn et al., 2008) Deviant peer affiliations (Vaughn et al., 2008) Race (Ryan & Testa, 2005)

High externalizing problem behaviours (Keller et al., 2007) Increased perceived stress (AguilarVafaie, Roshani, Hassanabadi, Masoudian, & Afruz, 2011) Older age (Guilbord, Bell, Romano, & Rouillard, 2011)

Placement instability (Hook & Courtney, 2010)

Placement instability (Cusick et al., 2011; Jonson-Reid & Barth, 2000; Ryan & Testa, 2005) Living in group care (Cusick et al., 2011) Older age at placement (Jonson-Reid & Barth, 2000; Ryan & Testa, 2005)

Placement instability (Keller et al., 2007) Living in group care (Keller et al., 2007; McMillen et al., 2005) Running away (Keller et al., 2007)

Risk Factors

History of running away (Dworsky & Courtney, 2009; Nesmith, 2006) Living in group care (Dworsky & Courtney, 2009) Place discharged to (Jones, 2011)

(continued)

7.1 (continued) Education Pre-care Experiences

Employment

Experience of abuse/ neglect (Smithgall et al., 2004; Snow, 2009) Poverty (Snow, 2009)

Housing

Delinquency

Mental Health

Experience of physical abuse (Dworsky & Courtney 2009; Robert et al., 2005) Parent-child conflict (Robert et al., 2005)

Type of abuse (Cusick et al., 2011; Ryan & Testa, 2005; Vaughn et al., 2008) Relationship with mother (Cusick et al., 2011)

Experience of physical abuse (McMillen et al., 2005) Family violence (Reinherz, Paradis, Giaconia, Stashwick, & Fitzmaurice, 2003) Low family cohesion (Reinherz et al., 2003)

Being employed (Jones, 2011) Close relationship with at least one adult family member (Dworsky & Courtney, 2009)

Being employed (Cusick et al., 2011; Vaughn et al., 2008) Family support (Vaughn et al., 2008) College aspirations (Cusick et al., 2011) Accessing independentliving services (Cusick et al., 2011)

Foster parents perceived as helpful (White et al., 2008) Relationship with female caregiver (Guilbord et al., 2011) Tangible resources upon leaving care (White et al., 2008) Positive attitude towards school (Aguilar-Vafaie et al., 2011) Extracurricular activities (Guilbord et al., 2011) Supplemental education services (White et al., 2008)

Protective Factors Employment Employment experiences while experiences while in in care (Pecora, care (Dworsky, 2005; Williams, et al., 2006) Goerge et al., 2002; Good relationship with Naccarato et al., foster family (Pecora, 2010) Williams, et al., 2006) Higher education Tangible resources level (Naccarato upon leaving care et al., 2010; Hook (Pecora, Kessler, & Courtney, 2010; et al., 2006) Pecora, Williams, Accessing independentet al., 2006) living services Older age at discharge (Pecora, Williams, (Dworsky, 2005; et al., 2006) Hook & Courtney, 2010)

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Protective Factors • Having a job or building some employment experience while in care was associated with better outcomes in the domains of education, employment, housing, and delinquency (four out of five domains). • A positive and supportive relationship with an adult family member was linked to improved outcomes in education, housing, delinquency, and mental health (four out of five domains). • Accessing independent-living services including the provision of tangible resources when leaving care was associated with improved outcomes in education, delinquency, and mental health (three out of five domains). • School factors including a positive attitude towards school, involvement in extracurricular activities, supplemental educational supports, and college aspirations were related to improved outcomes in the domains of employment, delinquency, and mental health (three out of five domains). Education Lower rates of high school completion among youth in care and former youth in care were associated with several individual risk factors as well as a few pre-care and in-care experiences. There is a consensus among authors reviewed that academic deficits beginning in grade school and continuing into high school contribute to poor educational outcomes for youth in care. These include low standardized test scores, absenteeism, failing one or more grades, and high rates of severe disciplinary action such as suspensions and expulsions. Additionally, higher proportions of youth in care than other students have a mental health diagnoses or special education classification such as emotional and behavioural disorder (EBD) or learning disability (LD) and are overrepresented in special education services. High school completion was jeopardized by multiple school changes over the academic careers of youth in care, often coinciding with entry into care and placement changes while in care. Experiences of abuse or neglect and family poverty prior to entry into care were also reported to share an association with dropping out of high school. Protective factors from the Northwest Study suggest that positive educational outcomes such as completing high school and pursuing other educational opportunities beyond high school can be encouraged by way of a good relationship with the foster family, providing youth with tangible resources

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upon emancipation from care, offering employment experiences while in care, and facilitating access to independent-living services. Employment The employment and earning potential of former youth in care is related to several individual factors and in-care experiences, but less so to any pre-care experiences. Overall patterns in the United States suggest African American youth consistently earn less and are less likely to be employed than white youth.3 Involvement in the criminal justice system and having a mental health diagnosis are negatively related to earnings and employment. The effect of gender on the employment of youth exiting care is mixed, with the Midwest Study reporting females with children were less likely to be employed and earn lower wages if employed, while others suggest males were less likely to be employed in the short time following discharge. Placement instability, group care, and running away were associated with lower wages in the months following discharge from care. Conversely, wages and likelihood of employment were higher for youth coming out of kinship care arrangements, youth who entered care because of parent-child conflict, youth who were older at initial placement, and youth who were older at discharge. Receipt of employment services did not have any impact on yearly earnings for former youth in care, while higher levels of education and having some employment experience in the months leading up to discharge were positively related to future total earnings. Delinquency While the majority of youth in care are non-offenders or at low risk for offending, there are a few common factors related to offending behaviours and arrest among this population. Much of the interest has focused on predicting delinquency using in-care variables. Several authors found a significant relationship between placement instability and delinquency. Each additional placement change (usually beyond three or four placements) resulted in increased odds of delinquent behaviour and arrest among former youth in care. Older age at initial placement into care was also linked to increased delinquent behaviour.

3 As there is some debate about which language to use when referring to racial groups, we mirrored that of the reviewed study included by Hook and Courtney (2010).

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Among youth in care populations (or former youth in care), factors such as deviant peer affiliations and externalizing behaviours such as conduct disorder and substance use were associated with increased likelihood of delinquent behaviours. Factors found to protect youth in care included employment, college aspirations, family support, and access to independent-living services. Housing Mental health diagnoses, externalizing behaviours, delinquent behaviours, and substance use were all found to place youth at increased risk for housing instability, running away, and homelessness. Similar to risk factors for homelessness among general youth populations, experiences of physical abuse and parent-child conflict were predictive of homelessness for youth in care. Running away from substitute care was predictive of future running away episodes, as well as increasing the likelihood of future homelessness among former foster youth. Living in group care, in contrast to other care situations, increased the odds of becoming homeless after care. Youth discharged to transitional housing experienced fewer moves than youth discharged to other types of living arrangements. Other protective factors included being employed and having a close relationship with at least one adult family member. Mental Health Youth whose substitute-care experience could be classified as “distressed and disconnected” (characterized by a constellation of adverse events including multiple placements, school expulsions, and running away) were more likely to report problems with alcohol and drug abuse than youth with less traumatic substitute-care experiences. Older youth were also more likely to report substance abuse, with each year increasing the odds of problems by 2.5. School factors – including a positive attitude towards school, receiving supplemental education services, and involvement in extracurricular activities – all had a protective effect against depression, alcohol dependency, and substance abuse. However, a relationship with externalizing behaviours was absent. Strategies to Improve Community Adaptation Outcomes There are few comparative studies of approaches to supporting youth aging out of substitute care. This section focuses on two popular

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programs for assisting youth with the transition to adulthood: independent living programs (ILPs) from child welfare and the Transition to Independence Process (TIP) model used in children’s mental health. ILPs are widely used in child welfare, and their use is guided and supported by legislation. There are many examples of ILPs, and we provide brief descriptions of several successful US programs as well as some Canadian applications. Two earlier narrative reviews (Montgomery, Donkoh, & Underhill, 2006; Naccarato & DeLorenzo, 2008) suggested that ILPs have some success in supporting youth as they transition from substitute care to independence. A more recent review (Yelick, 2017) called attention to the methodological shortcomings of the research available since 2006 and a general lack of progress in research examining the effectiveness of ILPs in improving outcomes for youth aging out of care. The TIP model (Clark & Hart, 2009) has been in use since 2002 to aid youth with emotional and behavioural disorders as they prepare for adulthood. Four outcome studies summarized here point to the value of TIP in fostering positive outcomes in several key transition domains. Relatively new to programming around transition supports for youth exiting care is the use of family group decision-making (FGDM) models. In this context, a transition conference is held to bring together people who could make up the youth’s support network during the transition process. To illustrate, we include a brief summary of one evaluation study of a US application of this model with a transition population. Independent Living Programs (ILPs) In broad terms, ILPs provide youth leaving care with life skills training to assist in their transition to independent living and adulthood (Montgomery et al., 2006). ILPs vary in their program design, delivery format, and delivery settings. They usually include life skills training focused on personal development and independent living that may be delivered in a group or individual format. Many ILPs also provide educational and vocational support. Length of involvement can vary, with some services extending well beyond exit from care. Despite the wide use of ILPs for youth exiting care, voices in child welfare have called into question the thin evidence base for such programming. Jones (2011) suggested that there is little evidence to support the effectiveness of ILPs to prepare foster youth for life after care. Similarly, Dworsky and Courtney (2009) concluded that, despite having components that make sense in light of the post-care needs of foster

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youth (like housing assistance), there is “very little in the way of empirical data regarding their effectiveness” (p. 50). A systematic review by Montgomery et al. (2006) found no randomized controlled studies of ILPs but summarized the results from seven outcome studies. A narrative review by Naccarato and DeLorenzo (2008) reported on 19 outcome studies conducted in the US and UK between 1990 and 2006. Three Canadian reports released in 2006 focused on transition services for youth in care. These included one at the national level (Reid & Dudding, 2006) and two provincial reports: the Youth Leaving Care Project by OACAS (Ontario) and the Office of the Children’s Advocate (Manitoba). Additionally, Massinga and Pecora (2004) provided an overview of US policy at the time affecting transition services for youth in care and include a few examples of local ILPs. All of these authors make recommendations to improve transition services. Montgomery et al.’s (2006) review of outcomes for ILPs suggested predominantly positive effects of ILPs on education, employment, and housing indicators. Similarly, Naccarato and DeLorenzo (2008) found that ILPs lead to higher rates of independent living and enrolment in post-secondary education. However, employment rates were only modestly higher than for non-ILP-involved youth one to three years after care. Both review articles identify several limitations of the evidence base, particularly the lack of uniformity in outcome measures, small sample sizes, and questions of program fidelity. Similar concerns were raised by Yelick’s (2017) review of six primary studies of the impacts of ILPs on outcomes for youth aging out of care, conducted since those two earlier reviews. Yelick (2017) posited that at best the evidence suggests youth obtain some positive benefits from participating in ILPs but cautioned against using the existing weak evidence for promoting any practice or policy transformations. Nonetheless, ILPs are widely used and many support their usefulness in preparing youth for independent living. Frequently endorsed ILP elements include incorporating youth voices as planners and decision makers (Manitoba Office of the Children’s Advocate, 2006; Massinga & Pecora, 2004; Naccarato & DeLorenzo, 2008; Reid & Dudding, 2006); fostering youth support networks that incorporate healthy relationships with at least one adult mentor (Manitoba Office of the Children’s Advocate, 2006; OACAS, 2006; Reid & Dudding, 2006); preparing youth for contact with their biological family members (Manitoba Office of the Children’s Advocate, 2006; Massinga & Pecora, 2004); and an emphasis on the systematic teaching of life skills to all older youth transitioning from care to independent living (Manitoba Office of the Children’s Advocate, 2006; Massinga & Pecora, 2004; Naccarato & DeLorenzo, 2008).

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Transition to Independence Process (TIP) Model The TIP model is designed to assist young people with emotional and behavioural disorders as they prepare for greater independence and self-sufficiency (Clark & Hart, 2009). The model is based on seven guiding principles and their associated core practices (table 7.2). Administered by a transition facilitator, the TIP system is “an integrated process with a young person, his or her informal key players (e.g., parents relatives, friends, spouse), and formal key players (e.g., therapist, teacher, supervisor). Thus, the transition facilitators and others working with youth and young adults need to apply the guidelines and core practices on an individualized basis, addressing the priorities, needs, and wishes of each young person to facilitate his or her goal planning and accomplishments” (Clark & Hart, 2009, p. 51). Program outcome studies suggest the TIP model is successful in fostering improvements in community adaptation for youth with emotional 7.2  TIP Guidelines and Core Practices TIP Guidelines 1. Engage young people through relationship development, person-centred planning, and a focus on their futures. 2. Tailor services and supports to be accessible, coordinated, appealing, nonstigmatizing, and developmentally appropriate – and building on strengths to enable the young people to pursue their goals across relevant transition domains. 3. Acknowledge and develop personal choice and social responsibility with young people. 4. Ensure a safety net of support by involving a young person’s parents, family members, and other informal and formal key players. 5. Enhance young persons’ competencies to assist them in achieving greater selfsufficiency and confidence. 6. Maintain an outcome focus in the TIP system at the young person, program, and community levels. 7. Involve young people, parents, and other community partners in the TIP system at the practice, program, and community levels. TIP Core Practices • • • • • • •

Strength discovery and needs assessment Futures planning Rationales In-vivo teaching Social problem-solving Prevention planning on high-risk behaviours and situations Mediation with young people and other key players

Adapted from: www.starstrainingacademy.com/tip-model-institute

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and behavioural disorders, in particular in the domains of education and employment. These studies evaluated three transition programs for youth with EBD based on the TIP model: the Partnerships for Youth Transition (PYT) implemented across five US sites, the Steps-to-Success program in Florida, and the Options program in Washington State. Haber, Karpur, Deschênes, and Clark (2008) reported that the greatest positive change for youth occurred in the first three months of involvement in the PYT initiative. Older youth, females, and African Americans showed greater improvement, as did youth with a history of incarceration. Younger youth and youth with a diagnosis of a disruptive disorder were the least likely to improve, with the latter group worsening on a substance abuse indicator during program involvement. Another study of the same program by Clark et al. (2008) showed significant trends towards improvement over time in the domains of employment, education, mental health, and substance use. Change in criminal justice involvement, while in the expected direction, was not significant. The Options program, based on the TIP model and supplemented with a supported employment component, was effective in reducing the rate of substantiated criminal offences among program youth from 61 per cent (pre-program) to 29 per cent (during program) (Koroloff, Pullmann, & Gordon, 2008). Additionally, the number of hours of employment services received was directly related to improvement in employment outcomes over time. The Steps-to-Success program, with a heavy emphasis on employment practicum and vocational training, significantly improved the rates of post-secondary enrolment and productivity levels among program-involved youth (Karpur, Clark, Caproni, & Sterner, 2005). In comparison to youth with EBD receiving services “as usual,” program youth fared better. Furthermore, odds of negative outcomes (such as unemployment, incarceration, and no post-secondary enrolment) were comparable to the likelihoods among a comparison group of youth in the same school district with no diagnosis of EBD. A more recent implementation of the TIP model by Muskegon County Community Mental Health in Michigan, with its rollout and evaluation also supported by the TIP model team, showed positive results on progress indicators for an initial cohort of youth with up to 12 months of program involvement (Dresser, Clark, & Deschênes, 2015). At followup, greater proportions of youth were enrolled in school, working, and living in the community (as opposed to a more restrictive living environment). Most of the evaluation studies of the TIP model have been conducted by the team who formulated the model; nonetheless, results show the value of the TIP system in improving community adaptation outcomes for youth with EBD in transition to adulthood.

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With particular success in the areas of education and employment, this model seems suited to address these same challenges for youth transitioning from substitute care into young adulthood. Family Group Decision-Making (FGDM) FGDM is a decision and planning process that endeavours to position families and youth as leaders in planning to address family concerns including child safety, permanency, and well-being (Merkel-Holguin, Tinworth, & Horner, 2007). A core principle of FGDM is that families are capable of nurturing their children and know best their own strengths, needs, and resources (Velen & Devine, 2005). Other parties to the decision-making process, like community members and child welfare representatives, facilitate access to resources needed to enact family-driven solutions (Merkel-Holguin et al., 2007). Typically FGDM has been used in child welfare to pursue outcomes of safety and permanency for children and is commonly applied as a technique for permanency planning for children facing out-of-home placement (Merkel-Holguin, Nixon, & Burford, 2003; Wang et al., 2012). There is a growing interest in using FGDM to address the permanency needs of older youth expected to age out of care. JusticeWorks YouthCare (JWYC) provides FGDM services for child welfare and juvenile justice sectors in 40 counties in Pennsylvania (justiceworksyouthcare.com). The KIN-nections Project in Arizona uses FGDM to address the permanency needs of children who have been in care for five years or longer. While securing a permanent placement for these youth proved to be challenging, a notable positive benefit to the process was the re-establishment of relationships with family members (Velen & Devine, 2005). Youth transition conferences are an initiative in the province of British Columbia that engage youth in decision-making to identify their needs in transitioning out of care and to create a network of people to whom they can turn for support (Vanon, 2011). While we noted the availability of reviews on the use of FGDM to reduce out-of-home placements (Burford, Connolly, Morris, & Pennell, 2012; Skaale Havnen & Christiansen, 2014), no evaluations of the effectiveness of FGDM with youth transitioning from substitute care to independent living were available. Overarching Themes and Implications Positioning youth as planners and decision makers in their transition process from care is considered an integral component of successful

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programming. An established guideline within the TIP model is to engage youth through relationship development, person-centred planning, and a focus on the future. Using a “strengths discovery approach,” the TIP model engages youth in identifying their talents, competencies, and resources on which to build attainable goals for the future. According to Clark and Hart (2009), this strategy is more compelling for youth engagement than a deficit-based approach. ILPs have focused mainly on skills training for all older youth prior to exit from care. Naccarato and DeLorenzo (2008) recommended ILPs could do more to engage youth by creating individually tailored plans and seeking youth input. Reid and Dudding (2006) suggested programs must be developed in consultation with youth and evaluations of programs should include youth evaluations as service users. More emphasis on providing youth with a voice is identified to bolster transition programming for older youth leaving care (Massinga & Pecora, 2004). The FGDM model, in contrast, is ideally a process in which youth determine the level of permanence they desire and who will be a part of their supportive networks. Common to all three program models is an emphasis on developing supportive networks for youth consisting of family, informal contacts, and formal service providers. This program element is linked to the identified protective factor of having a relationship with one or more supportive adults as a buffer against poor outcomes across several life domains. Additionally it suggests the importance of conceptualizing the transition to adulthood as a process towards “interdependence” (White et al., 2006). According to Smith (2011), “interdependent living is a goal that more accurately represents the process of emerging adult development ... resources develop and grow from connectedness to significant others, organizations, and communities” (p. 228). There is a misconception that families are out of the picture for youth who grew up in substitute care. Jones (2011) points out that a common place for youth to end up living after discharge from care is with their family. Successful transition planning should prepare youth for potential reconnection with their family of origin, including boundary setting, addressing expectations, and identifying sources of support (Smith, 2011). Transition programs would do well to engage families in youth transitions out of care whenever feasible. FGDM seems well suited to facilitate reconnections with family. Family circumstances may have changed while youth were in care and the family may be in a better position to join youth supportive networks. The notion of re-establishing relationships with family members, however, should not be romanticized. Negotiating roles of family

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members in youth supportive networks is a potentially delicate process, and ideally FGDM can provide a safe environment to do this. Patterns of the effectiveness of ILPs and the TIP model suggest that both can have a positive impact on post-care community adaptation in education and, to a lesser degree, employment. The narrative reviews for ILPs concluded that college enrolment and completion of vocational or technical training was higher for ILP-involved youth. Similarly, rates of post-secondary enrolment among TIP-involved youth were higher than rates for youth receiving “service as usual.” The most commonly identified risk factor across multiple life domains (e.g., housing, employment, education, delinquency, mental health) was living with emotional and behavioural difficulties. Conversely, having a positive relationship with at least one adult family member was pivotal in fostering more positive outcomes across key life domains. Recognizing the centrality of youth mental health needs and the potential buffering effect of having a positive relationship with an adult would be a worthwhile consideration in planning services for transition-age youth and other youth populations.

Chapter Eight

Systems of Care for Youth

As a general approach to improving community adaptation outcomes for youth with emotional, behavioural, and psychiatric disorders, systems of care (SOC) have received considerable attention and funding, particularly in the United States. According to Stroul, Goldman, Pires, and Mantueffel (2012), as of 2011, the Children’s Mental Health Initiative (CMHI) funded SOC in 173 communities across the United States, including 21 tribes or tribal organizations, that have served over 113,000 children and youth. An additional 123 grants were funded between 2011 and 2015 to support an expansion of systems of care (Azar, McCance-Katz, del Vecchio, Vasquez, & Blau, 2016). The focus for this chapter is to clarify whether it is reasonable to expect that SOC can improve community adaptation outcomes for youth leaving residential mental health treatment (RT). Main Patterns • SOC have garnered attention, particularly in the United States, as a system-level philosophy and framework for service provision for children and youth with emotional and behavioural challenges. • Research on their impacts at the levels of system transformation, service delivery, and child and family outcomes is plagued by criticisms of quality, including methodological shortcomings and issues related to definitions of SOC for evaluation purposes. • As an example of SOC in practice, Wraparound is described as a participatory way to work with families building capacity within natural and service networks to support youth confronting multiple challenges. • Wraparound programs with high fidelity to a core set of principles show positive changes in youth behaviour and functioning and restrictiveness of living situations.

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Consider the following scenario: Keagan, female, age 15 Keagan lived in a small, rural community and began to struggle after the death of two classmates. She had some success with a counsellor, but this ended when the counsellor left on maternity leave. After that time, Keagan spent three months in residential treatment, had not completed any high school credits, and had an angry relationship with her mother. Her attempt to return to school started well but derailed when the assigned teacher was a­ bsent. She then lived with her boyfriend and was trying to home-school.

Now, imagine a different scenario where Keagan and her mother engaged with a support team, and a contact person was available to help them access community supports. Collaborating with the family, this team focused on improving mental health, school, family, and community engagement outcomes. Common sense would suggest that Keagan and her mom might have experienced better community adaptation outcomes. SOC have been described as a set of principles that can guide integrated services in community settings. Wraparound services have been described as practice or front-line implementation of SOC. To describe the evaluation research about SOC, nine narrative reviews were examined. The review of Wraparound research included three narrative reviews and one meta-analysis. Overall, we concluded that, while there is some evidence that systemlevel coordination of services over time might help youth and families in designated neighbourhoods, it is not a particularly credible strategy to improve outcomes for specific cohorts of youth and families graduating from residential mental health programs. Nonetheless, we concluded that there are elements of SOC and particularly Wraparound that hold promise, such as youth advocates, family engagement, and diverse support networks. What Are Systems of Care? First and foremost, systems of care are a range of treatment services and supports guided by a philosophy and supported by an infrastructure (Stroul, 2002, p. 5). Systems of care typically coordinate treatment services and supports to assist youth with serious emotional and behavioural difficulties (Stroul, 2002). They are intended to draw resources from diverse sectors including mental health, education, substance abuse, employment, recreation, and juvenile justice services (Stroul, Blau, & Sondheimer, 2008). In theory, SOC build on youth and family strengths and assets, provide assistance in the most normal settings,

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build partnerships with youth and families, consider environmental contexts, and are culturally relevant (Biebel & Geller, 2007). Three core values guide SOC: (1) services are child-centred and family-focused so that the priorities of youth and families guide assistance planning and activities; (2) service provision and decision-­making takes place in the neighbourhoods where youth and families reside; and (3) services are responsive to neighbourhood cultural and linguistic characteristics. Ideally, families retain primary decision-­making roles in the care of their children, and youth make developmentally appropriate decisions about their own care (Stroul et al., 2008). Systems of care are intended to be flexible and evolving systems that fit the profiles of individual neighbourhoods (Stroul, 2002; Cook  & ­Kilmer, 2004). A foundational idea is that the responsibility for care lies in the community as a whole rather than with a specific agency (­Pinkard & Bickman, 2007). SOC are developed primarily to support youth with co-occurring challenges (e.g., mental health, substance abuse, school, family, juvenile justice). A core premise is that providing coordinated services that intervene as early and in as many areas as feasible can reduce the negative consequences of these challenges (Cook & Kilmer, 2004; Rogers, 2003). Evaluations of Systems of Care Research focused on the effectiveness of SOC is limited, and there have been criticisms about its quality (Rosenblatt, 2010; Weisz, Han, & Valeri, 1997). Problems with shifting definitions of SOC, differing levels of analysis (e.g., program evaluation versus system-level evaluation), populations served, and appropriateness of study comparison groups have plagued SOC research (Friedman & Hernandez, 2002; Rosenblatt, 2010). Overall, it was hard in this review to find motivating evidence that it would be reasonable to expect positive community adaptation outcomes from attempts by children’s mental health organizations to create SOC for youth leaving RT programs. The available SOC research usually examines outcomes at multiple levels (Azar et al., 2016; B ­ ickman & Mulvaney, 2005; Biebel & Geller, 2007; Cook & Kilmer, 2004; Manteuffel, Stephens, Brashears, ­Krivelyova, & Fisher, 2008; Stroul et al., 2008; Stroul et al., 2012): • Systems – policies, regulation, financing of services, and linkages among child-servicing agencies; • Service delivery and practice – services provided and how care providers interact with youth and families;

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• Child and family – youth and family psychosocial and functional indicators, use of services, and satisfaction with services. Systems Outcomes System of care sites had better adherence than non-SOC sites to the principles of providing family-focused care, individualized care plans, collaborative supports, cultural competence, adequate access to care, and use of the least restrictive settings possible. SOC have led to reductions in out-of-home care placements (including inpatient treatment, residential treatment, and group home care) and associated reductions in costs, all while increasing use of community- and home-based services for children and youth with emotional and behavioural difficulties (Stroul et al., 2012). SOC had the most difficulty with adherence to the principles of interagency collaboration and cultural sensitivity, although they did better than non-SOC sites (Cook & Kilmer, 2004; Manteuffel et al., 2008). Service Delivery and Practice-Level Outcomes Systems of care had better adherence to service delivery and practice principles than to infrastructure or systems-level principles. They were most successful with family-focused, individualized, and accessible care. Cultural sensitivity presented the greatest challenge (Manteuffel et al., 2008). Some SOC sites also struggled with transportation, individualization of treatment plans, and family involvement (Cook & Kilmer, 2004). In the earlier research in this review (Cook & Kilmer, 2004; Manteuffel et al., 2008), most of the SOC-served children were between the ages of 7 and 18 and had significant functional impairment in multiple life domains, including home and school. Two-thirds of the children were boys. Up to one-half of the children had a history of substance abuse, and one-quarter had troubled histories, including psychiatric hospitalization, abuse, and running away from home. Many of the children experienced three or more vulnerabilities. About half of the children and youth had multiple diagnoses, including attention deficit, hyperactivity, oppositional defiance, and mood disorders. Almost all of the children were attending school (90 per cent), but performance was typically below average and approximately half were in special education classes. About half had received outpatient treatment. The SOC sites increased the number and types of services offered to families. On average, children and families in SOC used six different kinds of services in

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their first six months. Families in the SOC sites received twice as many services as those in comparison sites (Cook & Kilmer, 2004; Manteuffel et al., 2008). Overall, the largest benefits were seen in caregivers’ satisfaction with services, with their interactions with service providers, and with service planning (75 per cent); fewer caregivers were satisfied with the progress of their child (66 per cent). The reverse was seen among youth: 74 per cent were satisfied with their own progress, and just less than two-thirds were satisfied with services and involvement (Cook & Kilmer, 2004). Manteuffel et al. (2008) reported that, after 36 months of SOC involvement, 80 per cent of caregivers reported being satisfied with services. Child and Family Outcomes Outcomes for children and families in SOC were assessed as part of an earlier National Longitudinal Study that compared SOC to baseline measures and to two non-SOC sites (Bickman & Mulvaney, 2005; Biebel & Geller, 2007; Cook & Kilmer, 2004). Youth from SOC showed marginally improved internalizing behaviour scale scores, going from an average of 67 at intake to 59 at the two-year point (just below the cut-off of 60, indicating clinical difficulty). Similarly, there were small improvements in externalizing behaviours, moving from 71 at intake to 64 after two years (just above the clinical cut-off of 60). Slightly over half of the children (53 per cent) had better overall Child Behavior Checklist scores after two years. CAFAS scores showed improvement in overall functioning from 107 at intake to 77 after two years, indicating that many children were still in the moderate impairment range. A very small proportion of children improved in total competence scores (7 per cent improved and 2 per cent declined) over two years. Moderately positive but mixed results were found with the total competence subscales: 46 per cent improved interpersonal strengths while 23 per cent declined; one-quarter improved school functioning and 11 per cent declined; almost equal proportions increased and declined in family involvement (23 per cent and 22 per cent, respectively); and 48 per cent of children improved their overall strength quotient while 23 per cent declined. After two years, children who received services from SOC did better at school (45 per cent improved vs 26 per cent deteriorated) and fewer had suspensions (29 per cent compared to a baseline of 41 per cent) (Cook & Kilmer, 2004). Comparisons of systems of care to treatment as usual showed that youth in both situations had improvements in emotional and

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behavioural measures, but there were no differences in clinical or functional outcomes between the two settings (Bickman & Mulvaney, 2005; Biebel & Geller, 2007). Children who had previous juvenile justice involvement and received services through SOC at the Stark County site had fewer school suspensions, had less need for special education, and associated with more prosocial peers than did children in the comparison sites (Cook & Kilmer, 2004). More recently, results of a US national evaluation of nine demonstration grant SOC initially funded in 2010 by the CMHI within the US ­Department of Health and Human Services showed improved outcomes over 12 months for children and youth accessing services within the identified SOC (Azar et al., 2016). Among the 3,218 children and youth served, the most prevalent mental health diagnoses at intake were mood disorders (29.3 per cent), ADHD (24.9 per cent), oppositional defiance disorder (15.8 per cent), adjustment disorder (15.3 per cent), and PTSD or acute stress disorder (12.6 per cent). Compared to the US population, children in the SOC evaluation were more likely to be male, younger in age, and American Indian/Alaska Native. The proportion of children and youth with clinical levels of impairment dropped from 70.6 per cent at intake to 56.4 per cent at 12 months. Improvements in educational outcomes were also observed, as were significant reductions in child symptoms of depression and caregiver strain. The proportion of youth (age 11 or older) to self-report engaging in delinquent behaviour (such as destroying property and stealing) decreased from 68.8 per cent at intake to 48.2 per cent at 12 months. Self-reports of arrest within the last six months fell from 19.9 per cent at intake to 7.1 per cent at 12 months. The four most frequently accessed services within these SOC were individual therapy, assessment/evaluation, case management, and medication monitoring. More recent funding and technical assistance has focused on supporting the widespread adoption of SOC in the United States, and evaluation efforts will examine the expansion and sustainability of the model (Stroul et al., 2012). There are several major difficulties in trying to draw lessons for programming for youth leaving RT from this review of SOC initiatives. First, the types of general neighbourhood service system reforms and coordination prescribed for SOC are simply beyond the reach of the children’s mental health organizations hosting RT programs in our program of research. Second, the types of services and supports included under the SOC rubric are so diverse and ill-described that, beyond some general process principles, it is not possible to be clear about what is to be done. Third, the youth populations served by SOC are much more diverse than those served by RT programs in our research described in

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chapter 2. Evidence also suggests that the RT youth were facing more severe challenges than many youth involved in SOC evaluations. In addition, it is striking that many of the youth and families graduating from RT in our program of research showed patterns of youth and family functioning improvements post-admission similar to the gains described in the SOC evaluations. Yet we did not find much connection between these gains and successful youth community adaptation outcomes over time. What Are Wraparound Programs? Wraparound has been described as a micro-practice strategy for implementing SOC ideas (Prakash et al., 2010; Stroul et al., 2008; Stroul et al., 2012; Walker, Bruns, & Penn, 2008). Wraparound philosophically aims to shift from holding families accountable for youth difficulties to engaging family members in the planning and implementation of initiatives to support youth. Ideally, it stresses family member voice and choice, unconditional commitment to support, and cultural responsiveness. Wraparound has been called a participatory planning process to build capacity in families (Prakash et al., 2010). Several US institutions have endorsed the Wraparound model, including various US state registries (e.g., the California Evidence-Based Clearinghouse for Child Welfare) and the National Center on Education, Disability, and Juvenile Justice (Bruns, 2008; Suter & Bruns, 2009). It is touted as an evidence-based approach with positive results that customizes services based on the individual needs of the child and family (Stroul et al., 2012). Like SOC, Wraparound typically involves children and families confronting multiple challenges. It uses a collaborative team to develop and implement a plan to access services and supports. Family members are to be equal partners on teams. Teams also often involve service professionals and other people close to the family. Wraparound focuses on family assets and strengths. Services help youth and families in their own communities and connect them with local supports when possible (Prakash et al., 2010). A basic claim of Wraparound is that, if these guidelines are followed, youth and families are likely to do better and more youth are able to stay at home (Walker et al., 2008). Walker et al. (2008) argued that individuals who make their own choices are more committed to following through with a plan and therefore likely to have better outcomes. They state that a better fit between interventions and youth and family circumstances will lead to better outcomes. In Wraparound, because youth and family members are an integral part of teams, they believe that services and supports can be

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more carefully matched to youth and family circumstances. Prakash et al. (2010) contended that the composition of Wraparound teams is the most important predictor of positive change in youth. The team should include the youth, a caregiver, and at least two or three other core members who create and implement a plan. Prakash et al. (2010) stated that overall there is little guidance about how to implement Wraparound principles. They report that implementations of Wraparound in various communities illustrate challenges at the team, organization, and system levels. However, some Wraparound implementation guidelines have been developed and are available on the National Wraparound Initiative Website (www.nwi.pdx.edu). The guidelines reflect what experienced practitioners and scholars believe is needed to effectively implement Wraparound. Choices, a coordinated care provider with services located in the US states of Indiana, Illinois, and Louisiana, is offered as an example program for the practical implementation of the Wraparound model. Choices: A Wraparound Program Choices supports youth (and adults) who face multiple and complex challenges. It collaborates with child welfare, education, juvenile justice, and mental health services. A Choices resource person works to engage local service providers, with the program including smaller, less traditional groups as well as cultural and faith groupings (Rotto, McIntyre, & Serkin, 2008). Each family in the Choices program works with a care coordinator whose first undertaking is to get to know the family. The care coordinator’s job is to document the family’s strengths and resources, to identify their immediate priorities, and to bring together the family’s Wraparound team. This team could include the people who know the youth best, such as family members and other caregivers, others who are close to the family, a representative of the referring agency, parent advocates, and representatives of appropriate education, juvenile justice, or mental health services. Team meetings are not to take place unless a family member or their spokesperson is present. The direction for the team is set by identifying the family’s vision – what they would like to be different. The top three to five priority Choices outcomes are to be addressed in the first 30 days of involvement. Each outcome is measurable and is assigned to a person who reports back at the next meeting. A primary aspiration is to access family, network, and other community resources that

Systems of Care for Youth  145 can continue to be available to families over time. Teams meet approximately once per month to monitor progress and make decisions about continuing priorities. When the team agrees that the family is ready, a transition plan and a post-Choices crisis plan are developed. External evaluations of the Choices program are available on their website, www .choicesteam.org.

Evaluations of Wraparound Programs There has not been a great deal of methodologically strong research about youth and family outcomes of Wraparound programs. Historically, much of the research has reported equivocal outcome evidence. In their comprehensive review of the last 25 years of evidence on Wraparound, Coldiron, Bruns, and Quick (2017) concluded that there remains a dearth of rigorous empirical research of Wraparound’s effectiveness. Pre-post designs were the most common type of study. Evidence from the 22 controlled-outcome studies that they did examine was mixed, with results somewhat in favour of the Wraparound model. Coldiron et al. (2017) noted, however, that fidelity measures or clarity on the model under study were rarely documented in over 80 per cent of the empirical studies they reviewed. Studies that report better fidelity to the 10 core principles, typically measured using the Wraparound Fidelity Index (WFI), showed better youth and family outcomes, including positive changes in behaviour, functioning, and restrictiveness of living situations (Prakash et al., 2010; Suter & Bruns, 2008). In Suter and Bruns’s (2008) narrative review of Wraparound outcome studies, quasi-experimental studies included showed mixed evidence for emotional and behavioural improvements for youth involved with Wraparound programs while randomized control studies provided modest support for improvements. In their related meta-analysis, Suter and Bruns (2009) reported that the overall effect size across seven included studies was between small and medium (ES = 0.33). In particular, the effect size for mental health improvements was 0.31 (p < 0.05) and 0.44 (p > 0.05) for improvements in living situation such as increased stability. In an update to their review, Bruns and Suter (2010) also noted positive effects of receiving Wraparound services for education, delinquency, and family outcomes. Overall, the evidence suggested that participation in Wraparound improved youth personal functioning scores, but there was less conclusive evidence that difficulties in community adaptation declined.

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Implications for Improving Youth Community Adaptation Outcomes Despite the lack of convincing evidence for improved youth community adaptation outcomes from engagements with SOC and, to a lesser extent, from Wraparound involvements, from our perspective, there are several important lessons for thinking about programming for youth leaving RT from this review. In light of the challenges in multiple life domains facing most youth leaving RT, and the multiplicity of risk and protective factors influencing youth outcomes in each of these domains, it seems evident that it will be necessary to facilitate access for youth and their parents to a variety of service and supports over time. In addition, there is no good reason to expect that current procedures to access and coordinate existing resources will be sufficient to significantly improve community adaptation outcomes for these youth. Evidence from previous chapters suggests at least three additional considerations: (1) youth need to be involved in programs that have strong conceptual and/or empirical connections to the desired community adaptation outcomes; (2) since all youth circumstances are not the same, program involvements need to be adaptable for specific youth and family initially and over time; and (3) programs need to be proactive in maintaining connections initially and over time with youth and families after RT. Throughout this book, we repeat the need for one or more people to engage and coordinate community adaptation resources for youth and caregivers. In various guises – mentor, advocate, and case manager – something akin to the coordinators role in the Wraparound program is proposed. In designing community adaptation programming for youth leaving RT, a focus on adaptation resource discovery as well as youth and caregiver engagement is recommended. Each of the previous chapters also highlights the value of creating diversified supports for youth and families. However, it is not clear that the specific guidelines for Wraparound processes should be followed. Indeed they may be overly complex and not adaptable enough. Evidence in these chapters also highlights the creation of specific supports for family members’ active involvement in youths’ community adaptation efforts, as well as the support of youth and family functioning in the home. The final chapter in this volume returns to a more detailed discussion of these considerations.

Chapter Nine

A Case for an Integrated Program

For the past 15 years or so, our program of research has been examining the lives of youth before, during, and after their involvement with residential mental health programs. There has been willingness in our jurisdictions to fund such academic initiatives. Funding has also been available for formal reviews of the literature and research about programming for these youth populations. However, despite disturbing evidence about what awaits these youth and their caregivers after residential mental health programs, the exorbitant costs to youth, to families, and to communities from current procedures, and the description of initiatives with some promise of improving community living outcomes for these groups, our work eventually ran into a barrier that neither our team nor our service partners could penetrate – an unwillingness or inability within existing service, policy, organizational, and research infrastructures to invest in service innovations to improve the community living outcomes for these youth and their families. We are certainly not the first to lament the reality of established interests and formal bureaucracies halting or perverting promising service innovations – the strongest forces often seem to be conformity and inertia (Schorr, 1988, 1997; Schorr, Sylvester, & Dunkle, 1999). Nonetheless, it feels unseemly to continue to document youth and family difficulties without moving on to thinking about how to bring improvements and without experimenting with promising ways forward. This book is an initial attempt to identify some strategies to improve community living outcomes for these youth and their caregivers. The balance of this chapter begins to elaborate a preliminary program approach intended to be both feasible and credible. Hopefully, amidst many competing priorities, some attention and resources can be devoted to experimenting with conceptually and empirically grounded ways to improve community living for these youth.

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The integrated program approach presented is both speculative and preliminary. No approach can fit with all circumstances. The ambition is to create improvements on more community living indicators for youth than is currently the case. The approach incorporates theoretically and empirically supported components that were selected to be feasible for children’s mental health organizations to develop and to implement. It was created to be practical in terms of the resources required and the skills available to these settings. However, without experimenting, it is not possible to know what implementation challenges await or what benefits will be forthcoming. In addition, if this approach or something similar is to be tried, information about the operational requirements about various program components would have to be gathered and put into practice. At this time, this case for integrated programming is presented to increase awareness about the need to try new approaches and to stimulate thinking about what we might do. One caveat among many possible cautions is that the general program approach outlined in this chapter was created in response to the youth community living profiles after leaving residential mental health programs that emerged from our research with youth who were preteens or early to mid-teens in age. Our later research with young adults who had graduated from residential mental health programs identified important concerns not substantially addressed by our review – including unemployment, early parenthood, post-care trajectories of youth aging out of child welfare care, and transitions to adult services. In addition, we have not explicitly considered the challenges of substance abuse and addictions since these did not surface clearly in the earlier phases of our research. We have not explicitly considered the relevance of our programming speculations to late teen and young adult challenges. On a more positive note, our approach highlights the importance of proactively following youth and families out of residential mental health programs and the importance of active engagements and assistance in the first few years after residential mental health programs. Pathways Many youth leaving residential mental health programs face poor community adaptation outcomes in multiple life domains. However, earlier pathways analyses in this volume indicate that a range of youth, caregiver, family, and community assets help youth to manage such difficulties in several life domains. A single program strategy cannot take advantage of everything that is potentially useful; a focus on assets that

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have relevance to multiple life domains is sensible. Previous chapters indicate the particular relevance of enhancing the following assets: • Supporting youth management of their emotional and behavioural challenges • Enhancing youth positive peer and community involvements • Fostering youth long-term connections with one or more prosocial adults • Fostering youth having continuing support from an adult family member • Developing youth relationship and life skills • Supporting sustainable and constructive relationships in the home where the youth lives • Supporting competent caregiver engagement with the youth • Supporting the well-being of caregivers Three important implications for community adaptation programming from the profile of youth challenges and coping emerged in this volume. First, there was a strong consensus among the reviewers in each of the life domains that better youth community adaptation outcomes require attention to a variety of risk and protective conditions. Second, a focus on short-term “fixing” of the youth or their families is unlikely to produce satisfactory community adaptation benefits. We would be better to imagine services and supports that could be available to support youth community adaptation processes for several years if necessary. Besides focusing on helping youth and their families directly, it is necessary to think of ways to ameliorate the community adaptation resources that they can access. Third, there was strong agreement among reviewers that “one size does not fit all.” Packages of services and supports need to be tailored for individual youth and parents/caregivers. A common response documented in this volume to youth facing challenges in multiple life domains or to youth and their families “falling into the gaps” between different service systems has been to prescribe broader service integration or coordination reforms. However, the evidence is that service coordination and integration efforts do not often lead to improved community adaptation outcomes for this youth population. There are two reasons: (1) the causal links between broad system reforms and improved youth and family outcomes are very long and indirect; and (2) better youth community adaptation outcomes depend on being involved in programming with convincing conceptual and empirical connections with the desired improvements. Such involvements will not necessarily come from coordinating

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existing services and supports. In addition, the obstacles to formal integration and coordination across multiple service systems to help these youth are formidable. Our conclusion is that a less ambitious focus on a program or programs specifically for youth leaving residential mental health programs is likely to prove more feasible and useful. It was clear from our prior research that referring youth to existing services and supports led to discouraging community adaptation outcomes for many youth leaving residential mental health programs. There were several likely reasons. First, existing residential programs were not able to invest substantially in connecting these youth with post-program services and supports. Second, a common observation was that existing programs that might be helpful to these youth often had waiting lists. Third, outside services were not designed to provide the multiplicity of long-term services and supports many of these youth require to improve their community adaptation outcomes. Finally, separate service networks were not able to coordinate their efforts on behalf of this youth population. Considering the comparatively small number of youth graduating from residential mental health programs, and the complexity of the community adaptation challenges they face, it is not reasonable to expect that educational, justice, child welfare, mental health, and other service systems will create the packages of responses on their own that these youth require. It also is unclear how programs in these systems created for diverse youth populations can be adapted and pieced together to meet the specific constellation of challenges facing youth leaving residential mental health programs. From our perspective, a better investment would be in a smaller integrated program or programs created specifically to improve community adaptation outcomes for youth leaving residential mental health programs. Ideally, such programs would establish relationships with youth while they are in residential mental health programs and would continue these relationships when youth leave. There are several reasons to consider making improvements in education outcomes a pivotal, but not exclusive, focus in any integrated program for youth leaving residential mental health programs. First, almost all the youth leaving residential mental health programs face serious difficulties at school. Second, positive engagements with schools, adequate academic performance, and graduating from high school have been identified as protective assets for multiple youth community adaptation outcomes. Finally, graduating from high school and securing employment have important long-term implications for youth well-being and community living.

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On the other hand, educational outcomes may prove more difficult to improve than other community adaptation outcomes for youth leaving residential mental health programs. Youth will attend geographically dispersed schools. In addition, youth educational outcomes will be determined substantially by their experiences within these schools. It will not be feasible to establish programming specifically for this youth population in every school. Our suggestion to improve educational outcomes includes helping these youth navigate their schools and making additional educational supports available to youth through integrated programs. Modifications to the suggested integrated programs will be required for middle years children (aged 7–11) and adolescents (aged 12+) that are involved with residential mental health programs. For example, younger children are less likely to leave school or get in trouble with the law. Relationships within their immediate family may be more central. The academic, family, and life skills supports required by younger children are likely to be different than those of adolescents. However, our sense is that the basic integrated program configuration will be relevant to improving community adaptation outcomes for both age groups. In our research, about half of the youth leaving residential mental health programs moved on to child welfare placements. The challenges of delivering integrated services and supports to youth living in state care need to be considered in creating integrated programming. It does not seem reasonable to expect the child welfare system to be able to make adequate accommodation for this specific group of youth in its care. The basic integrated program configuration should be relevant to youth living in child welfare care. Providing such assistance is preferable to simply transferring the responsibility for improving community adaptation outcomes for these youth to another formal service system. However, how such an integrated program would follow graduating youth across formal mental health and child welfare boundaries remains a puzzle to be solved. Another important consideration not addressed in our discussion is how the proposed integrated program would have to be adapted for different ethnic and racial youth populations. It is noteworthy that this topic was not addressed in the literature available for the various reviews of pathways and programming in this volume. For programming involving adolescents, an implementation principle from the prior chapters is the importance of actively involving youth in creating their plan of assistance and in deciding who would be part of any support network created for them. Similarly, the usefulness

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of parents being active in creating any plan of service for themselves or for their children is emphasized. Integrated Program Configuration Based upon the reviews in previous chapters, we have selected intervention strategies that, when combined, hold promise for producing enduring improvements in diverse community adaptation outcomes for youth leaving residential mental health programs. We have used the following criteria in selecting these intervention strategies: 1. There is evidence of positive community adaptation benefits for youth from each strategy in one or more of the life domains reviewed. 2. The combined strategies address multiple youth community adaptation risks and protective assets. 3. It seems feasible to include each strategy within an integrated program that connects with youth while they are in residential mental health programs and maintains these relationships in the community. Youth Advocates and Education Advocates The youth advocate and education advocate positions are pivotal in this integrated program configuration. These positions incorporate three insights from the earlier reviews in this volume: 1. The importance of trustworthy and sustained relationships between youth and one or more constructive adults. 2. The need to actively intervene in formal systems on behalf of youth – in particular with schools. 3. The importance of proactive, diverse, and flexible supports to assist moving from institutional to community living for youth and families. There might easily be a temptation to rely on a single advocate to provide or create all the helping strategies required by a youth and family. This is not a realistic expectation; theory and evidence indicate that it would undermine the integrated program’s usefulness. Other elements open to groups of youth and caregivers supported by various staff are required in this configuration. Even with this understanding, the probability is that the advocate roles will be very demanding. If the

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role is to be feasible, advocates must engage with a small number of youth and caregivers at one time. Ideally, we suggest investing in two types of advocates for youth in this configuration. Youth advocates have broad responsibilities: establishing ongoing relationships with youth; liaising with their families; intervening on behalf of youth and families within various formal systems (e.g., mental health, justice, employment training, recreation); developing support networks to facilitate youth transition to living in the community; and connecting with members of youth support networks. They would also support youth and parent involvement in the training provided by the program and, time permitting, participate in some of the training. Education advocates have more focused responsibilities. They would develop ongoing relationships with school personnel and become familiar with education procedures and resources. They would monitor and support youth in schools and intervene on their behalf for curriculum accommodations and academic supports. They would coordinate youth access to tutoring and academic enrichments available through the integrated program and, perhaps, participate in providing some of these supports. The two positions are discussed separately, although much of the rationale for youth advocates also applies to education advocates. Youth Advocates: Building a Relationship with Youth Resilience research supports the importance of a positive and caring adult in a child’s life (Spencer, Collins, Ward, & Smashnaya, 2010). This focus is particularly important for youth who do not have stable family connections (Spencer et al., 2010; Tolan et al., 2013). Programs emphasizing this role stress the advocate getting to know youth, solving problems with them, and being consistent and persistent. There must be enough time for a trusting relationship to develop between the advocate and the youth. Ideally, this relationship would be sustained long enough to put into place a suitable range of community adaptation resources for the youth and their caregiver – maybe for one to two years or longer. This trusting relationship is also considered the cornerstone around which supportive networks can be built. It can be particularly challenging to maintain mentor relationships as youth transition out of formal care; mentors need to be flexible and creative to maintain contact with youth. If mentor relationships begin early enough prior to youth transitioning from care, a stronger relationship may carry through the transition (Spencer et al., 2010). Knesting and Waldron (2006) emphasized that the match between adult mentors and youth is critical. Spencer et al. (2010) identified

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three components associated with better mentoring programs: longer duration, consistent contacts, and close emotional connections. In their review, longer mentoring relationships (at least one year) were associated with better outcomes. Shorter relationships were linked to decreased feelings of self-worth among youth and to worse academic performance. Across studies, there is considerable evidence to suggest that successful mentoring has benefits for youth in reducing delinquency, school difficulties, and youth aggressive and antisocial behaviours (Hawkins et al., 2010; Reid & Dudding, 2006; Savignac, 2009; Spencer et al., 2010; Tolan et al., 2013). Youth Advocates: Facilitating the Development of Youth Support Networks In general, evaluations of simple case management or service brokerage models have not demonstrated better outcomes for youth or families (Wilson & Tanner-Smith, 2013). Somewhat better outcomes were found when a committed adult took a more proactive approach to supporting youth and finding appropriate community adaptation resources (Ashford et al., 2007). A strategy with some evidence of effectiveness in assisting youth transitions is assembling ongoing networks of services and supports for youth. Facilitated support networks are based on the premise that vulnerable youth and families have diverse and complex concerns that cannot be met by a single helper or intervention (Bruns, 2008; Clark & Hart, 2009; Cook & Kilmer, 2004; Rogers, 2003; Walker et al., 2008). In the suggested integrated model, the youth advocate would collaborate with youth and, if appropriate, with their parents/caregivers to assess their circumstances, resources, and priorities. They would work together to develop a youth transitions plan. With youth and family approval, the youth advocate might bring together a network of services and supports including an appropriate mix of professionals, extended family, friends, and volunteers. The youth advocate would provide support for meetings of this network to make sure that the plan is moving forward. Ideally, some elements of this network would continue to be available to youth and their families when they are no longer involved with the youth advocate. There are several caveats to including youth support networks as part of the suggested integrated program strategy. It will not be possible to create a viable and acceptable support network for all youth. Creating and sustaining a support network is a complex and demanding process. A network will not be of interest to all youth or families. Finally, support networks are often difficult to maintain over

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time. On the other hand, as our program of research shows, managing transition challenges over the first year after RT can be an important contribution for many youth and families. Perhaps the prescription applies only when support network construction is feasible and likely to be positive. Youth Advocates: Advocating for Youth Tolan et al. (2013) suggested that advocates should provide information and intervene on behalf of youth in various systems and settings. Dynarski et al. (2008) suggested that a youth advocate could be a resource teacher, a community or agency member, or a social worker who develops a relationship with the youth and also acts as a case manager. Youth advocates would monitor youth behaviours and emotions. They would help the youth navigate social services, legal, or other systems. They would help youth connect with emotional supports and concrete resources (e.g., food, housing, employment, and health care) that have been associated with successful transitions to independence and community living (Spencer et al., 2010). Education Advocates: Assistance with Schooling Youth in residential care and youth living in state care often lack advocates who know their strengths and weaknesses and who intervene on their behalf at school (Snow, 2009; Zetlin, Weinberg, & Kimm, 2004). In this integrated model, education advocates would have ongoing relationships with youth focused on their schooling. Ideally, they would maintain their relationships with youth if they change schools or if they leave school in order to explore with the youth other ways to continue their academic and vocational preparation. They would monitor youth attendance and academics, possibly in conjunction with school counsellors. They would work with school staff to create flexible and relevant learning opportunities such as accessing vocational learning programs. They would encourage other forms of youth-school engagement. They would also arrange and support youth involvement in tutoring and other academic enrichments available through the integrated program. Tutors and Academic Enhancements In our program of research, most youth leaving residential mental health programs experienced serious school difficulties, including low

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academic achievement, absenteeism, grade retention, and poor relationships with peers or personnel. These difficulties were all associated with higher levels of dropout, further reducing their opportunities for successful adult outcomes. Building youth academic capability through tutoring and academic enrichment activities is a common strategy. Many of these approaches also strive to keep youth connected within schools (Abrami et al., 2008; Dynarski et al., 2008; Hammond et al., 2007; Klima et al., 2009; Lehr et al., 2003; Prevatt & Kelly, 2003). For example, Hammond et al. (2007) found that academic support was a major strategy in over one-quarter of programs with encouraging results that addressed youth community adaptation challenges in various life domains. Overall, there is reasonable evidence that academic support programs can improve academic performance for some youth at risk of academic failure (Dynarski et al., 2008; Lauer et al., 2004; Ritter, Albin, Barnett, Blankenship, & Denny, 2006). Ritter et al.’s (2006) review concluded that structured volunteer tutor programs that focused on reading did improve reading and language skills in elementary and middle school children. Lauer et al.’s (2004) review of out-of-school programs suggested that larger positive effects were noted for reading studies that used one-to-one tutoring. For both reading and math, programs that were longer than 45 hours had better results. Dynarski et al.’s (2008) review recommended individual or small group formats that build study and test-taking skills and target specific areas such as reading, writing, or mathematics. Parent Training and Support Programs Parent training programs have several objectives, including improving relationships between parents and their children, increasing parents’ ability to manage youth behaviour, and increasing appropriate parent behaviours (Hoagwood et al., 2010; Kaminski et al., 2008; National Institute of Health and Clinical Excellence [NICE], 2005; Savignac, 2009). Some parent training programs also focus on improving parental functioning (e.g., depression, marital problems), as well as child cognitive development, emotional well-being, and physical health (Kaminski et al., 2008; NICE, 2005). In child welfare, parent training is often used as a service component to help keep families together and teach alternatives to excessive discipline (Barth et al., 2005). Parent training programs often focus on the following (Hoagwood et al., 2010; Kaminski et al., 2008; NICE, 2005; Savignac, 2009; Thomas & Zimmer-Gembeck, 2007):

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• Learning youth behaviour management methods • Learning youth monitoring and supervision methods • Understanding youth development • Learning to manage other factors that may be interfering with parenting (e.g., marital problems, parental emotions) • Role playing and modelling of methods • Guidance to practising methods with their own children Parent training programs vary in service delivery settings and how the training is provided (Hoagwood et al., 2010). NICE (2005) identified seven essential characteristics of effective programs: 1. structured curriculum based on social learning theory; 2. use of relationship-enhancing strategies; 3. optimum number of 8–12 sessions; 4. enabling parents to identify their own program objectives; 5. role playing during sessions and practice in the home setting; 6. delivery by trained facilitators; 7. consistent implementation of the program through adherence to manuals and materials. Kaminski et al. (2008) found that the following program components were consistently associated with larger effect sizes: in-session practice of parenting strategies with their own children coupled with curriculum focuses on emotional communication, positive interactions between parents and children, and the use of consistent discipline. There is extensive research reported in this volume examining the effectiveness of parent training programs. Notwithstanding variations in the rigour of research designs, evaluations of parent training programs generally reported favourable impacts on parent, child, and parent-child indicators (Hoagwood et al., 2010; Kaminski et al., 2008; NICE, 2005; Sanders et al., 2014). High parental satisfaction with parent training programs was consistently reported. Benefits to parents included increased feelings of efficacy, parenting skills acquisition, knowledge about their child’s challenges, and perceived social support (Hoagwood et al., 2010). Impacts on child functioning of parent training programs generally were favourable, particularly for programs with a behavioural rather than relational focus (NICE, 2005; Buchanan-Pascall et al., 2018). Parent support programs provide emotional and informational support through parents’ sharing of experiences either one-to-one or in groups (Dunn, Steginga, Rosoman, & Millichap, 2003; Woolacott et al.,

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2006). Participants both give and receive support and advice (Chien & Norman, 2009; Dunn et al., 2003; Woolacott et al., 2006). Parent support programs reviewed in this volume varied substantially in types of program leadership, length of program involvement, and formats for involvement (Chien & Norman, 2009; Dunn et al., 2003). Our program of research indicated that parents of children in need of residential mental health treatment often experienced feelings of isolation and a heavy caregiving burden. Through participation in parent support programs, contact with others facing similar circumstances could help parents better manage daily stress and feel better about themselves. They could also gain confidence about their ability to care for their children. Research about the effectiveness of parent/peer support groups was scarce in this volume’s review. In addition, the rigour of the available research evidence was questioned (Chien & Norman, 2009; Woolacott et al., 2006). Despite these shortcomings, there was support in the available studies for the benefits of being involved in support programs. Improvements in parents’ knowledge and feeling that support was available to them were frequently noted in studies. Other benefits to caregivers included reductions in measures of family burden and caregiver distress. Parents also perceived improvements in their coping and quality of life (Chien & Norman, 2009; Dunn et al., 2003; Woolacott et al., 2006). Few studies of support programs showed direct impacts on child and youth outcomes (Kutash et al., 2013; Woolacott et al., 2006). There is no evident reason why parent training and parent support strategies cannot be complementary. It is probable that fewer parents will become involved in ongoing support groups than will participate in short-term training programs. Youth Life Skills Development In this volume’s reviews, youth social and cognitive skills-building strategies were common components in programs intended to reduce delinquency, educational failures, and conflict within the home. On the other hand, since residential mental health programs place a high emphasis on the development of useful youth life skills, why is youth life skills development included in our hypothetical integrated program? As discussed in chapter 2, most youth arrived in residential mental health programs with very high problem scores on a variety of behavioural, emotional, and relational indicators. Most youth demonstrated significant improvement on many of these indicators at the point of discharge from residential mental health programs. However, many of

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these youth continued to have scores on these indicators that showed continuing reasons for concern after leaving residential mental health programs. Helping these youth to develop, to sustain and to use a requisite set of community adaptation skills is best understood as an ongoing process. Typically administered in a group format, life-skills-building programs engage youth by utilizing role playing and practising skills in real-life applications. Various skill lessons or modules may be taught over a series of sessions, or the curriculum may be shorter in duration and focus on acquiring a specific skill like conflict resolution. Skillsbuilding programs generally last one to two months; however, some programs may last a year or more (Hammond et al., 2007). The most common life skills development strategy identified in this volume was cognitive behavioural (Cobb, Sample, Alwell, & Johns, 2006). There was ample evidence in our reviews on the effectiveness of life skills development programs in promoting better community adaptation outcomes in education, delinquency, and relationships at home (e.g., Beelmann & Lösel, 2006; Lipsey, 2009; Mackenzie & Farrington, 2015). The Integrated Program’s Links with Pathways to Improved Youth Community Adaptation Overall, this hypothetical integrated program has the potential to enhance many of the major assets associated in this volume’s reviews with successful youth community adaptation. In particular, the program can provide youth with connections to adults who are invested in their well-being, improve youth relationships with their families, improve youth life skills, and keep youth positively connected with peers and community. In these reviews, these assets were linked conceptually and empirically to better school outcomes, less delinquency, and better transitions to home and community relationships for youth leaving out-of-home care. The proposed program connects youth with adults who serve as youth and education advocates and, ideally, with adults from youth support networks. Theories of resilience suggest that having at least one trusted, supportive adult is related to better community adaptation outcomes for school, delinquency, mental health, and stable homes (Dworsky & Courtney, 2009; Guilbord et al., 2011; Hawkins et al., 2010; Spencer et al., 2010; Underwood & Knight, 2006). Good relationships with adults can contribute to decreased risky behaviours; better school attendance, grades, and completion; and improved communication and social skills (Dynarski et al., 2008; Test et al., 2009). Positive youth

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development theory highlights the importance of prosocial connections to healthy adolescent development (Larson, 2000; Lerner et al., 2000). The program has the potential to enhance youth relationships with supportive peers and staff within schools. Positive relationships with students and teachers and others at school have been linked to lower dropout rates (Lessard et al., 2008; Rumberger, 2004b). Conceptually, lack of academic and social engagement at school is considered the most important precursor to dropping out (Audas & Willms, 2001; Rumberger & Lim, 2008). Delinquency research suggests that factors that can reduce delinquency include discouraging negative peer associations, improving positive social ties, and receiving support from teachers and mentors (Howell, 2003; Savignac, 2009). Education advocates can help adjust experiences at school to be more congruent with youth capabilities and aspirations. At-risk students are more likely to persist in school if they believe that finishing school will contribute to their goals for a better life and will help them avoid the negative consequences of dropping out (Knesting & Waldron, 2006). Opportunities to make school-to-work connections can be a strong motivator for students (Abrami et al., 2008; Lehr et al., 2003). Some studies have shown that well-designed programs that make the links to the post-school paths identified by students can be effective (Dynarski et al., 2008; Test et al., 2009). Ideally, the program may empower parents/caregivers to support their child’s schooling. Expectations have significant effects on high school completion (Audas & Willms, 2001; Rumberger and Lim, 2008); parental/caregiver involvement influences whether low-achieving students stay in school (Audas & Willms, 2001; Rumberger, 2004b). In addition, potentially, the program can help to compensate for shortages of tangible and educational resources at home (Hammond et al., 2007; Rumberger & Lim, 2008). Parent training and support can help to improve relations within the home. Family assets that protect youth from engaging in criminal activity include positive parenting practices, good relationships with parents, good communication with parents, parental supervision of youths’ activities, and overall support to youth from families (Howell, 2003; Savignac, 2009). Youth skills development can help youth take advantage of the community adaptation supports available to them. Youth with emotional and behavioural difficulties often have problematic interactions with peers, family members, teachers, and other adults. This impairment can have significant negative consequences in the domains of education, employment, peer acceptance, and general community adaptation

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where social skills are needed for success (Audas & Willms, 2001; Clark & Crosland, 2009; Hammond et al., 2007; Rumberger & Lim, 2008; Weisz et al., 2017). A Final Appeal At the beginning of this volume, the main purpose was described as finding program strategies with the potential to improve community adaptation outcomes for youth leaving residential mental health programs. This volume has ended with the discussion of a hypothetical integrated program to improve youth community adaptation outcomes. We have emphasized that, if nothing different is tried to improve youth community adaptation, continuing to invest in studies of youth difficulties becomes practically and conceptually questionable. While many operational specifics remain to be clarified for the proposed integrated program, it is well grounded in available evidence about pathways to community adaptation and the effectiveness of a broad range of program strategies in various youth life domains. Equally important, if the resources can be found, the integrated program or other similar programs can be implemented on a relatively modest scale – in one or a few settings. Our goal was to suggest an approach and to encourage thinking about ways forward that are economically and practically feasible. If these ideas are to be tried, we also believe that it would be important to carry out good-quality implementation and outcome assessments of these efforts. We hope attention can now shift to trying out such possibilities. It is clear that community adaptation outcomes for youth leaving residential mental health programs need to be improved. Hopefully, this volume has made it clear that we are not without credible ideas on what we might try that will bring about improvements. The less comfortable question is whether sufficient motivation can be found to do so.

Appendix 1: Description of Review Methods

Because of the broad focus of this volume (i.e., improving community adaptation in multiple life domains necessitating the examination of a variety of program models in each domain), this volume adapted the inclusive approach to synthesis reviews developed by the EPPI-Centre, Social Science Research Unit, Institute of Education, University of London (September 2006). For specific aspects, this review also selected procedures developed to carry out Rapid Evidence Assessments for social policy (UK Government Social Research, n.d.; Underwood, Thomas, Williams, & Thieba, 2007). This undertaking was complicated by there being relatively little research focused directly on youth leaving residential mental health care in each of the life domains of interest. This required extrapolating lessons from programs focused on other youth populations having some similarities (e.g., youth leaving juvenile justice detention facilities or the care of child welfare authorities). Most of the topics of interest for this review (e.g., youth adaptation to school, independent living, youth employment, community engagement, and living with families) have been the focus of comprehensive reviews. The initial review strategy gathered and summarized available systematic and narrative reviews relevant to these topics produced between 2000 and 2011. In 2017–18, an additional search was conducted to locate more recent systematic and narrative reviews for inclusion. In addition, a number of reviews have synthesized evidence for “proven or blueprint” program models for various life domains that are relevant to this review. These were included in this “review of the reviews” strategy. A descriptive map of research studies about common or promising program approaches identified by the above procedures was constructed for each domain reviewed. Such maps help answer questions about what research is available and identify directions for future research.

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They allow a much broader field of research to be examined than is possible through a formal statistical synthesis of research findings. Maps are a resource in their own right, providing a description of research in specific topic areas and, as in this investigation, offering a foundation for identifying intervention strategies for closer investigation. The broader maps also provide contexts for interpreting the results of narrower syntheses or reviews in the literature (EPPI-Centre, 2006). Judgments about available systematic reviews were based upon how thorough their search of the available evidence was, the procedures used to assess and select studies for inclusion, the methods used for cross-study syntheses, and whether findings were presented in a balanced fashion. There are no established procedures for assessing narrative reviews. The research team used its own protocol based upon the scope and relevance of the research reviewed, the credibility of the research methods used in the studies reviewed, and the care with which the findings are summarized. Our assessment of the information contained in these “reviews of the reviews” gave equal consideration to three types of information: 1. Conceptual arguments and empirical evidence of the pathways to good and bad community adaptation outcomes in each life domain of interest; 2. The evidence from the research reviewed about the community adaptation outcomes (e.g., school dropout, recidivism for young offenders) for the different programs included in the reviews; 3. The characteristics of effective programming in each domain identified by the authors of each review. We used this three-pronged assessment strategy for several reasons. First, there were often discrepancies between the analyses of pathways to community adaptation outcomes and the most common focuses for programming in various domains. For example, the nature of involvement with peers was a very important predictor of community adaptation outcomes in several domains yet was seldom a focus for program interventions. Second, the most extensive outcome evidence might exist for the most common or easily evaluated program models. Yet such approaches still might not be convincing as stand-alone approaches or might not necessarily be the most promising program options in each domain. A reliance on outcome studies alone could lead to a stilted or excessively restricted image of what would be worthwhile attempting to produce better community adaptation outcomes for youth. For example,

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social skills education produced positive benefits for youth in several domains. Indeed, these were the most rigorously evaluated programs with the most convincing support for their benefits. Yet there was little reason to conclude that social skills development on its own was all that was required to produce improved youth community living outcomes or even that social skills development should be the main emphasis of a more multifaceted approach. Finally, it is instructive to know what other reviewers have concluded about effective programming in various domains. Once again, there may be discrepancies between the research evidence presented and the programming lessons identified by these reviewers. For example, quite a few reviewers in different domains argued for multi-component programming addressing a range of important risk and protective factors for youth. Yet few empirical studies of multi-component programs were available. So, in the end, making credible judgments about future initiatives required a consideration of these three types of information both within and across the domains of living examined in this investigation. Based upon discussion between the members of the project’s advisory group and the research team, the results of this review of the reviews across multiple life domains was used to identify specific community adaptation intervention strategies/programs for closer inspection. Our overarching purpose in focusing on specific intervention strategies was uncovering programming elements to improve long-term community adaptation outcomes for youth leaving residential children’s mental health programs. Another consideration was which elements might fit together to improve youth community adaptation outcomes in multiple life domains of concern. Ideally, our aspiration was that this process would lead to agreement about the nature of a specific program model or models to improve community living outcomes for youth leaving residential mental health facilities. We hope that this might lead to a demonstration project or projects. The syntheses of effectiveness evidence for specific program models of interest identified through this process was based upon studies using credible experimental and quasi-experimental designs. Only quasi-experiments with concurrent or pre-existing (time series) comparison conditions were considered for inclusion at this stage. Because this involved examining a variety of program approaches, the first search was for existing systematic and narrative reviews of each program model of interest. If these reviews were comprehensive, credible, and recent, our conclusions about a program model were based upon these reviews. If this was not the case, we carried out our own synthesis of individual studies for specific program models.

Appendix 2: Description of Research Methods

Research Procedures In the initial exploratory study, interviewers visited parents in their homes to explore dimensions of their everyday lives and reflect on their service experiences. Interviews consisted of a series of open-ended questions and were approximately 1.5 to 2 hours in length. All interviews were audio-recorded and transcribed verbatim. Parents received a gift of $25.00 for participating in the study. Following the interview, parents received a copy of their interview transcript to keep. In our 1.5- to 2-year follow-up study, participants were recruited from five children’s mental health agencies in south-western Ontario offering RT. Both qualitative and quantitative data were obtained from parents and CAS guardians, and admission data were abstracted from agency files. We typically interviewed parents in their own home, and interviews with CAS guardians were conducted at the offices of the Children’s Aid Society. All participants received $25.00 for their participation and were sent a copy of their interview transcript. Part of the research protocol in this phase was to ask for permission to keep parents’ or guardians’ names on file with the intent of approaching them for another interview approximately two years after our first interview. Our tracking efforts maintained a sample retention of 75 per cent over time. In our 3- to 4-year follow-up study, most parent interviews were conducted again in the home and interviews with CAS guardians were conducted at the offices of the Children’s Aid Society. All participants received $25.00 for their participation and were sent a copy of their interview transcript. In our transition age study, all youth from earlier phases of the research who were now at least 18 years old or older were eligible for another follow-up interview. Of the 63 youth who fit this criterion, we

168  Appendix 2

successfully interviewed 21 respondents. Given the tremendous challenges in tracking youth down many years after treatment, we also invited the participation of several additional children’s mental health organizations and Children’s Aid Societies in south-western Ontario and successfully recruited 39 new youth into the research (for a total of 60 youth in this study). Most youth interviews were conducted in person, typically at the interviewee’s place of residence, and were audio-recorded and transcribed verbatim. Youth received $25.00 for their participation and received a copy of their interview transcript. In our most recently completed study, we interviewed 22 youth, their parents and guardians, and primary residential mental health workers from seven RT centres in Ontario. We interviewed respondents approximately every 6 months (at discharge and then 6 months and 12 months following their exit from treatment). Youth were between 14 and 18 years old at the time of leaving RT. Each participant received $40 for each interview and received copies of their interview transcripts. Interview Questions and Scales Interviews in our initial exploratory study consisted of a series of open-ended questions addressing two areas of enquiry. We asked parents about their daily experiences of living with a child accessing RT and their experience of being involved with the services of the children’s mental health agency. In the subsequent follow-up studies, two parent-reported clinical measures of mental health were added to assess youth functioning at admission and discharge (obtained retrospectively from agency file data) and at our follow-up interviews. Data were obtained using the Brief Child and Family Phone Interview, 3rd version (BCFPI-3) (Cunningham et al., 2002), which is a descriptive measure of mental health problems, child functioning, and impact on the family completed at program intake. A score at or above 70 on any subscale of the BCFPI-3 is indicative of a significant problem. The Child and Adolescent Functional Assessment Scale (CAFAS) (Hodges, 2000) was also used, which assesses impairments in day-to-day functioning secondary to behavioural, emotional, psychological, psychiatric, or substance use problems at program admission. CAFAS subscale scores can range from zero, which suggests minimal or no impairment in the specific domain, to 30, indicating severe disruption or incapacitation in the measured domain. These two standard measures were already in use by the participating agencies at intake, admission (which could be several months after the initial intake assessment), and discharge.

Appendix 2  169

We conducted a retrospective file review to gather BCFPI-3 and CAFAS data. We administered the BCFPI-3 again in all of our follow-up studies. Additionally, we asked parents or guardians a series of semi-structured questions about youth functioning in important domains of living such as education, family relations, social connections, community conduct, and personal well-being. Analysis of the Interview Data Quantitative analyses of data from the standardized measures (BCFPI-3 and CAFAS) were performed using the software program SPSS. Subscale means and response frequencies for individual scale items were calculated to estimate prevalence of clinical severity. Several repeated measures tests were used to assess change over time (non-parametric Wilcoxon Signed-Ranks, McNemar’s Test, Friedman’s Test, or Cochran’s Q). For the BCFPI-3, changes from admission to discharge and follow-up were analysed with Repeated Measures Analysis of Variance (ANOVA). Qualitative interview data were subjected to a thematic analysis using the software program N-Vivo (Richards, 1999). In our follow-up studies, various qualitative data analysis strategies were employed. Specifically in our initial exploratory study, members of the research team read a subset of the interview transcripts and individually identified common themes appearing across interviews. We then shared these themes with one another and through a series of dialogues arrived at a thematic schema that was used to code the entire interview sample. A similar process was used to analyse the qualitative data obtained from youth interviews at 1.5–2 years and 3–4 years follow-up. A different strategy was used to analyse the qualitative data obtained from the 60 young adults in our transition age study. Information was summarized across 11 key life domains for each young adult that provided an overall picture of how they were functioning in their current daily lives. Two research team members then independently reviewed these descriptive summaries and began the iterative process of sorting young adults into emerging groups that shared similar key life domain experiences. Over multiple iterations of the grouping process, five distinct functioning profiles emerged, and each profile was defined by the experiences and outcomes most common to that group of young adults (Kluge, 2000). In the final stage, each young adult’s descriptive summary was assessed for whether it met the established criteria for inclusion in that group. We resolved any disagreements of group membership through a repeated review of the information in each of the

170  Appendix 2

key life domains for that young adult until a consensus was reached between team members. In our most recent study (an in-depth investigation of youth processes and outcomes in the year immediately following exit from RT), we analysed the qualitative data by preparing a “case study” summary document for each youth that included multiple excerpts from their interviews as well as their parents’/guardians’ and RT service providers’ interviews. We then used these case summaries to construct a narrative (or “story”) of the year following exit from RT that integrated multiple informants’ perspectives of how each youth was functioning within that time frame. Similar to our previous follow-up studies, information on youth community adaptation was organized by key life domains including education, family, social connections, health and well-being, and future hopes.

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Index

abandonment, 117–18 Abrami, P.C., 74 abuse/neglect, 12, 43, 52, 63, 71, 79, 87, 104, 109, 122–9, 140 acute stress disorder. See posttraumatic stress disorder (PTSD) Adams, G., 104 adjustment disorder, 142 aggression and aggressive behaviour, 5, 10–12, 30–1, 36, 51, 70, 81, 85–8, 93–8, 154 Akoensi, T., 91 alcohol dependency, 33, 42–3, 52, 89– 90, 104, 123, 129. See also substance abuse anger management, 25, 35, 80–2, 102–3, 114, 117 antisocial personality, 70, 86–8 anxiety disorders, 69, 111–13 Arnett, J.J., 55 asset theory, 60. See also youth assets attachment theory, 50–2, 60 attention deficit disorder (ADD), 27, 34, 40, 89, 140 attention deficit hyperactivity disorder (ADHD), 33, 53, 70, 84–5, 112–14, 140–2 Audas, R., 69–70

Augimeri, L.K., 98 Bandura, A., 50 Begin, J., 107 Benson, P.L., 59 Beynon, S., 112 bipolar disorder, 89 Bonta, J., 86, 91 borderline personality disorder, 53 Bouchard, C., 107 Boyle, M., 107 Brief Child and Family Phone Interview, 3rd version (BCFPI-3), 21, 24, 30, 44; Conduct Subscale, 32; Externalizing Behaviour Composite Scale, 31–2; Managing Mood Subscale, 31–2 Bronfenbrenner, U., 50, 53 Bruns, E.J., 145 Buchanan-Pascall, S., 108 bullying, 62–3, 90, 102 Burns, B., 104 California Evidence-Based Clearinghouse for Child Welfare, 143 Cameron, G., 104, 113 Campbell, M., 108

202 Index case management, 73, 77, 98, 142, 146, 154–5 Check & Connect, 77–8 Child and Adolescent Functional Assessment Scale (CAFAS), 21, 141; Behaviour Toward Others Subscale, 38; Moods/Emotions Subscale, 30–1; School/Work Subscale, 33–4, 40 Child and Youth Mental Health Lead Agency Consortium, 13 Child Behavior Checklist (CBCL), 98, 141 child psychopathology. See developmental psychopathology Children’s Aid Societies (CAS), x, 5, 17, 20, 26–9, 90, 116–17; outcomes for youth in care of, 44–5, 118–23 Children’s Mental Health Ontario, 13 children’s mental health system, 11–12, 21, 31, 89, 142; crossover with child welfare system, 116, 122; follow-up by, 6, 18; on-site schooling in, 34–6; program approaches of, 7; support from service providers in, 120 child welfare system, 14, 17, 21, 29, 44, 84, 113, 117, 151; crossover with children’s mental health system, 116, 122; pre-care and incare experiences in, 124–6; support from service providers in, 120 Choices program, 144–5 Clark, H.B., 133, 135 cognitive behavioural therapy (CBT), 4, 93, 97, 109, 112–13, 159 cognitive development theory, 50, 156 Coldiron, J.S., 145 community adaptation and living – age factors in, 133, 148 – attributes indicating success in, 48

– challenges of, 3, 6, 8, 14, 84, 148 – conceptual frameworks for, 15, 47–8, 91–2 – concerns about outcomes of, 8, 13, 147 – coordination of services in, 149–50 – delinquency factors in, 133 – education advocates in, 152–5 – engagement or involvement factors in, 60 – ethnicity and race factors in, 44–5, 133, 151 – family involvement in, 105, 151–2 – gender factors in, 42–4, 133 – implications for improving outcomes in, 100, 114–15, 146 – integrated program approach to, 146–61 – interdependent living in, 135 – life domains in, 7–8, 18, 22, 46, 62 – life skills development in, 158–9 – mental health factors in, 133 – mentoring in, 153–4 – multiple determination factors in, 61, 84 – outcomes research on, ix–xi, 7–21, 40–54, 71–80, 92–100, 112–61 – parent support and training programs in, 156–8 – pathways to outcomes and programs in, 6–9, 61, 91–2, 123–36, 159–61 – program exemplars for, 9, 77–9, 94–8, 108–15 – promotive/protective factors and assets in, 60, 124–9, 149 – relationships factors in, 60 – risk factors in, 52–4, 59–60, 72, 124–9, 136, 149 – strategies to improve outcomes in, 129–36, 147 – subgroups of youth in, 42–4

Index 203 – support in, 8, 13, 118, 135, 154 – symptoms of youth in, 33, 40 – systems of care for, 14–15, 137–46 – theories and constructs of, 8–9, 47–61 – transition, continuity, and discontinuity factors in, 60–1 – young parents in, 43–4; youth advocates in, 152–5 – youth involvement in planning for, 134–6, 151–2 – youth support networks in, 154–5. See also community conduct; education; employment; family relations; mental health and wellbeing; personal functioning; social connections; substance abuse; youth justice system community conduct, 8, 17, 22, 38–41, 44 community counselling programs, 3 “compensatory” model of resilience, 53 conduct disorder, 69, 84–5 conflict resolution, 75, 93, 159 Continued Care and Support for Youth Program, 117, 120 Coping Power, 94–5 Courtney, M.E., 128, 130 Cullen, F.T., 91–2 Dagenais, C., 107 Day, D.M., 98 delinquency and delinquent behaviours, 10, 30, 39–42, 62, 70, 76, 107, 116–29, 136, 142–5, 154–60 – behavioural problems in, 85–6 – community context and peers in, 87–8 – education factors in, 88 – family factors in, 86–7, 96 – gender differences in, 88

– individual characteristics in, 85–7 – main patterns in, 81–2 – mentoring programs to reduce, 95–6 – multiple living challenges in, 84–5 – parenting development programs to reduce, 96 – parenting practices in, 86–7 – pathways to, 81–100 – peer support groups to reduce, 95 – predictors of, 81–2, 85–6 – prior offending behaviour in, 86 – programs/interventions to reduce, 81–100 – protective factors for preventing, 85, 89 – rates of for youth leaving substitute care, 121–2 – repeat offending behaviour (recidivism) in, 86, 92–3 – risk factors in, 85, 89, 128–9 – social factors in, 88.   See also secure custody; youth justice system DeLorenzo, E., 131, 135 depression, 3, 10–12, 17, 30, 33, 43, 49, 53, 63, 69, 112, 117–18, 142, 156 Derzon, J.H., 87–8, 91 Deschênes, N., 133 developmental psychopathology, 47–50, 55–6 developmental theories, 50, 56–7, 60 dialectical behaviour therapy (DBT), 4 divorce, 20, 27, 41, 52, 71 Dudding, P., 135 Dworsky, A., 130 Dynarski, M., 74–5, 155–6 ecological systems theory, 50–4, 60, 85, 109

204 Index education – absenteeism from, 63, 66 – advocacy in, 72–3, 79, 152 – alternative schools, 99, 123 – apprenticeship in, 28 – behavioural interventions in, 75–8 – caregiving in, 71 – case management in, 77–8 – challenges in, 17, 33–6 – classroom placements in, x, 3–4, 6 – cognitive behavioural programs in, 75 – community influences in, 69 – correspondence studies in, 4 – dropout from, 17, 62–79, 121 – effects of poor-quality teaching on, 54 – engagement in, 68–9, 74–5 – enrichment in, 73–4, 155–6 – ethnicity differences in, 76 – evaluation of program interventions in, 71–2 – expulsion from, 63, 90 – family influences in, 70–1 – family strengthening in, 77–8 – financial assistance in, 79 – gender differences in, 76 – general equivalency diploma (GED), 118, 121 – general program considerations in, 76–7 – grade retention (keeping back) in, 67 – group norms in, 75 – Individual Education Plan, 90 – influence of on transitioning youth, 56 – influence of parents’ level of education in, 71 – internal and external influences on, 65–6 – intervention studies in, 76

– interventions with families in, 76 – life skills development in, 75, 158–9 – mentoring in, 72–3, 77–9 – monitoring in, 71–3, 77–8 – multi-component programs in, 76 – on-site schooling in RT, 34–6 – outcomes for youth leaving substitute care, 121, 150–1 – parent expectations in, 70, 75 – parent involvement in, 71–6 – of parents, x, 76, 80, 96 – pathways and programs in, 62–80 – performance in, 67–8, 76–8 – personalized learning environments and instruction in, 74–5 – pivotal role in integrated program approach, 150–2 – policy-based interventions in, 76 – positive factors in, 62 – practice interventions in, 76 – problem-solving in, 77–8 – program examples in, 77–9 – programs directed at multiple risk and protective factors in, 72 – programs/interventions to improve outcomes in, 71–80 – prohibitive cost of, 114 – relevance of, 67–8 – risk factors in, 127–8 – school characteristics in, 67 – social engagement in, 68–9, 75–6 – special education services, 63–5, 127, 140 – students’ connections in, 72–3 – support in, 77–8 – surveys about, 67 – suspension from, 79 – termination of, 37 – tutoring in, 79, 114, 155–6 – vocational training, 28, 74, 102, 118, 123

Index 205 – work/community-based learning interventions in, 74 – young parents in, 70 effect size (definition), 106 emotional and behavioural disorders (EBD), 74, 125–7, 133 employment – absenteeism in, 28 – difficulties in finding, 114 – earnings for youth leaving substitute care, 121, 128 – factors in outcomes, 133 – gender factors in, 128 – influence on transitioning youth, 56, 123 – mental health factors in, 99, 128 – race factors in, 128 – rates of for youth leaving substitute care, 121 – risk factors in, 128 – unemployment rate, 17, 37 Extended Care and Maintenance Agreement, 117, 120 Family Group Decision-Making (FGDM), 134–6 family relations – affect of violence by child or youth on, 22–4, 79, 102 – conflict in, 52, 66, 71, 102–5, 113– 15, 124–9, 158 – following residential treatment, 25–7, 32, 82–3, 101–15, 135 – main patterns in, 101 – maternal mental health in, 111–12 – mentoring in, 112 – multi-component programs to improve, 113 – parental mental illness in, 104 – parental substance abuse in, 104, 118, 122 – parental violence in, 104

– parent support programs to improve, 110 – parent training in, 107–10 – pathways and programs to increase stability in, 104–7, 134, 143 – reunification instability following RT, 104 – support in, 119–20, 135 – therapies to improve, 110 family therapy, 24, 93, 96, 110 Farmer, E.M., 104 Farrington, D.P., 91, 98 Filene, J., 107 the “five Cs,” 57, 60 Forbes, C., 112 Fortin, L., 107 foster care, 5, 23, 27–8, 82, 99, 117, 119, 122 Freeman, J., 76 Frensch, K., 104 functional family therapy (FFT), 96 gangs, 5, 39, 82, 88, 103 Germain, C.B., 54 Goldman, S.K., 137 goodness-of-fit, 51 Gordon, M., 108 Gray, K.M., 108 Green, S., 108 group homes, 5–6, 23, 27–9, 82, 89– 90, 102–4, 118–20, 129, 140 Haber, M.G., 133 Hammond, C., 70–1, 156 Hart, K., 135 Hawkins, D.J., 86–8, 92, 96, 100 Hoagwood, K.E., 107, 110–12 Homebuilders, 106 homelessness, 28, 44, 89, 122–3, 129 Hook, J.L., 128 housing, 56, 81, 99, 116–17, 120–31

206 Index Howell, J.C., 87–8, 91–2 Humphreys, D., 91 immigrants, 41, 45 The Incredible Years Parenting Program, 108 independent living, 14, 23, 30, 46, 100 independent living programs (ILPs), 116, 127–36 Indigenous diversion program, 90 Indigenous persons, 45, 98 intensive family preservation services (IFPS), 18, 96, 105–7 Johnson, G., 108 Jones, L., 130, 135 Jones-Walker, C., 100 JusticeWorks YouthCare (JWYC) (Pennsylvania), 134 juvenile justice system. See youth justice system Kaminski, J., 107, 157 Karpur, A., 133 Kearney, C.A., 71 Kelly, F.D., 78 KIN-nections Project (Arizona), 134 Kjellstrand, E.K., 78 Knesting, K., 153 Koegl, C.J., 98 Koehler, J., 91–2 Kutash, K., 112 Lakin, B.L., 104 Lauer, P.A., 156 learning disability (LD), x, 17, 33, 41, 53–4, 62–9, 125–7 Leffert, N., 58 Lerner, R.M., 57 Leschied, A., 85, 87, 91 Lessard, A., 71 Leve, L.D., 87

life domains, 7–22, 41–2, 125. See also community conduct; education; employment; family relations; mental health and well-being; personal functioning; social connections; substance abuse; youth justice system Lim, S.A., 67, 70–1 Lipman, E.L., 98 Lipsey, M.W., 87–8, 91–3 Littell, J.H., 108 Loeber, R., 91 Lösel, F., 91 Lundahl, B., 113 MacLeod, J., 106, 108, 111, 113 main patterns – community adaptation of children and youth accessing RT, 16–18 – delinquency pathways and programs, 81–2 – family, 101 – systems of care (SOC) for youth, 137 – youth educational processes and outcomes, 62 – youth transitions from substitute care, 116–18 Manteuffel, B., 137, 140 Massinga, R., 131 Maternal Stress Coping Group, 112 Maynard, B.R., 78 McWhirter, J.J., 70 medications, 4, 10, 80, 89, 114, 123, 142 Melvin, G.A., 108 mental health and well-being, 30–3; disorders in, 11–16, 53, 69–74, 85–6, 96, 115, 122–3, 129–32, 137–42 Midwest Evaluation of Adult Functioning of Former Foster Youth, 117, 122–3

Index 207 Ministry of Children, Community, and Social Services (formerly Ministry of Child and Youth Services), 13, 18 Ministry of Health, 13 Ministry of Long-term Care, 13 minorities (racial, cultural, ethnic), 11, 45 Montgomery, P., 131 mood disorders, 140–2 multidimensional treatment foster care (MTFC), 99 multiple-component programs (MCP), 99–100 multisystemic therapy (MST), 96–7 Muskegon County Community Mental Health (Michigan), 133 Mustillo, S.A., 104 Myers, L., 112 Naccarato, T., 131, 135 National Center on Education, Disability, and Juvenile Justice, 143 National Education Longitudinal Survey, 67–8 National Institute of Health and Clinical Excellence (NICE), 157 National Longitudinal Study, 141 National Wraparound Initiative Website, 144 neglect. See abuse/neglect Nelson, K., 106, 108, 111, 113 Northwest Foster Care Alumni Study, 117, 123, 127 obsessive-compulsive disorder, 113 Office of the Children’s Advocate (Manitoba), 131 oppositional defiance disorder, 69, 113, 140–2 Options, 133 Orton, L., 112

parent-child relationship therapy, 110 Parent Connections, 110–11 Parent Connectors, 110 parenting practices, 27, 54, 85–9, 95–7, 104–12 parenting training, 76, 96, 107–10, 156–7 parent support partner (PSP), 110–11 parent support programs, 79, 110–12, 157–8 Partnerships for Children and Families Project, xi, 16, 18, 116 Partnerships for Youth Transition (PYT), 133 Pathways to Education, 78–9 Pecora, P.J., 131 personal functioning, 7, 10, 30–2, 40–3, 84, 145; anger management and self-regulation techniques in, 24–7, 80–2, 102–3 Piaget, J., 50 Piquero, A.R., 108 Pires, S.A., 137 Positive Parenting Program. See Triple P – Positive Parenting Program positive youth development (PYD), 56–7 post-traumatic stress disorder (PTSD), 53, 113, 123, 142 poverty, 52–4, 69, 121, 126–7 Prakash, M.L., 144 Prevatt, F., 78 Preyde, M., 104 program exemplars – Check & Connect, 77–8 – Choices: A Wraparound Program, 114 – Coping Power, 94 – Parent Connections, 110 – Pathways to Education, 78–9

208 Index – SNAP Under 12 Outreach Project, 97 – Triple P – Positive Parenting Program, 108 promotive/protective factors, 49–54, 60–2, 72, 81, 85, 89, 95, 124–9, 135, 146 prostitution, 90 “protective” model, 53 psychiatric institutions, 10, 16, 140. See also residential treatment (RT) Quick, H., 145 Reid, C., 135 research methods, 18–22, 167–70 residential mental health care. See residential treatment (RT) Residential Services Review Panel, 12–13 residential treatment (RT) – advances in, ix–x – benefits of, 8, 24 – controversy about, 7 – difficulties in, 3 – discharge plans in, 3 – ethnicity differences in, 44–5 – follow-up after, 6, 16–17 – gender differences in, 44 – individual service plans in, 12, 63 – risk factors following, 80 – step-down programs in, x – symptoms of youth in, 10, 16–17, 63, 82.   See also psychiatric institutions resilience theory, 53, 77, 153, 159 resource coordination, 98–9 review methods, 18, 163–5 risk factors, 52–4, 59–62, 70–2, 79–80, 85–95, 104, 109, 124–9, 136 risk-need-responsivity (RNR) principles, 92

Ritalin, 80 Ritter, G., 156 Rumberger, R.W., 67–8, 70–1 Savignac, J., 86–7, 96 Scales, P.C., 59 Schlossberg, N.K., 55–6 Search Institute, 48, 57, 60 secure custody, 10, 12, 23, 29, 70, 82–3, 89–90. See also youth justice system self-esteem, xi, 27, 31, 51–8, 68, 90, 95, 112 Simonsen, B., 76 Smith, W.B., 135 SNAP Under 12 Outreach Program, 97–8 social cognitive skills development, 112–13 social connections, 38–43, 82, 91, 100, 160, 169–70 social learning theory, 50, 95, 109, 157 social phobia, 69 Southerland, D., 104 Spencer, M.B., 100 Spencer, R., 153 standardized measures, 21, 30–2, 169 Steps-to-Success, 133 stress-management programs, 93, 109, 112 Stroul, B.A., 137 substance abuse, 5, 11–12, 18–21, 27– 33, 39–52, 58, 64, 70–1, 76, 81–104, 113–24, 129–33, 138–40, 148. See also alcohol dependency substitute (alternative) care, 3, 29; youth transitions from, 116–36 suicidal ideation, 3, 69, 117–18 suicide, 58, 66, 104 Suter, J.C., 145 systems of care (SOC), 137–46

Index 209 – age, gender, and race factors in, 142 – benefits in, 140 – child and family outcomes in, 140–3 – comparisons to treatment, 141–3 – cultural sensitivity in, 140 – difficulties in review of, 142–3 – disorders in children and youth served in, 142 – service delivery and practice in, 139, 142 – systems in, 139 Tanner-Smith, E.E., 76 Teare, J.F., 104 Tennyson, H.R., 97 Test, D.W., 74 Thompson, A.M., 78 thriving theory, 58–60 Toews, B., 108 Tolan, P., 155 transition to adulthood, 117 – conferences to assist in, 134 – delinquency in, 45 – ethnicity differences in, 45 – factors for success in, 55–6 – planning and decision-making in, 134–6 – studies on, 29, 32, 37, 40, 44, 55–6, 81 Transition to Independence Process (TIP) Model, 116, 130–6 Triple P – Positive Parenting Program, 108–9 Trupin, E., 92 US Institute of Education Sciences, 78 Utting, D., 86 Valle, L., 107

Vanier Children’s Services, x video game addiction, 118 violence, 22–4, 30–1, 48–60, 69–70, 79, 86–99, 102–4, 119, 124–6 Waldron, N., 153 Walker, J.S., 143 Welsh, B.C., 86 Wessendorf, S.L., 78 Willms, J.D., 69–70 Wilson, D.B., 93 Wilson, S.J., 76 Woolacott, N., 112 Wraparound Fidelity Index (WFI), 145 Wraparound programs, 98, 137–8, 143–6 Yelick, A., 131 YMCA, 123 young adult studies. See transition to adulthood youth assets, 53, 57–60, 102, 138, 143, 148–52 youth engagement programs, xi, 6, 14, 48, 60, 77, 105, 135, 148 youth justice system, 7–10, 14–17, 27–8, 38–44, 81–100, 124–44, 150–3. See also delinquency and delinquent behaviours; secure custody Youth Leaving Care Project (OACAS, Ontario), 131 youth stories – Cindy, 89–90 – Cody, 79–80 – Damian, 40–1 – Evan, 35–6 – George, 3, 5–6 – Jamie, 27–9 – Jane, 3–5 – Jenna, 123

210 Index   youth stories (continued) – Keagan, 138 – Kenneth, 102 – Kyle, 118 – Megan, 66

– Scott, 63 – Sean, 82–3 – Stan, 114 – unnamed (includes parent stories), 27–39, 63–5, 84, 103–4, 119–20