Chapter 2. Defining, Assessing, and Promoting Adolescent Well-Being for Youth in Out-of-Home Care

Peter J. Pecora, Ph.D University of Washington
Joy Gabrielli, Ph.D University of Florida

Abstract

This chapter presents strategies at the youth, family, community, and general public levels for promoting adolescent well-being for youth and families served by child welfare. It builds on recent research from the National Transition Funders Group regarding principles and strategies for helping youth in care thrive and succeed in the community. Specifically, the six domains of youth well-being (cognitive development; social and emotional well-being; mental health and wellness; physical well-being; safety; and economic well-being) are used to guide discussion on the unique needs of adolescents served by child welfare. The chapter closes with a brief overview of how youth well-being is affected by the recently passed Family First Prevention and Services Act, and some considerations for youth, parent, and family assessment.

Introduction

While most youth placed in out-of-home care in the United States are reunified or adopted within one year of placement, 32% of the 391,098 youth in care in 2021 were ages 12 and older. Further, over 19,000 youth were emancipated from care without achieving legal permanence (reunification, adoption, or legal guardianship) (US DHHS, 2022). These adolescents, the young adults up to age 20 served by child welfare in extended foster care, and those youth that are likely to emancipate require not only efforts to ensure their safety from child maltreatment, but services to help them grow and develop in healthy ways to maximize their well-being. Adolescence is a time of emerging identity, experimentation with risk behaviors, and development of autonomy by learning independent living skills. Most adolescents lean heavily on familial and community supports for successful transition to independence. Adolescents residing in out-of-home placements often do not receive adequate support for transition to independence, and thus, require interventions from multiple systems. This chapter focuses on defining, assessing, and promoting child and adolescent well-being within the context of youth and families served by child welfare. It builds on recent research, principles, and strategies for helping transition-aged youth succeed provided by the National Transition Funders Group. The chapter closes with a brief discussion of evidence-based practices and practice-based evidence, and how those relate to the recently passed Family First Prevention and Services Act.

Defining Child Well-Being

The Department of Health and Human Services has identified four domains of well-being to guide policy and practice in child welfare: cognitive functioning, physical health and development, behavioral/emotional functioning, and social functioning (U.S. Department of Health and Human Services, 2012). While these original four domains are central to youth functioning, specific aspects of emerging adulthood related to transitions to independence (e.g., financial stability) are not well-explicated. The National Transition Funders Group expanded the set of domains of child and youth well-being below to provide a more comprehensive framework (Langford, Strauss & Legters, 2021, pp. 25-29):

1. Physical Health and Safety: All young people should have the opportunity and supports—through family, community, and public systems—to maximize their physical health, strength, and functioning, be physically safe and free from violence, abuse, and neglect, and have basic needs met.
2. Cognitive and Mental Health: All young people should have the opportunity and supports—through family, community, and public systems—to experience continuous cognitive health and intellectual growth and to optimize mental health, managing any mental health issues as they arise.
3. Social and Emotional Wellness: Social and emotional wellness require both a strong sense of self-efficacy and self-esteem and supportive, nurturing, and mutually satisfying relationships. Emotional wellness requires the development of a positive racial, gender, sexual, and cultural identity. This begins and is nurtured throughout life within the context of a lifelong family. Every young person needs the opportunity to have a meaningful and positive experience of living in, connecting with, and belonging to a family.
4. Mental Health and Wellness: All young people should have the opportunity and supports—through family, community, and public systems—to manage their mental health and wellness.
5. Economic Well-Being: All young people should have the opportunity and supports—through families, community, and public systems—to obtain the learning and work opportunities they need in order to experience economic security and advancement and to accrue the financial and social capital needed to afford and access quality education, employment, and housing.
6. Racial and Ethnic Equity: All young people should have the opportunity—through family, community, and public systems—to be treated with fairness and respect, have equitable access to opportunity, and have their wellness not determined by race or ethnicity.

Some of the practice approaches to promoting youth well-being use an approach informed by social ecological theory, situating the six domains within a social ecology, using Urie Bronfenbrenner's work (Bronfenbrenner, 1979, 2004). Different levels of the social ecology must be brought to bear to help a youth prepare for emancipation. For example, effective programs focus on leveraging the social supports both proximal (e.g., foster family; favorite teacher) and distal (volunteer or employment opportunities in the community) to support the financial needs of transition-age foster youth for education through scholarship awards or reduced education fees. The cognitive development of youth in out-of-home care also is important for their health.

Another example exists within the mesosystem within Bronfenbrenner’s model—involving the interaction and cohesiveness of microsystem supports (school, family, church, and neighborhood). For youth residing in out-of-home placements in this case, their mesosystem has experienced tremendous disruption due to loss of biological caregivers, disruption of community supports, and sometimes even removal from their school systems. Thus, social systems that are highly interconnected and stable may be an important factor for successful development for adolescent youth—foster systems should seek to prioritize some way for youth to stay connected to prior community supports. For example, policies that prioritize youth staying within their current local school allow them to maintain some aspects of their social support systems.

Finally, the safety domain is at the heart of the child welfare mission: keeping youth safe from emotional, physical and sexual abuse as well as neglect. While safety is understood to be a motivating factor for youth in out of home placement, ongoing safety concerns for youth within foster care (Pecora at al., 2019), and high rates of re-placement following foster care placement (Roberts et al., 2017) suggest safety remains an important ongoing emphasis for youth served by child welfare. Similarly, economic well-being is a key domain because the majority of families supported by child welfare fall within lower socioeconomic status groups (USDHHS, 2021). Parents and youth alike recognize the need for supports that improve economically stability, and youth need preparation within foster care to live successfully and independently in the community as adults (Valentine et al., 2015). For example, many youth in foster care struggle to obtain part-time jobs and require supports for reaching independence-related milestones (e.g., driver's licenses, individual insurance plans) (Courtney et al., 2004; Pecora et al., 2010).

Each of the above domains are distinctly important for youth development, but they do not function in isolation. For example, Behavioral Activation is a primary treatment approach for adolescent depression, but the effectiveness of that clinical approach is bolstered when a youth has a supportive social network, stable living situation, and a sense of hope for the future.

Guiding Values and Principles

The core values and principles of achieving child well-being that should underlie all child welfare programs are described in this section. The core values and principles are listed below (Langford, Badeau & Legters, 2015, p. 10, 12):

• Well-being is a satisfactory human condition, characterized by health, happiness, and fulfillment. Well-being is not a state of being that one achieves and then lives in for a lifetime. Defining for oneself, moving toward, and achieving well-being is a continual developmental process beginning at infancy and continuing throughout the course of life. Indeed, a better term for the process may be “well-becoming.” (Ben-Arieh & Frones, 2011; Langford, Badeau & Legters, 2015, p. 12). 
• Young People are Valuable: All young people are valuable, despite circumstances or actions that have caused them to come to the attention of public systems. Youth-serving professionals believe, expect, and speak the best about the young people they serve.  
• Equity: Young people of color and other marginalized communities, including homeless, pregnant or parenting, immigrant, and LGBTQ youth, deserve equitable opportunities, experiences, and well-being outcomes. Policies and practices should demonstrate intentional efforts to effectively identify, address, and mitigate racial, cultural, linguistic, gender, and other disparities among vulnerable youth.  
• Youth Voice and Self-Determination: What young people think and feel matters. Young people should be supported in expressing dreams and goals, defining well-being for themselves, developing decision-making skills, and in developmentally appropriate ways, exercising control over their journey to adulthood. 
• Developmentally Appropriate: All young people have a right to childhood and adolescence. Young people should be treated as young people, not adults. Science related to youth and adolescent development should drive practice and policy development.  
• Normalcy: All young people deserve to have access to developmentally appropriate activities, experiences, and opportunities even when they experience out-of-home placement through the child welfare or youth justice systems.  
• A Focus on the Whole Person: Well-being requires a focus on the whole young person (not a segment or part) and their relationship to communities where they live, work, and learn.  
• Family: Every young person needs, and belongs in, a lifelong family to love and support them. 
• Fairness and Second Chances: All young people deserve opportunities to heal from trauma. Policies and practices should be fundamentally fair. Balanced and restorative approaches to justice, which reduce or eliminate collateral consequences, should be the norm when systems respond to adolescent behaviors or needs. Use of harmful practices such as incarceration should be reduced and ultimately eliminated.  
• Youth Workers and Volunteers: The people who serve youth and young adults are valuable, and they need adequate resources, training, and ongoing support to do their work effectively.  
• Science-Based: Evidence generated from research, practice, communities, and experience should inform and improve implementation of this framework.  
• Communities: Communities (and community safety) are improved when young people have opportunities to thrive and contribute as community members. 

 

These principles may read as a guide for how to implement ethical and value-driven services, but in actuality, the principles should serve as a general frame or ethic that guides every decision on service creation and implementation; and every interaction that system supports have with youth in out-of-home care. Consider what is involved in planning and implementing services that fully embrace the principle of Youth Voice and Self-Determination, or uplifting a youth equity. This would require acceptance of a core belief that young people have value and the right to self-determination. It can be demonstrated by how agency staff and foster parents talk with youth, how they work with them, and how they involve them in their case planning (e.g., collaborative vs. autonomous decision making). A growing number of child welfare agencies are trying to implement these values by creating constituent advisory committees, inviting youth and parents with lived experience to assist with and shape program planning, and by hiring them as peer mentors (Chambers et al., 2019; Leake et al., 2012). Before these agencies roll out a new curriculum or foster parent assessment tool, they sit down with the youth or parents with lived experience and say, "We're thinking about introducing this change. What do you think about this? What have we missed? How do we make sure this goes well?" Collaborative decision-making models have demonstrated effectiveness within other service industries such as medicine and behavioral health care (Politi & Street, 2011); community-based participatory designs have long been used to enhance research effectiveness (Cacari-Stone et al., 2014; Wallerstein & Duran, 2006). These models are particularly useful for work with youth from underserved or underrepresented communities (e.g., LGTBQIA+ youth), as they may have had prior experiences with systems of support that undermined their ability to feel heard and understood.

Regarding normalcy, some group care agencies receive criticism when their service schedules, placement decisions, or rules prevent youth from participating in cultural or athletic events. Agency board members and staff have responded by assessing limitations on youth opportunities for normalcy because group care counseling or other sessions are scheduled in a way that interfere with extracurricular activities. Agencies can obstruct developmental and healing pathways in significant ways when youth lose opportunities to volunteer in the community or participate in extracurricular activities. Engagement with “normal life experiences” may also promote youth engagement with system-related supports, such as therapy and educational supports (e.g., tutoring), as many extra-curricular activities require academic and behavioral standards (Pokempner et al., 2015). Indeed, youth in out-of-home placements who are offered opportunities to engage in age-normative activities, such as extracurricular sports, have demonstrated more positive outcomes (White, Scott, & Munson, 2018).

The concepts of fairness and having second chances represents a rarely discussed principle—restorative justice, which is based partially on work with American Indian or first nations people in Canada and elsewhere (Bargen, 2018; Crampton & Rideout, 2010). This approach allows young people who have injured or harmed other people, such as their siblings or foster parents, the opportunity to apologize. Youth should have the ability to “make up for” prior transgressions in some way with their victims to avoid continuous punishment and self-blame for a mistake that may have been made when they were an impulsive 12-year-old. Similarly, social systems that interact with adolescents in out-of-home placement should consider the totality of their experiences to promote justice. For example, an older adolescent on probation with juvenile justice may struggle with trust and openness in their relations with their probation officer above and beyond what might typically be expected if they have a prior history of multiple foster placements. Youth with histories that involved experiences of discrimination, bias, or marginalization on top of added adversity related to system-involvement may be particularly averse to system supports. These youth require sensitivity from case workers and interventionists who are willing to work to understand the totality of their experiences. Further, system-induced adversity is regularly under-recognized as an explanatory factor in youth behavior, but has known influences on how adolescents with system-involvement perceive their world (e.g., Cooley et al. 2015).

Achieving Adolescent Well-Being by Focusing on Key Conditions and Capacities by Environmental Domain

The key conditions and capacities that older youth in foster care (including those who are planning to transition or emancipate from care) need to have or develop for well-being are highlighted below and described in much more detail by the National Transition Funders Group. This framework for building well-being for older youth in foster care describes in detail the conditions and capacities by environment: youth, families, communities, and the public environment.   

More specifically, the domains are Physical Health and Safety, Cognitive and Mental, Social and Emotional, Economic, and Racial and Ethnic Equality. And the areas of focus are government and systems, community, private sector partners, neighborhoods, families, youth, and young parents. Some of the capacities and strategies for developing youth well-being are listed  

• Maximize physical health, strength, and functioning, be physically safe and free from violence, abuse and neglect, and have basic needs met. 
• Experience continuous cognitive and mental health as well as intellectual growth, with the ability to address any mental health issues as they arise. 
• Cultivate a strong and resilient self-identity and supportive and nurturing relationships. 
• Obtain the learning and work opportunities needed to experience security and advancement; accrue financial and social capital to afford quality education, employment, housing, and transportation. 
• Be treated with fairness and respect, have equitable access to opportunity; wellness is not determined by race or ethnicity (Langford, Krauss, & Legters, 2021, pp. 21-24). 

Some of these have been discussed by other organizations and in other publications. For example, the Strengthening Families Approach identifies five protective factors as the foundation for a stable nurturing environment for children with birth, foster and adoptive parents: parental resilience, social connections, concrete support in times of need, knowledge of parenting and child development, and social and emotional competence of children (Browne, 2016). An extensive review of the research studies by the Center for the Study of Social Policy and other recent research studies (e.g., Fortson et al., 2016) support the idea that the presence of these protective factors is associated with reduced risk for child abuse and neglect. These protective factors can contribute to family cohesion and familial interaction promotive of positive outcomes for youth (Center for the Study of Social Policy, 2018). These recommendations were previously developed for younger children in care but have been aged up for the adolescent focus within this chapter: 

1. Parental Resilience. Given the focus on autonomy and independence during adolescence, this is a phase in parenting that is notable for conflicts in parent-child communication. A parent’s individual capacity for management of stress and internal resources for coping can impact how parents approach and resolve conflict with adolescents. Parents who engage in effective and collaborative problem-solving with their children, actively work to build and sustain trusting relationships that also allow for appropriate youth independence, and seek help from others to support the parent-child relationship will demonstrate capacity for resilience.  
2. Social Connections. From Bronfenbrennar’s ecological model, socio-emotional support and interconnected networks of support will provide an adaptive framework for youth development. Support can be obtained from multiple layers of the ecological network, and microsystem supports can come from friends, family members, neighbors, and community members. Networks of support are essential to parents and also offer opportunities for people to “give back,” an important part of self- esteem as well as a benefit for the community. Isolated families may need extra help in reaching out to build positive relationships.  
3. Concrete Support in Times of Need. Families and youth require food, shelter, clothing, and health care—basic needs essential for families to thrive. In the context of a family crisis, such as domestic violence, mental illness, or substance abuse, adequate services and supports need to be in place to provide stability, treatment, and help for family members to get through the crisis. Adolescents in out-of-home placements also require training around the process by which sources of concrete support can be obtained (e.g., WIC cards, application for Medicaid). 
4. Knowledge of Parenting and Child Development. Accurate information about child development and appropriate expectations for children’s behavior, particularly in the adolescent phase, will encourage parents to see their children and youth in a positive light and promote their healthy development. Provision of information to parents about how exposure to adversity may impact adolescent emotional and cognitive development will promote trauma-informed parenting and build parental capacity for understanding. Studies show information is most effective when it comes at the precise time parents need it to understand their own children. Parents who experienced harsh discipline or other negative childhood experiences may need extra help to change the parenting patterns they learned as children.  
5. Social and Emotional Competence of Children. An adolescent’s ability to interact positively with others, self-regulate their behavior, and effectively communicate their feelings has a positive impact on their relationships with their family, other adults, and peers. Adolescents are in a developmental phase also identified by increased autonomy in social functioning, which can at times create additional stress or challenges for them. Youth behaviors related to oppositionality or delays in emotional or social development may create extra stress for families; early identification and assistance for both parents and youth can reduce risk for maladaptive outcomes and keep development on track (Center for the Study of Social Policy, Undated, pp. 1-2). 

In 2019, the National Academy of Sciences (2019b) released a report on youth well-being that discussed advances in science, such as epigenetics and resilience, that should be utilized to refine child welfare practice. The report underscored how caregivers and social service agencies should work to support the ability of the brain and emotional systems to recover over time—with the right nurturance and care. Unfortunately, most child welfare workers know little about epigenetics and how the brain can heal. Staff and foster parents would benefit from training in how to help nurture the brain and build youth resiliency and protective factors (Center on the Developing Child at Harvard University, 2016, 2017).

The National Academy of Sciences report also discussed the importance of timing interventions. Many group care agencies and other behavioral health providers struggle with this dimension as approaches to intervention may be systematic (e.g., all youth entering care are provided with group therapy) rather than individually driven (e.g., after assessment, interventions are tailored to youth-specific needs). As an example, by the time some youth come to the attention of the child welfare system, they are so emotionally and behaviorally dysregulated that conventional talk therapies are not effective. For example, Cognitive Behavioral Therapy or Trauma-Focused Cognitive Behavioral Therapy have less utility with children that are highly dysregulated. Instead, these youth may require therapy that focuses on grounding and emotional regulation (e.g., equine therapy, raising service dogs, drumming, yoga, or some other type of non-talk therapy) to get their emotion management systems under control. Successful treatment may therefore depend on the use of non-talk therapies, such as those listed above, because they engage proprioception (the sense of the relative position of neighboring parts of the body and strength of effort being employed in movement; Mosby, 1994), and restorative vestibular mechanisms (Kranowitz & Miller, 2006; Warner et al., 2013). Further, within child welfare systems, the focus of therapeutic intervention is often centered on the child, whereas more often than not a family approach to treatment may be more appropriate to address the needs of the child nested within the family system (e.g., Kolko, Iselin, & Gully, 2011).

The National Academy of Sciences report also highlights the need to study the impact of laws and policies with respect to child development and well-being. For example, when the Federal Government began to subsidize adoptions as part of the Adoption Assistance and Child Welfare Act of 1980 (PL 96-272) in 1980, that law helped transform child welfare services in the following ways: more children were adopted and more children found permanent homes, which increased their likelihood of developing positive well-being. Thus this policy shift that emphasized regular case reviews and adoption incentives to improve permanency planning helped the child welfare system pivot and attend to at least one form of legal permanency linked to positive child and adult outcomes—adoption (Kawam, 2014; Pecora et al., 2019; Vandivere et al., 2009).

In addition, the social support, relationship skill-building, and resilience aspects of the framework listed earlier are essential and transcend various child welfare programs. For example, while the Chafee program provides various services delivered concurrently to prepare youth for life after foster care and to support youth who have recently left care, it is not the complete answer. The Children’s Defense Fund recently documented how the COVID-19 pandemic has been devastating for youth in extended foster care and those who have recently aged out of the foster care system (Olender, 2020). Across the country, these youth are losing their jobs and their homes, and also facing serious food and economic insecurity. The social support networks and skills mentioned above can be key for survival, particularly in times of crisis.

Finally, other program reforms are needed. A number of child welfare service organizations, such as those in Colorado, New York City, and New Jersey, are working to develop their child family service systems using a 21^st century approach to child and family well-being. This approach includes a sharper focus on addressing the root causes of child maltreatment, including intervening upon social determinants of health. With this approach, these agencies are focusing on socioeconomic factors that help determine well-being, such as the physical environment, economic opportunity and supports, what kinds of healthy behaviors they engage in, and what kind of health care services are available. Approaches that incorporate cross-cutting risk factors such as these will be robust to macrosystem level influences and crises (e.g., the COVID-19 pandemic reducing national resources for system services) that have trickle-down impacts on youth and families. 

With this approach, child welfare systems recognize that they cannot do this work alone. They must strategically partner with public health, public assistance, housing, the business community, faith-based communities, and others to comprehensively address the root causes of child maltreatment and maximize child well-being. To help support some of that work, the Family First Act has allocated dollars specifically for the selective prevention domain for families with a child at risk of foster care placement (National Research Council and the Institute of Medicine, 2009).

Family First Prevention Services Act

In contrast to some of the other well-developed policies and programs, the United States is at the very beginning of a policy experiment with the Family First Prevention Services Act (FFPSA). This landmark piece of legislation increased funding for placement prevention services for youth at risk of being placed in foster care using an open-ended entitlement (Human Resources Subcommittee Staff, 2016). Many experts, such as Jerry Milner, who recently was a senior leader at the U.S. Children’s Bureau, believe the law needs to extend even further in support of prevention services because families eligible for this program must have a child at risk of being placed in foster care (Milner, 2018-19). For example, one who utilizes the SafeCare home visiting program in one’s county would be able to obtain reimbursement up to 50% for SafeCare services provided to families if a child was at risk of going into foster care (i.e., if the child was a “candidate for foster care”). Other families being served with SafeCare would not be eligible to receive Family First reimbursement for that service if their children were not at risk of placement, thus potentially missing an opportunity to intervene earlier.

Assessment of Youth and Family Functioning

In this final section, we highlight the importance of careful assessment of child and family well-being as a prelude to services provision and other support strategies. Proper implementation of prevention and intervention services is dependent upon clear assessment of service needs, service effectiveness, feasibility of delivery, and acceptability of service provision for the target community. As child welfare moves to engage more with public health, behavioral health, public assistance, and other systems, it needs to improve how staff match needs and services for children and families. For all areas of child welfare, under FFPSA, trauma-informed multi-dimensional assessments must be consistently used within each state. (See Figure 1 as an example of the dimensions that should be assessed.) To efficiently and successfully address child well-being, agencies need comprehensive assessment data about child functioning (and by extension family functioning if that is the environment within which the child is being raised). In addition, with FFPSA, in order to place a youth in group care, a third-party objective trauma-informed child assessment by qualified clinician who is not employed by the group care agency is required. Consequently, states and counties across the country are considering what kind of standardized child and family assessment tools they should use—if they are not already using one—often in conjunction with behavioral health. In some cases, systems may be using multiple assessments, but in an inconsistent way. Moreover, assessment should be ongoing for the duration of service delivery to ensure services maintain effectiveness and continue to meet the needs of the child/family. Routine monitoring of key outcomes (e.g., child welfare referrals, utilization of behavioral health services, community-level needs/resources) provides more accurate data for system-level leveraging of resources; and it allows for flexible implementation of services that can be responsive to changes in circumstances and needs encountered by system-involved children and families.

For example, in the years leading up to 2018, Florida was using four different types of the Child and Adolescent Needs and Strengths Scale (CANS) with insufficient staff training and coaching, so some subscale scores could not be trusted. Florida state and local agency leaders were concerned with how they could capture youth functioning and how best to match needs with services if they were not using some kind of a standardized assessment (Thompson & Pecora, 2018). To conduct high-quality needs assessment and service planning, agency staff need access to valid multidimensional assessments and training in how to utilize them. For example, assessment of a youth’s internal resources to promote resiliency as well as other strengths they bring to a given situation may be critical to match youth to appropriate available resources. Identification of protective factors (e.g., youth expressed values related to education or internal flexibility in coping style) that might be operating in a youth’s life should be promoted when making placement decisions (e.g., prioritizing placement within school district zones). Other important individual factors include understanding youth identity around race, ethnicity, gender, spiritual orientation, and social systems of support. Other relevant microsystem factors include youth engagement with extended family, peer supports, academic supports, and religious communities. Across these factors (protective, individual, and microsystem-level factors), recognition of the contextual nature of their risk- versus resiliency-promoting nature must be at the forefront. For example, a youth’s identity related to minority status may increase risk for exposure to discrimination or marginalization in some settings, but it may also provide an opportunity for connection and support in other settings.

Figure 1
Key Assessment Domains for Child Assessment in Child and Family Social Services

To develop a preventative system approach that is grounded in thorough assessment, considerations of assessment duration/comprehension, cost, outcomes targeted, and implementation (e.g., staff training in assessment) must be addressed. How do you quickly assess a youth for life skills using a strength-based set of items? What criteria are states using in selecting a state-wide youth or family assessment tool? This section provides an overview of factors that should be considered for comprehensive youth, parent, and family assessment in child welfare, using the framework described above. While an exhaustive list of evaluation factors falls outside the scope of this chapter, the sections below discuss some foundational aspects that can serve to enhance child welfare assessments to promote youth positive outcomes.

Emotional and Behavioral Functioning.

As the cornerstone of most treatment delivery, emotional and behavioral functioning remains a critical component of assessment. Most tools derived for measurement of these outcomes have not been evaluated for use with youth in foster care, and recent studies suggest modifications may be needed to address differences in child-welfare populations (Jacobson et al., 2019).

• Is functional impairment evaluated across contexts (e.g., school, home)?
• How practical are the scores in terms of use for diagnostic evaluation, case planning, and routine outcomes measurement?
• If normed, what is the norming population, and is that appropriate for the given child’s circumstances? Have the measure’s psychometric properties been evaluated for welfare-involved youth?
• If used for measuring treatment progress, is it clinically sensitive (i.e., can it measure change over time)?
• How well does the child assessment tool address issue of diversity, equity, and inclusion in its design and how the scores are interpreted?

Family/Fictive Kin Family Functioning.

Fewer well-researched family assessment tools suitable for child welfare exist. Researchers and clinicians alike should prioritize the development and use of family-focused assessments to improve youth/family matching for child welfare placements.

• Will the assessor have adequate knowledge of the child and family required to complete the measure? In some situations, a youth self-report measure may be essential to capture the youth’s perspective. In other situations, it may be critical to capture the primary caregiver’s perspective.
• Whose perspective does the tool most directly measure: youth, parent, teacher, foster/resource parent?
• What family-specific outcomes may be important to assess across time (e.g., family or caregiver stress, placement disruptions)?
• How well does the assessment tool address issues of diversity, equity, and inclusion in its design and how the scores are interpreted? (Pecora, 2021).

Resiliency, Other Strengths, and Protective Factors.

The completeness of domain coverage, including strengths and protective factors, is important to consider in tool selection as well. Some community-based programs working to support children at risk of child maltreatment or suffering from a behavioral health disorder assess family functioning by using the protective factors framework from the Center of Social Study Policy. There are at least two scales that assess the protective factors. (See https://cssp.org/resource/papf-instrument-english/ and https://friendsnrc.org/protective-factors-survey).While a less commonly studied aspect of influence on child welfare outcomes, emerging research suggests individual, familial, and system-level strengths can have impact on youth outcomes. Evaluation of strengths and protective factors may look different than assessment of pathology, and thus, some recommendations are as follows:

• Does the informant provide context-specific or context-global information on youth strengths?
• Are strengths evaluated across the youth’s socio-ecological levels (e.g., microsystem, mesosystem, and macrosystem levels)?
• Are strengths as protective factors evaluated in a way that is useful for treatment and placement planning?

Self-Identification Factors.

Generally, evaluation that fails to address unique aspects of a youth important to their self-perceived value system will also fail to maximize potential strengths specific to that youth. How youth consider their religious, familial, cultural, racial, and sexual identities could serve as important contributors to their present-day functioning and access to social supports. Furthermore, measures that are mismatched to youth characteristics may pathologize aspects of a given youth in unintended ways or under-assess important risk factors for negative outcomes.

• Are measures selected appropriate for the age, gender, ethnic, or other cultural groups that are served?
• Are norms available for the population of interest under evaluation?
• What unique aspects of the youth being evaluated may be missed in traditional forms of assessment?
• What contextual circumstances related to discrimination or marginalization may impact the findings of the assessment? 

Dangerous Behaviors.

Given that most out-of-home placement decisions are made to increase the physical and emotional safety of youth, recognition and assessment of potential safety-related behaviors (e.g., runaway, self-harm, harm to others, health risk behaviors) should also be used to inform placement decisions. Assessment of these behaviors also must consider the context wherein they occur—for some youth, engagement in what would be considered “unsafe” behaviors such as running away may actually have served an adaptive purpose for them (e.g., running away from a perpetrator to seek safety).

• Are measures selected covering the full range of safety behaviors and have clinical cutoffs been examined in the population of interest?
• Is there a functional assessment of safety behaviors to contextualize the functional purpose of the behaviors for the youth under assessment?

Other Practical Considerations.

Many assessment measures are completed by the worker, and with this approach agencies must depend on the worker knowing that youth and the youth’s living situation enough to rate the youth. The worker has to assemble that information and synthesize it. For example, the Child and Adolescent Needs and Strengths Scale (CANS) is the most commonly used measure of this type (see http://praedfoundation.org/). This approach is in contrast to using first-person ratings from the youth or the youth’s caregiver. More well-developed measures have automatic scoring systems that can be used once the scores are scanned or entered into the program, and technology is advancing the use of measurement-based care online dashboard systems to ease the burden of repeated evaluation across time. Additional examples of criteria for selecting an assessment measure based on practical issues are listed below:

• Ease of completion in terms of clarity of instructions, clarity of items, and time to complete
• Training and coaching requirements for administration and interpretation
• Whose perspective does the tool most directly measure: youth, parent’s perspective, teacher, foster parent?
• What is the cost to use the measure (e.g., is it affordable), and how easy is it to score?
• Compatibility with the agency management information system, and accessing total and sub-scale scores for case planning and evaluation
• How well does the measure perform in terms of construct validity, “face validity,” concurrent validity, criterion validity, discriminant validity, inter-rater reliability, and predictive validity (Pecora, 2021)?

There are a number of challenges to assessment. Primary system-related obstacles to proper assessment include staff training, staff time, knowledge of appropriate tools for assessment, and system integration of assessment findings within a decision-making framework. Some child welfare agencies rely on behavioral health staff to complete youth assessment measures because the child welfare staff are not trained well enough to use these tools or lack the time. Some might argue that obstacles should be removed to assist welfare workers to complete measures as they often know the child and family the best. In some states, however, the behavioral health or other systems can function as a strong partner to a local child welfare agency if they are carefully trained to conduct these assessments. In Washington state, the Foster Care Assessment Program (FCAP) at the University of Washington assesses every child placed in foster care within 30 days with assessments conducted by experienced social workers and psychologists (see https://depts.washington.edu/uwhatc/FCAP/). With that approach, every child is afforded a fairly comprehensive assessment of strengths and needs when they first enter placement by a highly trained team.

Conclusions

This chapter presented strategies at the youth, family, community, and general public levels for promoting adolescent well-being for youth and families served by child welfare. It builds on recent research, principles, and strategies for helping youth in care succeed from the National Transition Funders Group. Finally, recommendations were provided using a key assessment domain framework to guide considerations for youth, parent, and family assessment.

Future research funding should support studies that enact holistic approaches to understanding outcomes for children and youth characterized by the consideration of achievement, health, and other outcome domains simultaneously. Further, studies that demonstrate the specific social conditions and supports linked to epigenetic mechanisms that activate processes related to resilience and positive outcomes for young people, despite challenging circumstances, are needed. For example, research that identifies, substantiates, and implements interventions that build autonomy, adaptive help-seeking, and agency in adolescents while also promoting resilience would offer a strengths-focused approach to management of behavioral and emotional difficulties for system-involved youth. One example is provided by the Strong African American Families study that delivered specified curricula to youth and their caregivers (see Brody et al., 2017). Models such as these would benefit from further research support and enhancements that extend program scope and impact.

Studies could be specifically designed to test optimal timing of interventions for youth in foster care, posing questions such as “What are the trajectories of true developmental change in connectivity within and between neural networks implicated in cognitive control and emotional processing? Are these trajectories of change steeper or quicker during some periods than others, potentially providing key windows for input and intervention?” (Fuligni et al., 2013, p. 151). Further, the field should seek to prioritize refinement and greater use of available tools as well as development of new tools for domains that are lacking to ensure adherence to FFPSA assessment requirements. Studies need to continue to assess how well measures capture constructs of interest for system-involved youth and how measurement-based care can be better infused in system-level decision-making processes.

We also need to better understand how the social and environmental context (and factors within that context) can offer opportunities for flourishing outcomes or for worsened outcomes for youth in out-of-home care. Studies should also aim to reduce discrimination and marginalization, with a focus on both neurobiological consequences as well as structural strategies (school, community, state policies and practices) that reduce the conditions in which discrimination and marginalization are prevalent, and that buffer individuals from such experiences. These include youth who historically have been underrepresented or who are most vulnerable (e.g., youth of color; immigrants; sexual and gender minorities; religious minorities; out-of-home youth; or those experiencing homelessness, foster care, or unstable housing). This also includes ways in which intersecting axes of oppression shape youth development, particularly against a backdrop of social stratification and oppression, where relationships between identity, experience, and behavior may not operate the same way for all youth (National Academies of Sciences, Engineering, and Medicine, 2019b). For example, these studies could focus on:

• Understanding the impact of laws and policies that improve or impede adolescent health, well-being, safety, and security;
• Ascertaining what social and economic policies may improve opportunities for youth placed in foster care to thrive and test whether their effectiveness differs by race/ethnicity or context; and
• Identifying what interventions might ameliorate and (or) enrich the outcomes of youth in care who have experienced childhood deprivation, oppression, or other negative experiences (such as poverty, trauma, separation, or displacement) (National Academies of Sciences, Engineering, and Medicine, 2019b).

While this chapter outlines key dimensions of child well-being, strategies for promoting child well-being, and ways to assess those dimensions, much work remains to be done to address gaps that continue to impact our most vulnerable youth. System approaches that maintain focus on primary tenants of factors promotive of adolescent well-being, as well as adherence to core values related to the promotion of adolescent well-being will support consideration of the whole child in assessment and intervention. Further, assessment methods that are grounded in the specific needs of the adolescent and family (Figure 1) and promotive of protective factors, while also responsive to system-level limitations, will be sustainable for the promotion of measurement-based care and effective recommendations for service delivery.

Acknowledgements

The authors thank Sue Badeau, Barbara Hanson Langford, Stephanie Malia Krauss and Lyman Legters of the Youth Transition Funders Group for permitting us to reprint material from their recent report; and to the many foster care alumni who have shared their experiences in out-of-home care with us.

Suggested Citation: Pecora, Peter J. & Gabrielli, Joy, Defining, Assessing, and Promoting Adolescent Well-Being for Youth in Out-of-Home Care, in The Future of Foster Care: New Science on Old Problems by the Penn State Child Maltreatment Solutions Network (Sarah Font ed. & Yo Jackson ed., 2021). https://doi.org/10.26209/fostercare2

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