Meeting Youth Where They Are
ACLP Bulletin | Summer 2021 | VOL. 39 NO.3
Anish Raj, MD, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
Meagan Fitzgerald, MS, CCLS, Hasbro Children's Hospital, Providence, Rhode Island
Four weeks in, the dam broke, and the questions arrived rapid-fire.
“Wait, you don’t have to come to this?”
“You want to be here?”
“Y’all are just here cause you care?”
As we sat around the group home dining table, the teenagers looked at each other incredulously. In their questions, we started to see answers. They were surprised that adults would simply make the choice to spend evenings with them when not required by their employer, child protective services, or other agencies.
According to national data estimates, more than 420,000 youth are in foster care at any given time with approximately 18,000 residing in a group home (United States Children’s Bureau, 2020). It is widely known that foster care youth are at greater risk for a variety of negative psychosocial outcomes compared to peers who have never been in placement (Lanctôt, 2020). Key distinctions between the challenges experienced by youth transitioning to adulthood from care have been documented across gender (Lanctôt, 2020). Existing literature has demonstrated that domains particularly affected for women leaving care involve well-being, relationships, and socialization, and that interpersonal relations are central to the resilience process (Lanctôt, 2020).
Emerging research suggests that the notion of perceived social supports can be crucial in promoting resilience and preventing negative psychosocial outcomes (Lanctôt, 2020). However, given the complexities related to histories of maltreatment, disrupted attachments, and resultant mistrust experienced by many youths in care, establishing supportive social networks can be challenging (Lanctôt, 2020). Nonetheless, a positive relationship with a supportive adult may be the strongest predictor of adaptation and resilience for these youth (Rabley et al., 2014). Non-parental caregivers, such as group home staff and mentors, are in a unique position to offer a surrogate family environment. Interviews aimed at gathering the perspectives of youth in group homes have revealed that the most positive of these relationships are often secondary to consistent interactions, open communication, trust, humor, and shared interests (Rabley et al., 2014). Recognizing that lack of engagement can be a barrier, studies have determined that youth-driven interventions, consistency, and incentive-based strategies can be beneficial in improving “buy-in” (Rabley et al., 2014; Boel-Studt et al., 2018).
Based on our clinical experience, the authors, a Triple Board resident physician and a child life specialist, observed that youth from local group homes seemed to present on a recurrent basis to the children’s hospital. Youth often voiced dissatisfaction with their living arrangements, any prospect of their circumstances improving, the health care providers they encountered, and the cycle of returning to their assigned placements if medically and psychiatrically cleared. It became evident to us that there was a disconnect between what the youth were seeking in the hospital and the care that was being provided.
In the fall of 2019, we collaborated to think outside the box of traditional clinical roles to engage local youth and meet them “where they are” — literally and figuratively. Past efforts by the hospital to provide outreach to youth residing in group homes largely took place at the juvenile justice facility, local sexual violence agency, or child protection center. It was hypothesized that youth may benefit from the experience of “health care outsiders” coming to them and cultivating positive relationships in a non-clinical setting.
After initial conceptualization was complete, a focus group was convened with administrative stakeholders from a local, non-profit social service organization that manages multiple residential programs for adolescent females who are in the custody of the state. Based on geographical location, the number of residential youths, average length of stay, level of acuity, and opportunity for continuity, a particular group home was selected as the site of the pilot project. The identified group home was estimated to serve six to eight adolescent females at any given time with ages ranging from 14 to 17. Categorized as a step-down program, youth generally remained in the group home for multiple months. Supervision was provided around-the-clock by a minimum of two staff members.
We formulated a model of unstructured and non-curriculum- based evening sessions held once weekly on-site in the group home, facilitated by an inter-disciplinary team comprised of two to four physicians and child life specialists. The hope was that experiences within the group could build resilience factors and translate to favorable outcomes across such domains as interpersonal relationships, engagement with health care, and school functioning. The group was therefore titled Empowering Youth Connections (EYC).
Sessions typically comprised of dinner, discussion, and a group activity over the course of approximately two hours. One evening, a broad conversation about family was initiated while engaging in a freeform art project. As residential youth reflected on their respective childhoods, how those experiences shaped their present, and what their future aspirations looked like, the discussion branched out into dialogue about identity, personal values, and self-esteem. As the youth continued to provide their perspectives, individuals tied in their experiences related to sexual orientation and violence within relationships. The open forum also allowed for the sharing of adolescent outlooks on social media and societal influence on gender roles and inequalities. Rather than evoking a specific goal-directed approach, our objective was to listen to the substance underpinning the views, process in real time, and assist with interpretation. It would not be an exaggeration to acknowledge that we organically learned more about the backgrounds and perspectives of those six adolescents in two hours than perhaps we could have in weeks of clinical service.
Despite being a non-clinical setting, EYC offered a myriad of opportunities for the arts of medicine and child life practice to be exemplified (Ring & Clairborne Johnston, 2018). Unlike a packed outpatient schedule, there was time and space for every youth to be heard. Interactive discussion was predicated on a foundational understanding that resilience can be cultivated through emotional support, nurturance, and education. Even at points of disagreement or gentle anticipatory guidance, the emphasis was to “soothe, not solve” (Ring & Clairborne Johnston, 2018). Residential youth voiced appreciation for having a safe space to express their thoughts openly and be able to utilize caring adults in brainstorming exercises. Silly jokes at our expense were welcome; friendly banter was encouraged. The notion of youth controlling the narrative and being able to access these conversations without involvement of “the system” or having it affect their “file” or “case” was viewed as crucial. We posit that de-emphasizing our clinical responsibilities and securing a more spontaneous, natural interface was invaluable. It became clear that connections were not made based on knowledge of our day jobs or professional degrees. Rather, it was the implicit reality that adults with those day jobs and professional degrees would choose to show up consistently that seemed to matter.
Ultimately, fostering connections with youth in a non-clinical setting may also benefit participating health care professionals in addition to the youth involved. Opportunities like EYC can serve as conduits for lifelong learning. Anthropologic studies have promoted home visit models to build providers’ understanding of how people from diverse backgrounds experience life (Blaylock, 2000). It has been
suggested that this awareness enhances the ability to meet needs more effectively, while also confronting personal biases and misconceptions (Blaylock, 2000). Similarly, evolving literature suggests that social empathy, which has been defined as the “ability to understand people by perceiving or experiencing their life situations, and as a result, gain insight into structural inequalities and disparities,” can be honed by exposure and experience (Segal, 2011). Arguably no exposure or experience is more valuable in appreciating the psychosocial nuances of an individual’s identity than spending time with them in their home.
As times change and generations evolve, it is imperative that health care professionals adapt to the needs of our communities and ensure that all youth, especially those at-risk for limited social supports, have access to positive relationships with responsible adults. However, as the Wednesday evenings in the group home reminded us, effective interventions do not necessarily have to be inherently sophisticated. Once we were able to demonstrate that we did not have to be there, but genuinely wanted to just because we cared, the guards came down, and a sense of cohesion emerged. EYC ultimately reaffirmed that a sense of togetherness is central to the universal human experience — regardless of age, background, or profession. For we were there to learn, to listen, to advocate, to validate, and to our pleasant surprise, we ourselves became empowered.
Acknowledgements: The authors would like to thank Christine Barron, MD, Ashley Adams, MD, and Katie Lavallee, CCLS, CTRS, for their collaboration on this project. The authors would also like to recognize the support of Hasbro Children’s Hospital’s Radiothon.
United States Children’s Bureau. (2020). The AFCARS report – preliminary FY 2019 estimates. https://www.acf.hhs.gov/sites/default/files/documents/cb/afcarsreport27.pdf
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Boel-Studt, S., Schelbe, L., Deichen Hansen, M., & Tobia, L. (2018). Increasing youth engagement in residential group care: A mixed methods pilot study of a youth-guided incentive program. Child & Youth Care Forum, 47(6), 863-880. https://doi.org/10.1007/s10566-018-9465-y
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Segal, E. (2011). Social empathy: A model built on empathy, contextual understanding, and social responsibility that promotes social justice. Journal of Social Service Research, 37, 266-277. https://doi.org/10.108 0/01488376.2011.564040