Sampling strategy.

A purposive sampling approach that incorporated snowball and opportunistic strategies was used to recruit participants. An electronic flyer was shared with community agencies, support services, and advocacy organizations that served Canadian former youth-in-care specifically, or indirectly, as part of another marginalized group (e.g., unhoused youth). The same flyer was also featured in targeted social media posts on Facebook and Instagram. All advertisements included a QR code and link to a brief summary of the study, as well as the email address and business telephone number of the lead author.

Potential participants were required to meet the following eligibility criteria for inclusion in the study:

1. Able to read, write, and converse fluently in English
2. Between the ages of 18 and 29 at the time of enrollment
3. Former permanent ward placed in foster care in any Canadian province or territory
4. Aged out of foster care in Canada upon reaching the legal age of child protection (16–19), as defined by the respective jurisdiction
5. Remained a resident of Canada from the time of emancipation until study commencement

Those interested in the interview portion of the study were required to meet two additional criteria:

1. Access to an electronic device with a video camera and internet connectivity, such as a smart phone, tablet, or personal computer
2. Agreed to the audio-recording and transcription of interview dialogue

While 203 participants were ultimately enrolled in the study, a modest sample size of 50 was initially targeted. Given the exploratory nature of the study design, effect size was prioritized over statistical significance. Using confidence intervals (CI) and effect size to guide sampling, power analyses conducted using a medium effect of 0.5 and a liberal 80% CI, consistently confirmed the suitability of a sample size ≥50 for exploratory purposes. However, anticipated logistical challenges related to the recruitment, retention, and engagement of the target population were not encountered, allowing for a much larger sample than originally proposed. To support future study comparisons, the original power calculation was adjusted to reflect a 95% CI, which demonstrated the need for a sample size of approximately 64 participants. This remains far below the actual sample size (n = 203) achieved for this study.

At the time of enrollment, participants were invited to take part in both the quantitative and qualitative arms of this study; however, involvement in the interview process was dependent upon participants’ decision to ‘opt in’ following survey completion. An information power approach was used to determine the final size of the interview subsample [56]. Owing to high participant specificity and strong interview dialogue, among other factors, sufficient information power was achieved earlier than anticipated. Consistent with established methodological precedent among studies that use an interpretive description approach [54], 31 interviews were conducted, of which 26 transcripts were cleaned and analyzed. Included participants were selected purposively to maximize the representation of diverse intersectional identities and lived experiences.

Quantitative data collection.

Participants completed a self-administered online questionnaire through Qualtrics XM [59]. Surveys included multiple choice and Likert-style questions about participants’ personal characteristics and foster care histories, as well as ten validated self-report measures assessing experiences of structural violence (Adverse Childhood Experiences, Intersectional Discrimination Index–Anticipated and Day-to-Day, Perceived Stress Scale), protective factors (Benevolent Childhood Experiences), mental health challenges (Abbreviated PTSD Checklist for DSM-5, PROMIS Emotional Distress and Anxiety Short Form 4a, and PROMIS Depression Short Form 6a), and positive adaptation (Brief Resilience Scale and Secure Flourishing Index) (Table 1). The study surveys were pilot-tested with an individual who was representative of the study sample. Surveys took approximately 15 minutes to complete and could be paused and resumed at any time. Participants received a $30 CAD electronic gift card following submission of the questionnaire.

Quantitative data analysis.

All quantitative data were cleaned and imported into SAS 9.4 [86] for analysis. Descriptive statistics were calculated to describe sample characteristics and variables of interest, assess the normality of data distribution, identify possible outliers, and any missing data. With a total Fraction of Missing Information [87] of only 3.6%, it was determined that a multiple imputation approach was not needed to treat missing data [88]. A correlation matrix was developed to examine bivariate associations. Those with moderate to strong correlation coefficients (r ≥ 0.3) were included in subsequent regression analyses (Table 5).

Multiple linear regression analyses were conducted with a block sequential approach for the direction and strength of relationships among quantitative variables, when controlling for six covariates (age, total time in care, Black racial background, Indigenous ethnicity, LGBTQ+ status, and a history of five or more foster care placements). These covariates were selected since they were unique intersectional identities that may have meaningfully influenced participants’ lived experiences and perceptions [50]. Ten different associations were examined through regression modelling (Fig 3).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 3. Variable Associations Tested Through Regression Modelling.

https://doi.org/10.1371/journal.pone.0338574.g003

Qualitative data collection.

Thirty-one participants completed individual semi-structured interviews guided by an interpretive description approach [54]. A preliminary interview guide was developed, pilot-tested, and revised with help from an individual who met study eligibility criteria. Refinement of the interview guide was an iterative process, and prompts were continually adjusted based upon quantitative findings and ongoing qualitative interview experiences.

All interviews were conducted remotely using Zoom.us [89] video conferencing software and were approximately 45–60 minutes in length. Interviews were conducted by the first author—a PhD Candidate and Psychiatric-Mental Health Registered Nurse with qualitative research and clinical interviewing experience. Prior to the interview, introductions and explanations of the study were reviewed and informed consent was obtained. For a complete description of virtual methods and participant safeguards, see Jackson et al. (manuscript under review). Field notes were made following each interview. Participants received a second $30 CAD electronic gift card for engaging in the interview process. Participants were reimbursed for any travel, childcare, or phone charges incurred, up to a maximum of $15 CAD. Half of the interview subsample (n = 13) was invited to review emergent theme descriptions as part of member-checking, which took place after thematic analysis was complete. Participants were purposively selected to reflect diverse sociodemographic characteristics and foster care experiences.

Qualitative data analysis.

Interview dialogue was audio-recorded through Zoom.us [89] and a back-up digital recording device. It was then transcribed verbatim, using Temi [90] advanced speech recognition software. Transcripts were reviewed for accuracy, cleaned, and de-identified. Inductive thematic analysis of interview dialogue was used to describe how the conceptual model (Fig 1)—comprised of three converging theoretical frameworks—manifested in this unique clinical context [91]. Following Thorne’s [54] interpretive description framework, qualitative analysis proceeded through five iterative phases: (1) immersion in data and open coding; (2) identification and categorization of patterns; (3) development of interpretive themes through constant comparison; (4) synthesis and integration of thematic relationships; and, (5) validation through team consensus and participant member-checking. The cross-sectional and emergent nature of this study supported concurrent analysis that coincided with ongoing recruitment and continued revision of the semi-structured interview guide, based upon participant and researcher experiences during preceding interviews. This process yielded rich thematic findings that informed integration with quantitative results.

All qualitative analysis activities were conducted by the first author and senior (last) author. Blinded transcripts were open coded, the coding structure was discussed for consensus, and all transcripts were imported into ATLAS.ti software, version 24.1.0 [92] for further analysis. An iterative codebook contained detailed definitions of codes and subcodes. Following review of the first five transcripts, initial codes were compared to establish an integrated axial coding structure and to assess intercoder agreement. A consensus of 80% was not achieved, so all remaining interview transcripts were co-coded by both researchers. Codes were clustered into networks and overarching categories. This process continued until no new information could be gathered, and sufficient richness of data was achieved.

Themes were developed by combining categories, and were defined using a thick description technique. Exemplar quotations were selected to represent each theme. Following thorough examination, revision, reflection, and explication [91], resulting theme descriptions were shared with thirteen interested participants for their review and comment. Two participants responded and agreed with the themes presented, and they were highly enthusiastic about the qualitative findings.

Trauma through time.

Trauma and violence shadowed participants before, during, and after their time in foster care. Early adverse experiences were found to be an indicator of traumatic exposure encountered upon aging out and entering adulthood. The compounding effects of such deep and layered trauma served to shape participants’ future relationships, personal identities, and mental health: “I definitely hit some rough patches. I think leaving foster care, you’re left with many open wounds” (Participant 12).

Continued chaos.

Participant 11 likened youth-in-care to “feral children not being taken care of”. Throughout childhood and adolescence, participants were tasked with navigating and balancing complex relationships with both their biological and foster families. A general sense of precarity, detachment, and abandonment led many participants to feel alone and disenfranchised. While predominantly negative, foster care placements were extremely polarizing, varying from rehabilitative to abusive. Ever-changing caseworkers, foster parents, and circumstances supported a constant and chaotic state of flux, with 14 participants having had five or more foster care placements.

Searching for stability.

Participants represented diverse identities, communities, and lived experiences, yet shared a common ‘foster kid’ status. Participants spoke of social isolation during childhood, as well as divergent behaviors in response to stressors (e.g., defiance vs. perfectionism). Many felt that the nature of their foster care experience—that is, whether it was positive or negative—was “just a circumstantial roll of the dice” (Participant 11). A sense of transience and instability was described by all participants (n = 26), with most moving frequently from placement to placement. Understandably, they craved a sense of belonging and a place to call home. Marginalizing identities affected participants’ interactions with the foster care system, and were associated with experiences of racism, discrimination, and stigma.

Helpers and havens.

While navigating the foster care system, myriad supports and services were available to participants; however, many participants lacked access to, or even awareness of, such essential resources. caseworkers (typically social workers) had powerful influence over participants’ individual trajectories: “I think that your social worker plays a big part in your success” (Participant 2). Whether due to positive or negative experiences, caseworkers influenced the career and community engagement choices of participants; many of whom were inspired to work with foster children or those aging out. Feeling as though “the system is terribly failing” (Participant 15), systemic challenges and barriers have motivated participants to become involved in advocacy efforts, with respect to Canadian foster care reform: “I’m fighting for what we went through. I’m fighting for more help, more assistance, more resources” (Participant 12).

Aging Out and Adulting.

The process of aging out, and the coinciding transition to adulthood, felt like a “big looming thing that’s over your head” (Participant 25). Filled with much anticipation, uncertainty, and apprehension, all participants (n = 26) voiced a general lack of control during this time. Many also described a sense of instability, amid the absence of supportive relationships. Aging out marked an abrupt and dramatic shift in participants’ lives. Seemingly overnight, participants were granted independence, freedom, and autonomy. They were also entrusted with greater responsibility and were expected to make complex decisions without assistance. Most participants reflected upon the experience as a meaningful opportunity for personal growth and development, even if the process itself was negative: “this is … where your life starts” (Participant 21). While this transition marked an exciting new era, many “felt extremely ill-equipped” (Participant 8) when aging out of care. Participants were left to navigate the complexities of emerging adulthood with minimal guidance and assistance, and were often unaware of their rights and available benefits.

Among the many issues discussed during interviews, (1) housing, (2) life skills, and (3) mentorship were most commonly raised by participants, with many describing unstable housing and periods of homelessness following emancipation. Participants reported “couch-surfing”, relying on friends or temporary accommodations, or exhausting transitional-housing supports after eligibility expired. These experiences were attributed to insufficient financial assistance, limited affordable housing options, and systemic barriers that disproportionately affect former youth-in-care. Housing instability was often intertwined with poor mental health, employment insecurity, and disruptions to education. Lacking learned skills concomitant with the adult role, such as cooking and budgeting, participants also expressed a keen interest in acquiring diverse knowledge and expertise that would assist in everyday situations. Further, participants craved formal mentorship by trusted adult role models who could serve as both a guide and confidant as youth approached the point of aging out, and continuing post-transition. There were varying opinions on when youth should age out of care, with the “ideal age” ranging from 18 to 30. When asked, all but one participant (n = 25) felt that youth should age out later than is currently mandated in their jurisdiction (typically 18 or 19), or at least be given the option to do so.

Relationships and responsibilities.

Participants sought safe and supportive relationships at every stage of their development, but had greater choice and control over those connections after aging out of care. Many spoke of building their own network of “chosen family,” friends, partners, and even pets that served as a support system and safety net: “I created my own family [tree]” (Participant 24). For some, continued or cyclic involvement in harmful relationships stemmed from a fear of being alone. Unfortunately, experiences of abuse and abandonment were all too common among participants with partners, and particularly those with children. Of the seven interview participants who were parents, all wanted a good life for their children and families, and in many cases hoped to provide a better future than they, themselves were offered. Participants demonstrated persistence and adaptability as they learned to navigate relationship and parenting responsibilities.

Health challenges and changes.

Participants discussed how past experiences of trauma and violence, embedded within toxic environments, laid the groundwork for various health challenges. Self-identified mental health symptoms and formally diagnosed conditions were pervasive, with every participant sharing at least one psychological complaint. Among the many symptoms described, issues related to mood dysregulation, anxiety, relational attachment, and grief were most prevalent. Several participants also shared devastating previous experiences of self-harm, suicidal ideation, and attempts. Other common mental health challenges included developmental disabilities, disordered eating behaviors, substance use, and alcohol dependence. Nearly all participants expressed frustration regarding the accessibility of mental health care post-transition. Participants referenced the prohibitively high out-of-pocket costs, lengthy wait times for counselors and specialists, and the abrupt loss of pediatric care upon aging out and entering young adulthood. It was also felt that mental health practitioners were untrained, under supported, and ill-equipped to meet the needs of former youth-in-care. Participants sought intensive trauma-focused therapy that was specifically tailored to those with foster care system involvement. When asked about their mental health directly, participants reported that their overall mental health was better than they had experienced in the past; however, most also described some variability depending upon the circumstances or context: “mental health is like, like it’s peaks and valleys” (Participant 8). Physically, most participants were in good health, with many engaging in health promotive lifestyle behaviors as a form of adaptive coping. Unfortunately, many faced difficulties finding an appropriate and consistent primary care provider. Of those available, very few clinicians had any knowledge of the foster care experience, and often applied harmful stereotypes to the provider-client relationship.

Remarkable resilience.

Despite facing incredible adversity throughout childhood, adolescence, and emerging adulthood, all participants demonstrated characteristics consistent with resilience; although some far more than others. While a few participants struggled to cope with life’s challenges, most were able to ‘bounce back’ in response to negative experiences. Participants carefully considered past experiences and thought deeply about their personal identities, beliefs, and behaviors. By exploring the past, participants were better able to make sense of their current life circumstances, as well as future goals and dreams: “if it wasn’t for my experience, I wouldn’t be where I am right now” (Participant 12). Through such introspection and reflection, many participants achieved personal growth: the process of “becoming a warrior” (Participant 1). Participants also used a wide variety of coping strategies and self-care practices to support their overall wellbeing. Many expressed gratitude and satisfaction with respect to their current life circumstances, and above all else, were thankful for the person they had become (irrespective of the trauma they had endured): “I’m like comfortable with who I am. I know who I am … I’m just more sure of myself” (Participant 17). Participants thrived when they had adequate support. This required most to build connections proactively through self-advocacy. Recognizing that “a closed mouth doesn’t get fed” (Participant 5), participants often had to ask for help explicitly in order to meet basic needs. Along their personal journeys toward growth and healing, many participants sought to bring about change through advocacy and altruism. Specifically, participants devoted time and effort to supporting current and former youth-in-care to “be who you needed when you were younger” (Participant 22). Participants looked forward to the future and set meaningful goals for themselves: “I feel like I’m more empowered than I have ever been, and I’m excited finally to see where life’s gonna take me” (Participant 24).

Moving Onward and Upward.

Participants spoke of the future, including hopes for themselves, their families, and the foster care system at-large. Many felt that the system was changing for the better, and planned to draw upon their own experiences when “fighting the good fight” (Participant 20) and advocating for continued improvements. However, some worried that their changemaking efforts may have been hindered by a lack of power and resources. Most participants simply desired freedom, calm, and a better life than they had growing up. There was a resounding preference for a low-stress living environment, featuring a kind and supportive community: “I’ve had enough drama to last me a lifetime. I’ve had enough, you know, uncertainty to last me a lifetime. I don’t need to go find myself or explore or something like that. I just … wanna chill” (Participant 5). Many wished to own a home, pursue higher education, travel, and sought healthy relationships with people who truly cared. Career goals were often altruistic in nature, with many participants wanting to work with current or former youth-in-care in some capacity. However, some feared the potential for emotional burden and re-traumatization concomitant with such a role. In achieving greater independence and self-sufficiency, participants wished for transitional housing programs, robust financial supports, comprehensive life skills training, and professional mentorship.

Structural violence and mental health.

Experiences of structural violence—encountered before, during, and after foster care—were associated with greater mental health challenges. Evidence of early adversity and continued traumatic exposure was captured through survey results and personal narratives, with participants reporting the many ways in which trauma and violence manifested across the lifespan. Through chronic activation of the ‘fight or flight’ stress response system [101], the lasting effects of emotional hardship were felt throughout the mind and body, both immediately and over time [102]. Participants endorsed high rates of PTSD, anxiety, and depressive symptoms, among other physical and mental health challenges, with many classifying their illness experience as a disability that interfered with daily functioning. Despite such clinical complaints, participants developed myriad self-preservation and defensive strategies to preserve their safety and wellbeing.

Having been repeatedly let down, or even harmed, by a system designed to protect them, participants acquired a dual sense of distrust and determination that helped them navigate the transition to independence. Despite such learned resourcefulness, participants were reliant upon various social services to meet their most basic needs, including safe and affordable housing. An objective lack of instrumental support, combined with experiences of discrimination, perceived stress, and complex trauma histories, led many participants to seek mental health care services as a means of coping with their past and current circumstances.

Structural Violence and Positive Adaptation.

Interestingly, the relationship between lived experiences of structural violence (as indicated by ACE and InDI-D scores) and positive adaptation was mixed. Direct comparisons of participant profiles suggested that for some, higher levels of adverse childhood experiences and daily intersectional discrimination were associated with lower levels of positive adaptation, while for others, structural violence was positively correlated with resilience and flourishing. Interview dialogue supported such divergent findings, with participants describing how adversities have either thwarted their success, or—perhaps less obviously—have served as a powerful motivator in their pursuit of ‘overcoming’ life’s hardships.

Conversely, perceptions of structural violence (InDI-A and PSS) were inversely associated with positive adaptation, suggesting that higher levels of anticipated intersectional discrimination and perceived stress were associated with less resilience and flourishing. This may indicate that participants’ worldview was more influential in determining their post-care trajectory than objective experiences of structural violence. Indeed, the meaning participants ascribed to past and present circumstances may have played an important role in their ability to navigate life’s challenges and stressors.

Common attributes associated with positive adaptation included advocacy, altruism, and self-care. Participants desired to influence positive change within the foster care system, and devoted their time and expertise to its sociopolitical advancement. Several volunteered with local community organizations, sat on advisory boards, participated in peer mentorship programs, and were involved in legal activism and policymaking efforts. Demonstrating a commitment to ‘giving back’, many also sought out opportunities to serve youth-in-care through careers such as social work. Some even voiced an interest in working for the child welfare system or becoming foster parents themselves. This interest in ‘helping the person behind you’ is a common finding across child welfare literature [103].

While such activities were outwardly focused and philanthropic in nature, participants disclosed that they derived great benefit from helping others. Participants’ involvement provided an opportunity to translate first-hand knowledge and experience into action [104]. Further, their leadership and community engagement contributed to a sense of empowerment and fulfillment conducive to resilience and flourishing. Those who exhibited high levels of positive adaptation typically benefitted from a robust social support network made up of ‘chosen family’ and trusted allies. Participants who were highly adaptive also engaged in a variety of health promotive behaviors, including physical activity, restorative sleep, recreational activities, personal reflection, and self-advocacy, among others. Such strategies mirror recommendations for same-aged peers, and are not unique to former youth-in-care [105].

Mental Health and Positive Adaptation.

Participants who exhibited higher levels of positive adaptation had fewer mental health challenges. While directionality was unclear, correlations and regression analyses demonstrated the inextricable linkage between these two constructs. Personal narratives bolstered such findings, with those exhibiting higher levels of resilience and flourishing less likely to report current symptoms of PTSD, anxiety, or depression; a finding consistent across studies and populations [106,107]. However, existing positive adaptation characteristics were not an indicator of past mental health status. Many participants shared stories of psychological distress and instability during adolescence, sometimes escalating to self-harm or suicidal ideation.

Further, an absence or lack of PTSD, anxiety, or depressive symptoms did not necessarily correspond with participants’ current mental health status—not only because measures focused solely on very recent experiences (within the past week to month) and may not have been a true reflection of more generalized attitudes and beliefs, but also because mental health is multifaceted [108], and mood, quality of life, and daily functioning can be affected in ways that do not align with traditional assessment tools. Indeed, participants’ self-appraisal of their mental health status was often a closer reflection of their positive adaptation level than objective measures of symptomatology, as determined through case constructing (participant profiles).

Intersectional Identities.

Compounding intersectional identities influenced how participants interacted with services and supports. Participants’ unique attributes not only affected how they perceived other people, places, and systems, but also how they were treated by those in positions of social, economic, or informational power [50]. Indeed, access to resources and opportunities was often influenced by institutional gatekeepers, who must have possessed the requisite knowledge, skill, and motivation to take appropriate action. Far too often, participants ‘missed out’ because they were not made aware or because they were told ‘no’ by caseworkers, Foster parents, and others. Owing to their unique background, some participants faced additional barriers to their success. For example, those who were Black or Indigenous frequently spoke about the challenges associated with foster care placements that were not culturally congruent [109].

It is also important to recognize that while not all identities were externally visible, they may have still influenced participants’ connections with the world, by guiding their thoughts, feelings, and behaviors, or by influencing their sense of safety and comfort [110]. The act of trying to conceal one’s identity when accessing services and supports may have also been distressing. When developing Fig 5, intersectional identities was removed as a quantitative construct because it was linked to all nine themes and overwhelmed the table. Indeed, intersectional identities are omnipresent and influence all interactions [50].

Trauma History.

When completing the Adverse Childhood Experiences (ACE) questionnaire, respondents frequently responded affirmatively to questions about the loss of a parent, living with someone who was mentally ill, and verbal abuse by a parental figure. The mean ACE score was 3.73 (SD = 2.62) out of 10, enough to pose a significant threat to physical and mental wellbeing [111], but just below the high-risk threshold for toxic stress [112]. These questions closely aligned with the top three reasons participants were initially placed into care: abuse or neglect, exposure to domestic violence, and parental death or illness, and were supported by descriptions of trauma and violence that continued as they entered the foster care system.

Protective Factors.

Several factors were protective, facilitating positive adaptation and guarding against mental health challenges. Of the items on the Benevolent Childhood Experiences (BCE) checklist, having at least one safe caregiver, comforting beliefs, and opportunities to have a good time were the most commonly selected responses. The mean BCE score was 6.27 (SD = 2.46) out of a possible 10. This total falls slightly below the average for studies involving comparable young adult populations [113], indicating that former youth-in-care may possess fewer protective factors than their peers. While this modest difference suggests limited clinical significance, it may nonetheless indicate the presence of specific protective factors that warrant further exploration.

Perhaps most influential, caseworkers were cited as ‘making or breaking’ the foster care experience. A strong caseworker maintained a professional, yet therapeutic, relationship and offered knowledge about the foster care system, including available resources and opportunities. They possessed authentic interpersonal skills and genuinely cared about participants’ success. Similarly, good foster parents served as positive role models committed to guiding, teaching, and providing for their foster children. Those who gave emotional, informational, and instrumental support as participants aged out (e.g., apartment hunting) were particularly valued. Emotional support encompasses empathy, care, and belonging; informational support includes guidance and advice; and instrumental support refers to tangible aid such as housing or financial assistance [114]. Participants described significant deficits across all three domains, underscoring the importance of holistic support systems. These findings align with a growing body of evidence on the capacity of a single adult caregiver—who provides diverse and comprehensive support— to buffer the effects of childhood trauma and adversity [115].

Participants expressed tremendous gratitude for the opportunity to take part in recreational activities, such as team sports leagues or summer camp. Such experiences gave participants the chance to ‘just be kids,’ and briefly set aside the stressors and worries associated with life as youth-in-care. For many, these served as highlights of participants’ childhood and adolescence. Among those who chose to pursue higher education, financial aid and tuition assistance programs offered by the provincial/territorial government afforded some participants the opportunity to attend college or university at little to no cost [116]. This supported their growth and development with respect to social networking, knowledge generation, and exposure to diverse perspectives.

Transition to Independence.

When aging out, participants encountered many systemic challenges and barriers that negatively affected their transition to adulthood. This finding closely aligns with that of other studies involving this population [4]. Time and time again, participants spoke of frustrations related to housing insecurity, financial hardship, and a lack of adult mentorship. Specifically, the pipeline from foster care to homelessness [117] was discussed at length. Without safe and affordable housing, several participants became street-involved, with others resorting to couch surfing or renting tiny, unkempt apartments in dangerous neighborhoods. While this was certainly a problem in its own right, poor (or absent) housing conditions were also credited with jeopardizing the most basic of needs, such as nutrition and hygiene, which in turn may have compromised other important dimensions of daily living, including education, employment, and personal relationships. Housing insecurity also promoted access to unsafe and illicit activities, including substance use and street crime. Indeed, interviews featured conversations about overdose, sexual assault, theft, and gun violence. Such findings lend support for a ‘housing first’ philosophy, which views housing as a pre-requisite for life improvement [118].

Financial strain served to restrict participants’ choices and freedoms. A modest living stipend seldom covered much beyond the cost of basic necessities, leaving participants to actively seek out additional sources of income. For some, this meant having to choose between education and full-time employment, while others worked tirelessly to strike a balance between both priorities. By contrast, same-aged peers from more ‘traditional’ households often received financial support that allowed them to focus solely on their studies and engage in opportunities for self-exploration, including participation in extracurricular activities and independent ventures such as travel. Participants also desired mentorship and guidance from a trusted adult role model, as well as basic life skills preparation. Many lacked confidence in basic activities associated with adulthood and independent living, such as cooking, budgeting, and home maintenance. Despite mandatory financial literacy classes offered in some jurisdictions, participants felt ill-prepared to manage their finances self-sufficiently.

Participants offered several systems-level recommendations that addressed the abovementioned barriers and facilitators to their wellbeing. They wanted individualized transition plans based on their unique strengths and needs, rather than a generic checklist. Another common request was for earlier and more robust preparation for the aging out process, encompassing close collaboration with a caseworker, practical transition assistance and life skills training (e.g., securing housing, establishing a personal budget, applying for post-secondary school), as well as activities to support emotional readiness. Many advocated for transitional housing specifically, identifying homelessness and housing instability as one of the most critical issues facing youth upon aging out of care [119]. For most, exiting the foster care system and entering emerging adulthood rendered participants ineligible for established pediatric supports. The continued provision or coverage of important and widely accessed services, such as dental care or therapeutic counselling, was also recommended. It should be noted that in recent years, some jurisdictions have made strides toward more comprehensive after-care benefits programs [120].

Mental health recommendations.

Participants were very appreciative of the system-specific mental health services they received while in foster care. Unfortunately, these were often not made known or available to all youth-in-care; rather, they were offered to the ‘most serious’ cases, such as those who had experienced psychosis or attempted suicide. Among participants who did receive such care, many wished that it would continue beyond the point of aging out—particularly with respect to prescribing and counseling services. Instead, services were typically discontinued abruptly without transition planning or a formal referral process. Further, former youth-in-care often fell to the bottom of wait lists for adult mental health services following their 18^th or 19^th birthday. During interviews, participants discussed a variety of barriers that interfered with their efforts to obtain psychological support as an adult, including prohibitive out-of-pocket costs, lengthy wait times, and inconsistent providers even when the need for care was urgent.

Many also had difficulty finding a provider who was the right ‘fit.’ Participants listed empathy, active listening, compassion, and lived experience as a foster child as desirable qualities that might improve their overall mental health care experience. Participants also recommended that psychiatrists, therapists, and others should receive dedicated training that addresses some of the unique strengths (e.g., courage, resourcefulness, self-advocacy), challenges (e.g., limited guidance and financial resources), and mental health needs (e.g., trauma- and violence-informed counselling) of former youth-in-care. It was felt that such education may also help to reduce healthcare provider stigma toward the ‘foster kid’ identity label. Participants desired intensive trauma- and violence-informed (TVI) therapy that focused on deep-seeded trauma, not just superficial or transient issues. Additionally, participants looked for providers who were skilled prescribers, as many experienced challenges related to medication use, such as finding the right formulation or guarding against substance use/addiction. For those who received inpatient psychiatric services, negative interactions with officers in uniform, such as police or security personnel, during the management of high-risk incidents were often reported. Participants recommended that officers be dressed in street clothing when present in mental health care settings to prevent re-traumatization.

Research and Scholarship.

The exploratory nature of this study facilitated the dissemination of novel findings and insights, and served to assess feasibility with respect to recruitment strategies, procedural safeguards, and virtual data collection methods. With scant descriptive data pertaining to Canada’s current or former youth-in-care, our success regarding cross-country recruitment validates the need and feasibility for large scale, nationally representative data collection efforts that reflect the diversity and experiences of Canadian emerging adults aging out of foster care. Grounded within an emancipatory paradigm, and theory-driven conceptual framework, the study design and findings may also encourage the adoption of equity- and justice-oriented research approaches that promote participant empowerment. Knowledge mobilization strategies that incorporate participant perspectives and leverage existing advocacy efforts may facilitate awareness and understanding of key study findings among current and former youth-in-care and their allies, as well as those in positions of power and influence. Future research may more wholly integrate participatory and community-engaged methods.

Based on study findings, we recommend further investigation regarding mental health care service delivery gaps encountered upon aging out of care, and research that focuses specifically on the unique experiences and needs of former youth-in-care with a second marginalizing identity (e.g., Indigenous, LGBTQ + , disability). Studies that explore the research problem from alternative viewpoints—by describing the perspectives of caseworkers, foster parents, or healthcare providers, for example—may help to provide a more comprehensive understanding of the challenges faced by this population, and additional opportunities for action. Greater exploration of protective factors may also support the development of health-promotive interventions. Striking qualitative findings suggest the need for quantitative analysis involving the examination of individual items contained within the Benevolent Childhood Experiences (BCEs) questionnaire, which closely aligned with participants’ interview responses. Issues such as the presence of a safe caregiver and opportunities to have fun may serve as the basis for further study.

Health and Social Policy.

Study findings have the potential to inform upstream policies and procedures that address sources of structural violence, as opposed to reactive approaches that target its negative consequences. Evidence of varied participant transition experiences and trajectories lends credibility to the growing national push for flexible emancipation policies that are based on ‘readiness,’ rather than chronological age. Building off the sample diversity achieved in this study, continued efforts to recruit participants from across Canada may illuminate legislative differences by jurisdiction, thus highlighting regional strengths and shortcomings, and encouraging the cross pollination of innovative ideas.

Participants voiced an interest in policies that would support expanded access to mental health care upon aging out. Dedicated mental health providers assigned to former youth-in-care transitioning to independence would help to alleviate some of the fears and anxieties that accompany emancipation. Full coverage for psychiatric and counselling services would also lessen the financial burden that is a barrier to both preventative and rehabilitative mental health care. Many participants also commented on the enormity of their caseworkers’ caseloads, making it challenging for them to devote the necessary time, energy, and attention to each foster child on their roster. This was particularly problematic for youth actively preparing to age out of care, as they required individualized administrative support. Policies that cap caseloads and stipulate target client ratios may reduce caseworker fatigue and burnout, and encourage more helpful and supportive relationships.

Transitional housing was raised time and time again as an innovative solution to housing insecurity and homelessness among former youth-in-care. While the provision of free or subsidized physical accommodations would undoubtedly be ideal, policies that mandate child welfare agencies to seek out, secure, and approve housing options for youth aging out would help to reduce stress and enhance their health and safety. Other youth-championed policy recommendations that should be considered include consistently placing family members (particularly siblings) together, offering a tuition waiver for post-secondary education, and implementing mandatory life skills training with measurable objectives for foster children and their foster parents. While certain provinces/territories may have versions of these policies, they have not been implemented in most jurisdictions nationally.

Clinical Practice.

Findings illuminated unique challenges and stressors faced by this population when transitioning to independence, as well as common characteristics and circumstances associated with positive adaptation. Such evidence may support the development and testing of tailored TVI mental health care interventions for youth aging out of care, and contribute to greater clinical awareness of their unique mental and physical health needs. Lessons learned may extend beyond the foster care domain, highlighting important care considerations for other ‘high risk’ groups of youth (e.g., Indigenous, justice-involved, or unhoused).

Findings from this study suggest that the health care system is mostly ill-equipped to meet the physical and mental health needs of former youth-in-care. Participants desired health professionals, who were knowledgeable about the child welfare system. Unfortunately, most participants had grown accustomed to educating their clinicians about foster care, and often had to deal with harmful stereotypes and stigmatizing language. A mandatory online interdisciplinary clinical education module could improve understanding of the foster care system and the unique challenges faced by former youth-in-care, and may also enhance empathy toward such patients. Participants also shared that their foster parents were woefully unprepared to support them through mental health challenges and crises. Given the high prevalence of mental illness among foster youth [121], participants recommended that foster parents be required to complete comprehensive mental health training as part of their onboarding.

Qualitative interviews revealed an overwhelming commitment to advocacy and altruism as forms of positive adaptation. Participants were eager to ‘give back’ to current or former youth-in-care by offering their knowledge, experience, and support as professionals (e.g., social workers), volunteers, or potential foster parents. This dedication to bettering the foster care system and its youth can be channeled into robust clinical interventions that draw on community engagement and service to others (e.g., peer mentorship) to enhance mutual wellbeing. Such strategies have been shown to improve mental and physical health and longevity in a variety of populations [122].