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UCPN0146-08621521-043XIssues in Comprehensive Pediatric Nursing, Vol. 32, No. 2, April 2009: pp. 1–21Issues in Comprehensive Pediatric Nursing

FROM HOMELESS TO HOPELESS AND HEALTHLESS?: THE HEALTH IMPACTS OF HOUSING CHALLENGES AMONG FORMER FOSTER CARE YOUTH TRANSITIONING TO ADULTHOOD IN CALIFORNIA

Housing and Health Among Former Foster YouthI.H. Yen et al. Irene H. Yen, PhD

Department of Medicine, University of California, San Francisco, California, USA

Wizdom Powell Hammond, PhD

School of Public Health, University of North Carolina, Chapel Hill, North Carolina, USA

Margot B. Kushel, MD

Division of General Internal Medicine, University of California, San Francisco/San Francisco General Hospital, California, USA

A childhood history of placement in the foster care system makes the emerging adult period more complicated and problematic in a variety of ways including meeting basic needs, such as housing and health. We conducted focus groups with 31 former foster youth in San Francisco and Oakland, California to explore their housing and health care circum- stances since “aging out” of the foster care system. Five key themes were identified: 1) housing circumstances have direct and indirect impacts on access to health care; 2) housing instability can impede the flow of infor- mation between social services staff and youth; 3) housing circumstances and health care differed for men and women; 4) service agency rules and structures may be developmentally mismatched with participant needs; and 5) emerging adults experience repercussions of institutional life including the suspicion of authority and mistrust of medical providers.

Received 26 October 2008; accepted 9 January 2009. Address correspondence to Irene H. Yen, Division of General Internal Medicine, Department of Medi-

cine, University of California, 3333 California Street, Suite 335, Box 0856, San Francisco, CA 94143-0856.

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Keywords: Healthcare access, Homeless, Youth, Fosterare

INTRODUCTION

There has been a crisis in foster care in recent decades, with caseloads more than doubling between 1985 and 1999, as a likely result of changes in criminal justice policy (e.g., three strike laws) (Swann & Sylvester, 2006). Currently, there are approximately 500,000 foster youth in the U.S. and approximately 90,000 (18%) of these youth live in California (Adoption and Foster Care Analysis and Reporting, 2004). Every year, 20,000 youth leave the foster care system nationwide without reuniting with their families of origin because they become legal adults. This transi- tion is also referred to as “aging out.” In 1999, Congress passed the Foster Care Independence Act (FCIA), requiring states to extend social services to former foster youth until the age of 21 (Fernandes, 2008). Note that FCIA does not provide specific entitlements or funding for these services but rather requires that there be services in place which can serve this population. As a result of the FCIA, some ties to the social welfare system may remain, though the extent of support varies from state to state.

The struggle to establish stability after separation from the foster care system compounds other instabilities of this developmental transition that occurs in any young person’s life. Meeting basic needs, such as housing, can be challenging. Having a history of being in foster care as a child is an important risk factor for adult homelessness (Bassuk et al., 1997; Herman, Susser, Struening, & Link, 1997; Morrell-Bellai, Goering, & Boydell, 2000; Roman & Wolfe, 1995; Stein, Leslie, & Nyamathi, 2002), which is known to be associated with poor physical and mental health (Barrow, Herman, Cordova, & Struening, 1999; Hwang, 2000; M. B. Kushel, Perry, Bangsberg, Clark, & Moss, 2002).Cognizant of the connections between a history of involvement in the foster care system and homelessness, housing instability and homelessness, and homelessness and poor health, this project sought to uncover linkages between housing instability and health among former foster youth. In the following discussion, the concept of housing will instability be defined, the concept of “emerging adulthood” will be used to frame the transition period for former foster youth, and what is known about former foster youth, housing, and health will be discussed.

Housing Instability

While outright homelessness is a serious problem for youth who have aged out of the foster care system, housing instability is more prevalent (Courtney, Piliavin, Grogan-Kaylor, & Nesmith, 2001; Fowler, Toro, Tompsett, & Hobden, 2006). Housing instability has various definitions.

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The most common are having difficulty paying rent, spending more than 50% of household income on housing (The Urban Institute, 2002), moving frequently, living in crowded conditions, or “doubling up” with friends or relatives (Appleby & Desai, 1987; Bassuk et al., 1996; Duchon, Weitzman, & Shinn, 1999). The health implications of housing instability among former foster youth are less well understood. Therefore, the inves- tigators studied housing and health circumstances of former foster youth during the years after leaving the foster care system.

Emerging Adulthood

The “aging out” period occurs between the ages of 18 and 25. This life phase, in industrialized societies, has been deemed a period of “emerging adulthood,” a time when people do not see themselves as fully adult. When a nationally representative U.S. sample was asked, “Do you feel you have reached adulthood?”, more than 60% of 18–25-year-old respondents said, “in some respects yes and in some respects, not yet” (Arnett, 2000, 2001). Cohen and colleagues describe this period as a time when people “have left the dependency of childhood and adolescence but have not yet assumed the enduring responsibilities that are normative in adulthood”(Cohen, Kasen, Chen, Hartmark, & Gordon, 2003). Emerging adulthood is a period of transition and fluidity. For example, residential instability is a common experience during the emerging adult period (Arnett, 2000). Emerging adults tend to go back and forth from home to school living settings or other more independent living circumstances (Goldscheider & Goldscheider, 1994). Commonly, they move away and then move back into their parents’ home, and then out again at least once during their late teens and twenties (Boyd & Norris, 2000; Goldscheider & Goldscheider, 1994; Mitchell, 2005).

Former Foster Youth, Housing, and Health

Former foster youth who are emerging adults often do not have tradi- tional families or parental figures to turn to for material or emotional support. To the extent that data are available, the older the person when they enter foster care, the more likely they are to age out of the system rather than reunify with the traditional families (Fernandes, 2008). When they do not reunify they also are less likely to have the ties to receive material or financial assistance from their traditional family (Fernandes, 2008). If they do reunify, the family relationships are often strained (Courtney & Hughes Heuring, 2005). As a consequence, transi- tioning foster youth have to negotiate housing, education, work, and social services on their own or with the aid of agency staff (Courtney & Hughes Heuring, 2005).

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Since there is no national database on foster care, data on foster chil- dren are not standardized, making tracking of youth after they age out particularly problematic (Swann & Sylvester, 2006). In a recent report to Congress regarding transitioning foster youth, Fernandes wrote, “Research on the transition for former foster youth is limited and most of the studies on outcomes for these youth face methodological challenges— they tend to be dated; include brief follow-up periods (e.g., no more than a year after exit from care); have low response rates, non-representative samples, and small sample sizes; and do not follow youth prior to exit from foster care” (Fernandes, 2008). There are at least two large-scale studies that have focused on former foster youth whose findings should be highlighted: The Midwest Evaluation of Adult Functioning of Former Foster Youth (Midwest Study) and the Casey Family Programs National Alumni Study. The Midwest Study is a longitudinal study of foster youth as they age out of the child welfare system and transition to adulthood in three midwestern states (Illinois, Iowa, and Wisconsin) (Courtney et al., 2005). Casey Family Programs, a non-governmental organization, was established in 1966 to serve children for whom adoption and family reuni- fication were not viable alternatives. In 2003, Casey conducted a study using interviews and data collecting from case records of over 1,000 of its program alumni to investigate how the youth who went through their program were faring as adults (Pecora et al., 2003). Records of the Casey alumni indicated that 20% of the alumni were homeless for one or more nights within a year after leaving foster care (Pecora et al., 2003). Similarly, the Midwest Study reported that, for youth at age 21, 18% had been homeless at least once (Courtney et al., 2007).

One analysis of the Midwest Study data examined how housing instability (e.g., high-cost housing, frequent moves) might be associated with health care utilization and health status (M. K. Kushel, Yen, Gee, & Courtney, 2007). Unstable housing was not associated with reduced ambulatory care utilization and access, however homelessness was. Being in the system (as compared to having aged out) was associated with better access to health care during the three-year period studied. However, because transitioning adults in Illinois do not have to age out until they are 21, the Midwest Study sample included 19-year-olds who had aged out (in Iowa and Wisconsin) and 19-year-olds who were still in foster care (in Illinois). The different policies for aging out in these three states suggest that investigating the housing–health circumstances for former foster youth in other states would be useful. For example, in California, where 20% of the country’s foster youth live, most foster care system benefits run out at age 18 (advocates are investigating extending benefits to age 19).

In order to explore the nature of the connections between housing circumstances and health care experiences in other locations where foster

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youth demographic characteristics and social policies differ, focus groups were conducted with former foster youth in San Francisco and Oakland, California. The study aims were to learn about the dynamic relation between housing and health care access during the five-year period after foster youth leave the foster care system. A key question guiding this inves- tigation is “Are youth choosing housing over health care or vice versa; are they a competition of priorities or are they compounding pressures?”

The investigators chose a qualitative approach for its capacity to gener- ate hypotheses and to access ranges of experiences. Focus groups were conducted because of the noted cost effectiveness and utility for exploring shared experiences (Morgan & Kreuger, 1993).

METHODS

From January to June 2006, five focus groups were conducted with former foster youth in San Francisco and Oakland, California. The groups were held at community organization offices and at a university. At the conclusion of each focus group, participants were asked to complete the brief survey that included questions about housing circumstances, per- ceived health status, and demographic characteristics. Study procedures were approved by the University of California, San Francisco (UCSF) Institutional Review Board.

Subject Recruitment

We recruited participants with the help of community organizations that provide services to foster youth and former foster youth. People were eligible if they had been in the foster care system, were emancipated or aged out, and between the ages of 18 and 24. [Note: while the research on emerging adulthood typically uses the range of ages 18 to 25 for this developmental period, we chose the range of 18 to 24 for our recruitment efforts because of eligibility criteria for certain programs. At age 25, medical coverage changes for this population in this region.]

Topics

We prepared an interview outline that included questions about housing circumstances, housing expenses, doctors’ visits, dentists’ visits, hospital- izations, and access to medications. Topics were included based on literature (Courtney et al., 2005; English, Morreale, & Larsen, 2003; M. K. Kushel et al., 2007; Pecora et al., 2003), and discussions with policy advocates and program staff. Examples of questions included: 1) Please describe where you are currently living; what is one thing you particularly like about your

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living situation? What is one thing you do not like about your living situa- tion? 2) When was the last time you had a doctor’s appointment? Did you go to see someone you had seen before?

Procedure

All focus groups were held at 5 pm, at the recommendation of program staff. Dinner was provided. Participants arrived and ate dinner. One of the authors (IHY) facilitated each group. When the formal group began, the facilitator introduced herself and the purpose of the group. The first question was an icebreaker to give people an opportunity to learn some- thing about each other, and the second question inquired about the partic- ipants’ housing and health care circumstances since leaving foster care. The topics were raised in the same order for each group. After two groups, when some common themes seemed to be emerging, questions about impressions of these themes were raised at subsequent groups. After the focus group discussion, we asked participants to fill in a brief survey with questions about demographics, housing circumstances, and perceived health status.

Focus group discussions were audiotaped and transcribed word-for-word by a professional service. Transcript content was checked by the tran- scription service against tapes for quality control.

Analysis

Two of the authors (IHY and WPH) analyzed transcripts by systematically coding text, guided by the interview topics, as well as themes that emerged from the data (Strauss & Corbin, 1990, 1994). Each author coded the transcripts independently and then met to discuss coding and resolve dif- ferences. Consistent with qualitative methodology (Patton, 1990; Strauss & Corbin, 1990), these authors applied an open coding procedure accompa- nied by analytic memos to document phenomenological details of the participant narratives. These analytic memos were then used to develop thematic categories which were organized into a preliminary codebook. Internal validity was established by discussing preliminary findings with service providers, and policy advocacy staff. In addition, the emerging key themes were raised during the final focus group in order to verify their reflection of the circumstances these emerging adults experience.

Two coders finalized the coding scheme and carried out the final descriptive analysis. All of the data was coded by hand. A word processing program was used to organize the codes, copy excerpts from transcripts, and record memos. Beyond these uses for computer software, we elected not to use software to aid in the analysis of the data (Weitzman, 2000).

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RESULTS

We held five groups totaling 31 participants including 19 women (61%) between the ages of 18 and 23 [see Table 1]. Four of the 19 female partici- pants had a child, and one was pregnant. Among the 31 participants, 19 (61%) identified as African American; 23% as mixed; 10% as Latino, and 3% Asian. (Point-in-time figures for July 1, 2005 show that 68% of foster youth were African American in the two counties where we held focus groups) (Needell et al., 2007). Based on the responses to the brief survey, about one-quarter of the participants (25.8%) were living with family or relatives, one-quarter (22.6%) were renting together with friends or on their own, one-quarter (22.6%) were living under the auspices of some sort of housing program (i.e., Section 8 housing, transitional housing, rent-subsidized housing, or treatment program), 16.1% were staying in dorms, and 12.9% were staying with friends and not paying rent. Other than the college students, only one participant was mostly satisfied with his/her living circumstances. Everyone else wanted more space, privacy, or a better neighborhood. Regardless of the level of satisfaction, only one person was living in a long-term stable housing situation (in this case, with a Section 8 voucher).

Almost one-half (45%) of the participants said they were in excellent health; 13% said they were in fair or poor health. As a comparison to the overall California data for the same age group, in the 2005 California Behavioral Risk Factor Surveillance Survey, 9% (95% confidence interval

Table 1. Characteristics of focus group participants

Characteristic n (%)

Sex Men 12 (39%) Women 19 (61%)

Age in years 18 10 (32%) 19 9 (29%) 20 5 (16%) 21 2 (6%) 22 3 (10%) 23 2 (6%)

Race/Ethnicity African American 19 (61%) Latino 3 (10%) Asian 1 (3%) Mixed 7 (23%)

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4.6–14.2%) of 18–24-year-olds reported fair or poor health (National Center for Chronic Disease Prevention and Health Promotion, 2005).

Based on the analytic process described above, we identified five key themes: 1) housing circumstances have direct and indirect impacts on access to health care; 2) housing instability can impede the flow of information between social services staff and youth; 3) housing circumstances and health care differed for men and women; 4) service agency rules and structures may be developmental mismatched with participant needs; and 5) emerging adults experience repercussions of institutional life including the suspicion of authority and mistrust of medical providers.

Housing Circumstances have Direct and Indirect Impacts on Access to Health Care

Participants described experiences that drew direct and indirect connec- tions between their housing circumstances and health care access. Direct connections were primarily about the lack of proximity to health care providers, particularly providers that accepted Medi-Cal (California’s version of Medicaid) and the disruptions to continuity of care due to moving. For example, one female participant described a problem accessing care due to her housing being in Vallejo, a city about 35 miles northeast of San Francisco, but her Medi-Cal coverage being in San Francisco because she was a San Francisco foster youth.1 In addition, the bureaucratic hassle seems to have frustrated her motivation to find health care providers. Because it was so much to work through before, finding a health care provider was set aside due to limited energy to negotiate matters.

So Vallejo, out there, they would be like, “Wait a minute. You’re supposed to be going to see the doctor in San Francisco.” And I would call San Francisco, and they say “No, you can use your Medi-Cal anywhere.” But it was like. . . I had to go through so much—I had to call Sacramento, I had to call Medi-Cal, I had to do it all . . . . And I would call her [her social worker], she was usually not home. . . . And so now that I’m eighteen, I’m kind of like. . . I know I need to go get a doctor’s appointment, but. . . I don’t feel like goin’ through all that again.

Another female participant had a similar problem accessing dental services.

1 Due to a limited number of foster homes and group homes, San Francisco places about half of its foster youth in homes outside of the county.

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I have. . . three out of four of my wisdom teeth came in? And one of ’em was botherin’ me, so I had it removed? And. . . there’s only one doctor I could go to, to get all of ’em done, even the one that hasn’t come in, and he’s in Oakland, and I live in Hayward (about 15 miles from Oakland), and he has like, a really long wait list. And so I haven’t. . . even thought about it.

Regular dental checkups were an even lower priority than medical checkups. Several participants mentioned a large store-front dental business as being the only option (and a last resort) for those who lacked insurance.

Indirect connections involved financial strains and the demands of daily living that shifted the emerging adults’ focus away from their own needs to the needs of others. This was the case with one male participant who had been cared for by his grandmother.

When I was at home, I was basically just helpin’ my grandmother, and— it was school, applications, college applications, scholarship meetings, and. . . homework, basically. It was no time for goin’ to the dentist, or. . . doin’ that.

Another male participant simply had no time for health care:

It’s not that easy livin’ by yourself. There’s a lotta, a lotta, a lotta responsi- bilities that I need to do? And there’s—like, you need to pay bills every month, and. . . I need to pay for transportation, I need to commute every morning, and that was the most hard part. And—after our commute to my high school, at the end of the high school, I have to go to work. And . . . by the time I get home it’s already 8:00, and I won’t have enough time to do my homework, and the next day, you know, just repeating, and just, you know, have different meetings with you know, therapists, and . . . and the ILSP class? So it was just—my schedule was just hectic.2

Likewise, a female participant described having a scheduled medical appointment, but not being able to go because she started a new job and could not take unpaid time off from work.

In some cases, the demands were related to their housing situation. As mentioned above, about one-quarter of the participants was receiv- ing assistance through some sort of transitional housing program for former foster youth. These programs had requirements as well as rules

2 Independent Living Services Program, which teaches foster youth life skills in preparation for aging out of foster care.

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and regulations which could change at any time. Fulfilling these obliga- tions and keeping up with the changes leaves less time and energy for other activities, including regular health care. As one female participant noted:

They stay like—like in the beginnin’ when we first came to the program, they set us up a certain way? And then when we got in they sent us a letter, and they CHANGED everything without even talkin’ to us, and it’s like, how do you expect for us to function on somethin’, when you keep changin’ what’s goin’ on? . . . . It’s like, we can’t never really just like, keep up.

Housing Instability Impedes the Flow of Information Between Social Services Staff and Youth

Social service staff serves as a bridge between housing and health. Unstable housing circumstances can affect the flow of health relevant information between social services staff and former foster care youth. All of the study participants had caseworkers while they were in foster care and knew that those caseworkers had information about services they needed. Some had ties to “after care” workers whose role was to help them access services after aging out. Despite these relationships, several participants mentioned frustrated attempts to get information from or access to services through case workers, such as multiple unanswered phone calls or trying to get on waiting lists for housing programs but not knowing the eligibility require- ments. The situation was often exacerbated by living somewhere with no phone line or not having a working cell phone.

One male participant noted the connection between information and health care benefits:

I think that. . . the, just the lack of information is what keeps certain people. . . from getting that type of. . . benefits—medical coverage, . . . like they were saying, . . . A person needs connections to know about these programs.

Another male participant talked about the emotional impact of not knowing where to go for help.

Cause you know, . . . people find out at the last minute, you know (others agree). . . to get help. And when they get to, to the last minute, the help, . . . it basically dramatize they life. They don’t know what else to do. . . and. . . they just break down, because they don’t know what else to do. I mean. . . they’re hopeless, helpless, everything.”

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To which a female participant in the group added: “Then they become HOME-less!” When asked about how programs and policies could be improved, participants emphasized the need for dissemination of information about services and responsiveness of case workers and other agency staff.

Housing Circumstances and Health Care Differed for Men and Women

Gender can influence housing circumstances. Because female participants with children could be assigned to studio apartments without a roommate in transitional housing programs, they were more likely to have stable housing than males. Male participants who were fathers rarely lived with their children and were assigned to shared living quarters with other single men. Wanting to have one’s own place and privacy was a commonly expressed desire.

Gender also played an important role in access to and frequency of contact with health care providers. Women would have regular contact for contraception and pregnancy-associated care and, if they had a child, for immunizations or well-child checks. Men, on the other hand, did not have healthcare contact unless they were injured or had a severe infection. One man talked about getting treatment for a fracture; another man talked about being injured in an assault. A third man had a high fever for five days and eventually went to the emergency room for treatment. Otherwise, the men did not schedule regular checkups nor did they mention that it was something they wanted to do or felt was important to do.

The existence of these gender differences suggests a need to increase opportunities for male former foster youth in California to access care, including preventive screenings for chronic conditions such as hyperten- sion or diabetes or for advice about substance use, smoking cessation, or risky sexual practices.

Service Agency Rules and Structures may be Developmentally Mismatched with Participant Needs

Emerging adulthood is a time when individuals are trying on adult roles, becoming more independent, and staking out their own space. However, agencies have to monitor the recipients of public dollars for accountabil- ity to tax payers, creating a tension when the recipients resist and resent the surveillance and oversight. Focus group participants in transitional housing or treatment programs described their programs’ requirements and rules as overly paternalistic and expressed a desire for more autonomy. For example, participants talked about having to show receipts and having their apartments regularly inspected for cleanliness.

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They just, you know, wanted us to do it like that, or whatever. And then . . . the PG&E [local utility company], they want us to show bills on that, they want us to show bill that we pay telephones . . .

They just inspect your house, and look if it’s clean or not. She don’t do nothin’ but look. . . Once a week, yeah. Every week.

Every two weeks they look, though. But she comes every week. . . . They come see us every week. But every other week, they come and inspect our house.

It was clear from the participants that these inspections added to their already overburdened schedules, which shifted their attention further away from their health needs. Another participant described her choice to find a place to rent unattached to a program in order to avoid the scrutiny and rules.

I think that if you put someone in a program, and you have all of these rules and demands, then it makes it harder for the individual to. . . I don’t want to say “succeed,” but it makes it harder for the individual to complete the program or go through the program, or to make any progress, as opposed to them getting their own place, . . . because there’s just so much you have to do. It’s like, a whole list of things you have to do, and you’re only limited to. . . how much you CAN do.

Participants also gave examples of coping strategies to give the appear- ance of adherence in order to get by when the rules impeded them (e.g., presenting a false receipt for child care to a case worker because they were not paying for child care but rather had bartered for it).

These participants also expressed anxiety about losing access to ser- vices once they reached a certain age. In California, emerging adults may receive Medi-Cal until they are 21 if they have a history in the child welfare system or if they had been covered by Medi-Cal as children. This leaves many former foster youth without access to health care at age 22. One participant commented:

My Medi-Cal runs out, once I hit 21. And I’m s’posed to be lucky,’cause that just got extended from 18 to 21. But it’s not good enough (chuckles).

During the emerging adulthood period, individuals often want to stake out their own space by keeping parents out of their rooms, for example. Former foster youth who are receiving government services may be subject to scrutiny and monitoring that is at odds with this developmental phase.

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Emerging Adults Experience Repercussions of Institutional Life Including the Suspicion of Authority and Mistrust of Medical Providers

Being in the foster system, by definition, means the state is the parent, thus the participants had extensive experience with institutions. Diffi- culties in securing housing (e.g., multiple calls to social workers or housing offices to check on waitlist status) or adapting to housing- related policies breed distrust or dissatisfaction with other institutional agencies.

Dissatisfaction and accompanying mistrust of institutions and service providers affected how participants interacted with the medical care system. A few participants mentioned that they suffered from a chronic condition (e.g., migraines, stomach pains, and seizures) and were frustrated about the care they have received. In one case, a woman wanted more tests for her migraines, but doctors thought the tests were not necessary:

You know what? I’ve had that thing for about four years. I’ve been askin’ for a CAT scan. . . for my migraines. And I’m like. . . “You know what? I’ve had ’em. I’ve had ’em since I was. . . earliest memory? Sixth grade. Probably before that. ’Cause my mom remembers me saying my head hurt when I was little, stuff like that. But they won’t do it. They said “Oh no, it’s common,” and stuff like that, and I’m like, “Well, if there’s something really wrong with me, somebody’s gonna be in big trouble,” because I’m askin’ for a CAT scan, or SOMETHIN’. . . .

Another participant with chronic stomach pains concluded that her medical coverage made her a second-class patient:

And I think they do that because of. . . your medical coverage level. If you’re on Medi-Cal, then they treat you as if, “Oh, you’re not really impor- tant.” But if you’re paying for it yourself, just—I guess they’ll treat you like royalty, and do whatever they can to . . . But if it’s like you’re, the regular class, then they treat it as if, “Oh, it’s just nothing.” And I think that’s WHY. . . they would make those excuses, or. . . make up the, a. . . what do you call it? A fake diagnosis when it’s really not the case?

Participants experience the monitoring and surveillance described in the prior section as distrust by the agencies. As a result, they respond with similar feelings of distrust for the agencies and their staff, other institutions and services providers, including health care providers.

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DISCUSSION

The relationship between housing and health has been established in the literature (Saegert, Klitzman, Freudenberg, Cooperman-Mroczek, & Nassar, 2003; Sampson, 1990). Our focus groups with former foster youth further document the nature and context of the connections between housing and health, both directly and indirectly. Because of their unusual circum- stances (i.e., a history in the foster care system) and their ongoing connec- tion to social service agencies, these connections are noteworthy and can inform policy and practice. Recognizing the developmental phase of these youth can help policy makers.

Just as this period of emerging adulthood is neither adolescence nor adulthood, there is an analogous “neither pediatric or adult” in medical practice. The medical community has observed that 18–25-year-olds often do not have an access to practitioners where their special circumstances are taken into consideration (Park, Paul Mulye, Adams, Brindis, & Irwin, 2006). While adolescent medicine is a subspecialty of pediatrics or internal medicine with a focus on youth and emerging adults, ages 12–25, many medical professionals recognize a significant gap in staffing for this subspe- cialty such that transitioning adults may receive care from an internal medi- cine or family medicine practitioner without training in adolescent medicine (Althouse & Stockman, 2007; Djuricich, 2002). This highlights the complexity of these years for emerging adults regardless of their foster care system history or other vulnerabilities.

Focus groups have some important limitations. We talked with a relatively small number of people and cannot claim that they represent the entire popu- lation of former foster youth in the San Francisco Area, not to mention the state of California. Since former foster youth have fewer social and material resources than other emerging adults, those who did participate perhaps were those with more social resources. We recruited participants by distributing flyers to social service agencies and by mailing information to former foster youth through the Independent Living Skills Program. Since we did recruit through agencies, it is also likely that we did not reach “successful” graduates of the foster youth program, particularly those well-adjusted transitioning adults with resources. However, some participants did mention stories of friends or acquaintances who were not doing as well as they were. In addi- tion, focus-group participants may be influenced by group-think processes (Sim, 1998). Emerging adults may be more developmentally susceptible to social desirability. However, it is plausible that their need to demonstrate independence might override these impulses.

Despite these challenges, the study has some notable strengths. Our find- ings do suggest that the period after leaving the foster care system presents multiple challenges for emerging adults. Housing instability threatens many

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aspects of their lives including health and health care access. The partic- ipants offered some suggestions for how they can be better supported during this period. They suggested providing the option to stay in the foster care system longer; disseminating information about programs and services available to former foster youth in a variety of formats (e.g., on the Internet, in social service agency offices) and to different audiences (e.g., social workers, foster youth, and foster parents), and extending health insurance coverage to older ages. These suggestions are plausible first steps to narrowing the gap in healthcare experienced by this population.

ACKNOWLEDGEMENT

This research was supported by a grant from the Stuart Foundation. Dr. Kushel was also supported by the Agency for Healthcare Research and Quality grant K08 HS011415-03. Dr. Powell Hammond was supported by the Robert Wood Johnson Health and Society Scholars fellowship. We thank Amy Dworsky for comments on previous drafts.

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