Children and Youth Services Review 94 (2018) 27–34

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Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

Mental health outcomes among youth in foster care with disabilities T

a,⁎ a b a,b b
Junghee Lee , Laurie Powers , Sarah Geenen , Jessica Schmidt , Jennifer Blakeslee ,
Insik Hwangc
a
School of Social Work, Portland State University, Portland, OR, USA
b
Regional Research Institute for Human Services, Portland State University, Portland, OR, USA
c
School of Social Work, Yonsei University, Seoul, Republic of Korea

A B S T R A C T

Background: The mental health outcomes among youth in foster care with
disabilities are under studied. Increasing our understanding of mental health risk and protective factors is essential for improving the mental health and quality of life
of this population. This study tests the associations of risk and protective factors on mental health outcome variables of youth in foster care with disabilities.
Methods: All Oregon youth in foster care who were ages 16.6–18.5 and attending study school districts were invited to participate in a federally-funded longitudinal
RCT evaluation, which sought to assess the effectiveness of self-determination enhancement on outcomes of youth transitioning from foster care to adult life. Only
baseline data was used with a final sample of 305. Receipt of special education services was used as the proxy for disability status. The risk factors included trauma
exposure, hopelessness, placement type, perceived placement restrictiveness. The protective factors included social support and self-determination. The outcome
variables included internalizing and externalizing mental health symptoms, quality of life. Preliminary analyses organized by special education (SPED) involvement
vs. study variables were conducted, and stepwise regressions were followed.
Results: Findings revealed SPED was associated with being in a restrictive foster placement. Youth involved in SPED reported higher perceived placement restric-
tiveness and hopelessness, but lower quality of life (QoL). Self-determination was a consistent protective factor. Post-traumatic symptomology was a consistent and
strongest risk factor for all outcome variables.
Conclusions: Although it is not possible to change previous adverse childhood experiences that result in currently experienced trauma, well-designed self-determi-
nation enhancement interventions and the support of caring adults may reduce negative mental health outcomes and improve QoL

1. Introduction typically risky transition to adulthood.

1.1. Youth in foster care
For a child to grow as a healthy and full participant of a society, a
sense of permanent home and family is key. All children benefit from
stable, nurturing family lives, positive school environments and
friendship, as well as supportive networks of caring relatives and
neighbors. However, some children unfortunately enter the foster care
system where they often experience temporary living arrangements,
and such stability and support are not available. On September 2016
(Department of Health and Human Services, Children's Bureau, 2017),
there were estimated 437,465 children and youth in foster care in the
United States who were placed in relative (32%) and non-relative
(45%) foster family homes, and institutions and group homes (12%).
More than half of those in foster care were males (52%) and people of
color (56%) including 23% who were Black or African American, and
21% who were Hispanic. Approximately 15% of the children and youth
in foster care were ages 16 to 19, nearing or already experiencing a
Numerous studies have documented the troubling outcomes ex-
perienced by many young people transitioning out of foster care. For
example, the Midwest Evaluation follow-along study of 736 youth ex-
iting foster care found that at age 19, only 63% had a high school di-
ploma or GED, compared to 91% of youth in the general population
(Courtney, Dworksy, Brown, et al., 2011). At 19 years of age, approxi-
mately 41% of these young people were employed, compared to 58% of
their general population peers; and only 39% were enrolled in higher
education, compared to 59% of their peers. As they age through young
adulthood, these young adults also are dramatically more likely to be
incarcerated than their peers not in foster care (Courtney, Dworsky,
Lee, & Raap, 2009; Courtney et al., 2011).
1.2. Youth in foster care with disabilities
Many youths in foster care experience compounded disparities, of
which, disability is prominent. At least one-third of children in foster
care are identified as having disabilities that are most often associated

⁎
Corresponding author at: School of Social Work, Portland State University, 1800 SW 6th Ave Academic and Student Recreation Center 600, Portland, OR 97201,
USA.
E-mail address: jungl@pdx.edu (J. Lee).

https://doi.org/10.1016/j.childyouth.2018.09.025
Received 2 May 2018; Received in revised form 16 September 2018; Accepted 17 September 2018
Available online 18 September 2018
0190-7409/ © 2018 Elsevier Ltd. All rights reserved.
J. Lee et al.
with special education eligibility ranged from developmental delay to
specific emotional, behavioral, sensory, health and physical impair-
ments (Courtney, Piliavin, & Grogan-Kaylor, 1995; Fuchs, Burnside,
Marchenski, & Mudry, 2007; Geenen & Powers, 2006; Lambros, Hurley,
Hurlburt, Zhang, & Leslie, 2010). Disability rates appear much higher
(50%–60%) among older foster youth (Hill, 2012a, 2012b; Schmidt,
et al., 2013; Wulczyn, Smithgall, & Chen, 2009).
Studies have found that U.S. children with disabilities are 1.7 times
(Crosse, Kaye, & Ratnofsky, 1993) to 3.4 times (Sullivan & Knutson,
2000) more likely to be maltreated than children without disabilities.
Further research by Lightfoot, Hill, and LaLiberte (2011) indicates that
maltreated children with disabilities are about twice as likely to be in
out-of-home placements, compared to maltreated children without
disabilities. Thus, these already vulnerable children and youth may be
more likely to be relinquished to the child welfare system than children
and youth in general.
Being identified with a disability does not necessarily mean a child
or youth is not healthy or experiences more hardship in his/her life.
However, compared to their peers in foster care without disabilities,
youths in care with disabilities have been found more likely to have
restrictive foster placements (Schmidt, et al., 2013), and to have ex-
perienced placement instability, as well as a lack of permanency plans
or kin placements (Hill, 2012a, 2012b; Slayter & Springer, 2011). Foster
youth identified with disabilities also have been found to experience
greater restriction and poorer outcomes in secondary education, com-
pared to youth in foster care without disabilities or youth with dis-
abilities who are not in foster care (Geenen & Powers, 2006). They also
have poorer postsecondary outcomes, compared to students not foster
care (Day, Dworsky, Fogarty, & Damashek, 2011).
1.3. Mental health challenges for youth in foster care
Mental health challenges are particularly prevalent among children
and youth in foster care. Nearly half (48%) of these children and youth
have been identified with clinically significant emotional or behavioral
problems, compared with 22% of the general population (e.g.,
Merikangas et al., 2010). Among young people in foster care, 25% have
been diagnosed with post-traumatic stress disorder and 20% have been
identified as experiencing major depression (vs. 4% and 10% of the
general population respectively) (Vaughn, Shook, & McMillen, 2008).
Additional studies using behavioral checklists found that the 25% to
31% of older youths in foster care scored above borderline clinical cut-
off scores for internalizing and externalizing problems (Auslander et al.,
2002; Heflinger, Simpkins, & Combs-Orme, 2000). Among young adults
who recently exited the foster care system, Courtney et al. (2011) found
that 33% had social anxiety, 25% had depression, 60% had PTSD, and
14.5% were taking psychotropic medications. Likewise, differences
have been found to be substantial and significant for diagnoses of major
depression, panic disorder, phobia, and generalized anxiety disorder
among foster alumni, compared to the general population (Grayson,
2012; Landsverk, Burns, Stambaugh, & Reutz, 2006).
1.4. Mental health challenges for youth in foster care with disabilities
Mental health outcomes among children and youth in foster care are
very concerning; furthermore, those of youth in care with disabilities
may be even worse. For example, findings specifically available on
youth in foster care with disabilities suggest they disproportionally
experience mental health challenges, compared to other youth with
disabilities who are not in foster care (Hill, 2011a, b; Smithgall,
Gladden, Yang, & Goerge, 2005). Youth in foster care with develop-
mental disabilities, ADHD and depression also have been found to re-
ceive the most mental health services (dosReis, Zito, Safer, Soeken,
2001). Youth in foster care with mental health disabilities appear
especially vulnerable to poor outcomes, including educational disrup-
tion (Smithgall et al., 2005), poorer physical health and self-esteem
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Children and Youth Services Review 94 (2018) 27–34
(Anctil, McCubbin, O'Brien, Pecora, & Anderson-Harumi, 2007), and
illegal behavior and arrest (Vaughn et al., 2008). Increasing our un-
derstanding of mental health risk and promotive factors is essential for
improving the mental health and quality of life of youth in foster care
with disabilities, who have some of the poorest outcomes.
1.5. Risk factors that could affect mental health outcomes
Numerous traumatic experiences are inextricably linked to removal
from biological parents and placement in foster care (e.g., exposure to
neighborhood violence, caregiver abuse, caregiver incarceration, care-
giver mental illness or an alcohol or drug problem) (Bramlett & Radel,
2014). Likewise, maltreatment while in the foster care system has been
reported by one-third of former foster youth (Pecora et al., 2003). A
growing number of studies demonstrate that such traumatic childhood
experiences are associated with negative mental health outcomes
among young people (e.g., Brockie, Dana-Sacco, Wallen, Wilcox, &
Campbell, 2015; Schilling, Aseltine, & Gore, 2007). Consistent with this
research, the rate of PTSD among foster alumni (30%) has been found
to be nearly double the rate of PTSD found in U.S. combat veterans,
while approximately 7% of general population young adults have been
found to experience this hardship (Pecora, White, Jackson, & Wiggins,
2009)). Lifetime PTSD prevalence among former foster youth appears
to be about twice that of the general population (Breslau, Wilcox, Storr,
Lucia, & Anthony, 2004; Keller, Salazar, & Courtney, 2010; Merikangas
et al., 2010). While exposure to trauma has been identified as a risk for
poorer mental health among youth in foster care overall, further in-
formation is needed on the association of trauma and mental health
among youth in foster care with disabilities.
In addition to trauma, there may be other risk factors that are more
likely to be experienced by youth in foster care with disabilities and
could potentially affect their mental health. One such risk factor could
be perceived hopelessness. Hopelessness is an expectation that the fu-
ture will be negative and this outcome cannot be altered. Hopelessness
is considered a pattern of thought that contributes to depression (e.g.,
Abela, 2001) and suicidality (e.g., Beck, Steer, Kovacs, & Garrison,
1985; Corrigan, Rafacz, & Rüsch, 2011). Specifically, the hopeless
theory of depression (; Abramson, Metalsky, & Alloy, 1989) suggests
that exposure to negative life events can foster an attributional style
that contributes to the formation of hopelessness, which in turn con-
tributes to development of depression symptoms. Given traumatic
childhood experiences, placement instability and educational and social
disruption that surround many youth in foster care and appear to be
even more prevalent for those with disabilities, hopelessness may be
particularly salient for their mental health.
Additional factors that could potentially be associated with the
mental health of young people in foster care, especially those with
disabilities, are placement type and perceived placement restriction.
Findings indicate that youth in foster care with disabilities are more
likely to be placed in restrictive placement types and perceive greater
restriction in day-to-day life than their peers in foster care who are not
identified with disabilities. Research identifies White males with dis-
abilities are the most restricted group (Schmidt, et al., 2013). Research
further documents that youth with disabilities living in more restrictive
settings have limited opportunities to make choices, which could ne-
gatively affect their mental health (Holtan, Rønning, Handegård, &
Sourander, 2005) and quality of life (Wehmeyer & Schwartz, 1998).
Other findings on youth with disabilities not in foster care suggest that
type of placement influences their level of self-determination (Stancliffe
& Wehmeyer, 1995; Tossebro, 1995; Wehmeyer & Shogren, 2016).
However, information is not available on the potential associations of
placement type and level of perceived restriction with mental health
status among youth in foster care with disabilities.
J. Lee et al.
1.6. Protective factors that could affect mental health outcomes
Numerous factors have been identified as important for supporting
the mental health of youth in foster care. Of high importance is social
support, which has been shown to be a key factor affecting mental
health, overall and for youth in foster care who often have disrupted
natural social networks and may have to rely on short-term, system-
connected support (Ahrens, DuBois, Rechardson, Fan, Lozano, 2008).
Findings further suggest that access to prosocial support is constrained
for youth with disabilities (Wagner, Newman, Cameto, & Levine, 2005),
and the only comparative study conducted on youth in foster care with
disabilities found they had lower level of social support, compared to
their peers in care without disabilities (Cook et al, 1991). Social support
appears to be highly modifiable and can promote positive outcomes
even during difficult periods for youth transitioning out of foster care
(Collins, Spencer, & Ward, 2009; Courtney, Piliavin, Grogan-Kaylor, &
Nesmith, 2001). Conversely, lack of social support has been associated
with adverse outcomes for youth exiting foster care (Vaughn et al.,
2008). Findings suggest that emotional distress for youth in foster care
that is associated with disruption of placement and usual support net-
works can be alleviated with provision of strong social support from
other biological family members, new foster family and peers (Perry,
2006). Further study is needed to clarify the association between social
support and mental health outcomes for youth in foster care with dis-
abilities.
Comparatively recent research has identified self-determination
enhancement as a promotive factor in positive youth development
overall (Catalano, Berglund, Ryan, Lonczak, & Hawkins, 2004), in
quality of life outcomes for youth with chronic health conditions
(McDougall, Baldwin, Evans, Nicoles, Etherington & Wright, 2016), and
in transition to adulthood outcomes for youth receiving special edu-
cation services (Wehmeyer & Palmer, 2003). Experimental research has
shown that self-determination enhancement improves the educational
and transition outcomes of young people in foster care with disabilities
and provided preliminary support for the potential impact of self-de-
termination enhancement on internalizing aspects of mental health and
quality of life (Geenen et al., 2013; Geenen et al., 2015; Powers et al.,
2012). Theoretically, self-determination is concerned with the social
conditions by examining “how biological, social, and cultural condi-
tions either enhance or undermine the inherent human capacities for
psychological growth, engagement, and wellness, both in general and in
specific domains and endeavors” (Ryan & Deci, 2017, p. 3). Self-de-
termination thus has been described in association with change agency
(Wehmeyer, 1996), empowerment (Shogren et al., 2007; Wehmeyer &
Schalock, 2001), intrinsic motivation (Deci & Ryan, 2002) and self-ef-
ficacy (Geenen, Powers, Hogansen & Pittman, 2007; Powers et al.,
2012). Thus, self-determination could be especially relevant to the
mental health of youth with disabilities in foster care who experience
additional hardships (Geenen, Powers, Hogansen & Pittman, 2007).
1.7. Study purposes
Much has to be done to ensure success for children and youth with
disabilities in foster care and key is developing a comprehensive un-
derstanding of the nature and associations of known protective and risk
factors on their mental health status. This cross-sectional study draws
upon baseline data from a regional population-based, experimental
research study evaluating the impact of a self-determination enhance-
ment intervention on the transition outcomes of youth in foster care,
with and without disabilities. This study examines the associations of
risk factors of trauma exposure, hopelessness, placement type and perceived
placement restrictiveness, as well protective factors of social support and
self-determination, on internalizing and externalizing mental health and
quality of life of youth in foster care with disabilities. Demographic
variables of sex and race are controlled for, given their complex asso-
ciations with both disability (Bécares & Priest, 2015) and mental health
29
Children and Youth Services Review 94 (2018) 27–34
(Breslau et al., 2006; Riecher-Rössler, 2016). Findings from this study
are intended to inform the growing inquiry into factors influencing the
mental health of youth in foster care and, in particular those with
disabilities, and to highlight potential prevention and intervention
strategies for promoting their mental health and quality of life.
2. Methods
2.1. Participants
All Oregon youth in foster care who were ages 16.6–18.5 and at-
tending study school districts were invited to participate in a federally-
funded longitudinal RCT evaluation, which sought to assess the effec-
tiveness of self-determination enhancement on outcomes of youth
transitioning from foster-care to adult life. Ninety percent of youth
opted to participate in this larger study. Participants were enrolled
across a three-year period, and study variables were measured at three
annual time points during the six years (2010–2016) of this evaluation
study period. However, for the purpose of this study's analysis, only
baseline data prior to randomization was used, with a final sample of
305. Each participant's sex, race and other demographics were assessed
at baseline, based on youth self-report during in-person structured in-
terviews.
Several steps were used to accurately identify the disability status of
eligible study participants. Every six months, a list of all youth who met
the eligibility criteria for the experimental research study was gener-
ated by the state child welfare agency. This list was then cross-refer-
enced by a school representative with special education records in order
to determine all youth under child welfare guardianship who received
special education (SPED) services. The list also was cross-referenced by
a Developmental Disabilities (DD) Program representative to determine
all youth receiving DD services. All youth who received DD services
were found to receive SPED services, and thus, receipt of SPED services
was selected as the overall variable proxy for disability status in this
analysis. University and agency human subjects approvals and data
sharing agreements were established to permit this exchange of in-
formation (Schmidt et al., 2013).
2.2. Measures
Mental health and general well-being outcome variables were
measured using Youth Self Report (YSR; Achenbach & Rescorla, 2001)
and Quality of Life Questionnaire (QoL-Q; Schalock & Keith, 1993). The
YSR is a thoroughly validated measure designed for use with adoles-
cents between the ages of 12 and 18, and contains a list of 119 specific
behavior problems including internalizing and externalizing health
problems (Achenbach & Rescorla, 2001). Youth filled out the YSR in-
dependently by indicating the degree to which each problem was evi-
dent, on a 3-point Likert scale (0 = Not true to 2 = Very true or Often
true). Responses were then analyzed to calculate the total score of in-
ternalizing and externalizing mental health symptoms which were
discretely considered in data analysis as outcome variables. Internalizing
mental health symptoms were identified in three categories including
anxiety/depression (13 items), withdrawn (8 items), and somatic
complaint (10 items). The internal reliability of the overall internalizing
mental health outcome variables in this study was 0.89 (0.82, 0.70, and
0.79, respectively for each subscale), and the total score was included
for data analysis. Externalizing mental health symptoms were listed in
two categories addressing rule breaking behavior (15 items) and ag-
gressive behavior (17 items). The internal reliability of the overall ex-
ternalizing mental health outcome variables in this study was 0.86
(0.75 and 0.82 for respective rule breaking and aggressive behavior
subscales), and the total score was used as an outcome variable.
The Quality of Life Questionnaire (QoL-Q) is a youth-self report
measure that includes four subscale domains: satisfaction, competence/
productivity, empowerment/independence, and belonging/community
J. Lee et al. Children and Youth Services Review 94 (2018) 27–34

integration) to comprehensively assess self-rated quality of life Table 1

(Schalock & Keith, 1993). Each subscale includes 10 items that are Study variables organized by SPED.
rated on a 3-point Likert scale. It has been used with older foster youth Non-SPED SPED Statistical
with behavioral and educational impairments (e.g., Geenen et al., 2013, (n = 124, (n = 175, Comparison
2015; Powers et al., 2012), and has well established validity and re- 41.5%) 58.5%)
liability. The internal consistency of the overall QoL-Q outcome vari-
Gender
ables in this study was 0.83 (0.78, 0.91, 0.57 and 0.59, respectively for Female 82 (66.1%) 79 (45.1%) x2 = 12.86 (p < .001)
each subscale), and the total score was used for data analysis. Male 42 (33.9%) 96 (54.9%)
Self-determination and perceived social support were identified as Race/Ethnicity
protective factors in this study. Self-determination was measured with White 76 (46.1%) 89 (53.9%) x2 = 3.27 (p < .05)
Non-White 49 (35.8%) 88 (64.2%)
The Arc's Self-Determination Scale (ARC) (Wehmeyer, 1996), originally
Placement Type
validated with youth with disabilities, particularly students with mild Kinship 39 (57.4%) 29 (42.6%) x2 = 41.16 (p < .001)
developmental and learning disabilities. The ARC has been successfully Non-Relative 72 (51.4%) 68 (48.6%)
utilized in studies of young people in foster care with and without Restrictive 13 (14.1%) 79 (85.9%)
Restrictiveness x =4.30 x =5.51 t(293.86) = 5.35
identified disabilities, including those with mental health challenges
(SD = 1.66) (SD = 2.25) (p < .001)
(e.g., Geenen, et al., 2015; Powers, et al., 2012). As a multifaceted ARC x =107.21 x =101.35 t(294) = 3.20
construct, the ARC is comprised of four domains, and the maximum (SD = 14.74) (SD = 16.13) (p < .05)
total ARC score is 148. The internal consistency of the overall ARC MSPSS x =67.31 x =67.19 ns
variables in this study was 0.87 (0.87, 0.61, 0.70, and 0.66 for the (SD = 13.58) (SD = 11.93)
Hopelessness x =28.12 x =29.84 t(283.03) = −2.20
autonomy, self-regulation, psychological empowerment, and self-reali-
(SD = 6.35) (SD = 7.13) (p < .05)
zation domains, respectively). CROPS x =15.29 x =16.66 ns
The Multidimensional Scale of Perceived Social Support (MSPSS) (SD = 8.49) (SD = 8.75)
(Zimet, Dahlem, Zimet & Farley, 1988) was utilized to assess youths' Internalizing x =51.81 x =53.24 ns
perceptions of the level of support they received from family, friends, (SD = 10.89) (SD = 10.77)
Externalizing x =53.13 x =55.02 ns
and significant others. Each of 12 items is a statement rated by parti- (SD = 9.19) (SD = 9.81)
cipants on a Likert scale ranging from 1 = Very strongly disagree to Quality of life x =77.17 x =79.27 ns
7 = Very strongly agree; higher scores indicated a greater level of (SD = 10.29) (SD = 9.52)
perceived social support. The internal consistency of the overall MSPSS
in this study was 0.91 (0.89, 0.92 and 0.93 for significant other, family Note. The numbers of study participants vary by variables due to missing data.
and friends domains, respectively).
Trauma exposure, hopelessness, placement type and perceived 2.3. Data analysis
placement restrictiveness were identified as risk factors in the study.
Trauma exposure was assessed using the Child Report of Post-traumatic Data analysis took two steps. First, bivariate level preliminary
Symptoms (CROPS) (Greenwald & Rubin, 1999), a widely used 25-item, analyses organized by participant involvement in SPED and study
3-point Likert scale (0 = None to 2 = Lots), self-report for children and variables were conducted. Then, three hierarchical stepwise regression
adolescents covering a broad range of post-traumatic symptoms was models were tested starting with demographic variables, protective
administrated, and found to have very good internal consistency factors, and risk factors in order to predict the outcome variables of
(Cronbach a = 0.89) in this study. internalizing mental health problems, externalizing mental health
A 15-item version of the Beck Hopelessness Scale (Kazdin, Rodgers, & problems, and quality of life.
Colbus, 1986) was included to assess the extent to which study parti-
cipants held negative expectations about their future. Respondents 3. Findings
were to answer each item in 1 to 4 point format based upon the events
of the past week. Total scores range from 15 to 60 with higher scores 3.1. Preliminary findings
representing a greater degree of hopelessness. This scale was found to
be reliable with study participants (Cronbach a = 0.82). Of the total study participants (n = 305), 53.8% were females,
Each youth's placement at study entry was recorded from child 45.4% identified being White, and all were in foster care including
welfare records and categorized into three main types of care: (1) 22.7% residing in kindship placements, 46.7% in non-relative place-
kinship placements (relatives or others such as teachers or neighbors ments, and 30.7% in specialized placement settings. Overall six out of
with existing relationships with the youth), (2) non-relative place- ten youth (n = 177) were involved in SPED (see Table 1). Gender, race/
ments, and (3) specialized placements (requiring special certification(s) ethnicity, and placement type were found to be significant in asso-
and/or receiving higher rates for providing more intensive support ciating with SPED involvement (x2 = 12.86, p < .001; x2 = 3.27,
(e.g., group homes, treatment foster care, residential care). p < .05; x2 = 41.16, p < .001 respectively). More males and non-
Perceived placement restrictiveness was measured with three items White participants were involved in SPED than expected. Since place-
drawn from the Restrictiveness Evaluation Measure for Youth (REM-Y; ment type was significant, post-hoc comparisons were conducted
Rauktis et al., 2009): “What best describes how much you are allowed (findings are not seen in Table 1) and revealed that more residents in
to move around where you live?”, “…how much you are allowed to use specialized placements were involved in SPED than residents in either
the telephone or internet to communicate”, and “…how much you are kinship or non-relative foster care placements (x2 = 33.30, p < .001;
allowed to go out into the community.” Participants respond to each x2 = 33.27, p < .001 respectively). Youth who were involved in SPED
item on 1- to 5-point scale with higher scores representing a greater also reported significantly higher perceived placement restrictiveness (t
degree of perceived placement restriction. The internal consistency of (293.84) = 5.35, p < .001). The mean of total ARC scores among
this 3-item scale in this study was 0.61. As expected, perceived place- study participants in the non-SPED group was higher than the SPED
ment restrictiveness was correlated with placement type at 0.42, with group (t(294) = 3.20, p < .05), but hopelessness scores were found to
kinship care rated by youth as least restrictive and specialized place- be in an opposite direction. The mean of the total hopelessness scores
ments rated as most restrictive. among youth receiving SPED services was higher than their counter-
parts not identified with educational disabilities (t(283.03) = −2.20,
p < .05). Interestingly, mean CROPS PTSD scores and all three mental

30
J. Lee et al. Children and Youth Services Review 94 (2018) 27–34

Table 2
Internalizing mental health outcome variable.
Model 1 Model 2 Model 3

Beta Sig. 95% CI Beta Sig. 95% CI Beta Sig. 95% CI

(Constant) 0.00 40.73 49.42 0.00 61.51 82.50 0.00 30.59 48.46
Female 0.23 0.00 2.34 7.42 0.29 0.00 3.74 8.67 0.13 0.00 1.39 4.29
White −0.07 0.22 −4.04 0.94 −0.05 0.36 −3.48 1.27 −0.01 0.71 −1.63 1.11
SPED 0.04 0.48 −1.73 3.69 0.03 0.60 −1.90 3.29 −0.02 0.62 −1.87 1.12
Non-Relative P −0.06 0.40 −4.56 1.81 −0.09 0.19 −5.07 1.02 −0.02 0.69 −2.11 1.41
Restrictive P 0.04 0.63 −2.97 4.90 0.00 0.97 −3.69 3.84 0.02 0.63 −1.62 2.70
Restrictiveness 0.21 0.00 0.40 1.74 0.13 0.05 0.01 1.32 0.05 0.20 −0.14 0.63
ARC −0.25 0.00 −0.26 −0.08 −0.12 0.00 −0.13 −0.03
Social Support −0.13 0.04 −0.21 0.00 −0.01 0.80 −0.07 0.05
Hopelessness 0.10 0.01 0.03 0.27
CROPS 0.75 0.00 0.86 1.03
Model Description F(6, 270) = 5.52, p < .001; F(8, 268) = 8.35, p < .001; F(10, 266) = 74.96, p < .001;
R2 = 0.11 R2 = 0.20 2
R = 0.74
Δ R2 = 0.09, p < .001 Δ R2 = 0.54, p < .001

Bold signifies the statistically significant findings (< .05).

health outcome variables (internalizing and externalizing mental health
syndromes, and quality of life) were not significantly different between
study participants who were receiving SPED services or not.
3.2. OLS regression findings
OLS regression analysis findings (see Table 2-4) indicated all three
final models predicting the outcome variables: internalizing, ex-
ternalizing and quality of life (QoL) total scores were significant with
sufficient model description (R2 = 0.74, 0.42, and 0.39 respectively).
All coefficient of determination score changes in the three outcome
variables were significant from Model 1 thru Model 3. Specifically, the
additional predictive power by risk factors for internalizing and ex-
ternalizing scores was relatively strong compared to its additional
prediction by protective factors to demographics (ΔR2 = 0.54, 0.35
from protective to risk factors in both internalizing and externalizing
scores, in comparison with ΔR2 = 0.09, 0.05 from demographics to
protective factors respectively). In contrast, with QoL outcome variable,
the additional prediction from demographics to protective factors were
stronger than that found from protective to risk factors (ΔR2 = 0.19 vs.
0.06). Overall predictive power of risk factors in predicting inter-
nalizing and externalizing mental health symptoms is much stronger
than that of protective factors. However, this finding was opposite with
the QoL outcome variable.
Female participants were found to have higher internalizing scores,
but lower quality of life scores, compared to males, while no significant
association in externalizing scores was found. Being White was not a
significant predictor for all three outcome variables, holding constant
all other predictors. Residing in non-relative and specialized placements
reduced QoL compared to living in kinship placements, but placement
types were not significant in predicting internalizing or externalizing
scores. A similar trend was found with perceived placement restric-
tiveness; higher perceived placement restrictiveness was associated
with lowered quality of life. Mean CROPS scores and all three mental
health outcome variables (internalizing and externalizing mental health
syndromes, and quality of life) were not significantly different between
study participants who were involved in SPED or not. Interestingly,
SPED involvement was found to be a protective factor associated with
higher QoL scores, while it was insignificant in predicting internal and
externalizing scores.
Higher ARC scores were found to be a significant protective factor,
associated with lower internalizing scores and increased QoL scores,
however the ARC was found to be insignificantly associated with ex-
ternalizing scores in Model 2 when measures of risk factors (i.e.,
symptoms of trauma exposure and hopeless feelings) were introduced
to the model. Greater social support also was found to be a protective
factor predictive of increased QoL. Similarly to the ARC, social support
was no longer significant in predicting internalizing and externalizing
scores when risk factors were included in the final models. As predicted,
CROPS was found to be a consistent risk factor, associated with an in-
crease in internalizing and externalizing scores, and a reduction in QoL
scores. Although expected, symptoms of trauma exposure, as measured

Table 3
Externalizing mental health outcome variable.
Model 1 Model 2 Model 3

Beta Sig. 95% CI Beta Sig. 95% CI Beta Sig. 95% CI

(Constant) 0.00 47.49 55.59 0.00 0.00 58.58 0.00 34.56 58.20
Female −0.01 0.86 −2.58 2.16 0.03 0.62 0.62 −1.77 −0.09 0.07 −3.72 0.11
White 0.00 1.00 −2.33 2.32 0.02 0.79 0.79 −1.98 0.05 0.31 −0.88 2.74
SPED 0.04 0.54 −1.74 3.32 0.03 0.59 0.59 −1.81 0.00 0.94 −2.05 1.90
Non-Relative P 0.05 0.56 −2.09 3.85 0.02 0.78 0.78 −2.50 0.08 0.18 −0.73 3.93
Restrictive P 0.10 0.29 −1.67 5.66 0.07 0.42 0.42 −2.12 0.09 0.21 −1.03 4.68
Restrictiveness 0.06 0.41 −0.37 0.88 0.00 1.00 1.00 −0.63 −0.07 0.23 −0.82 0.19
ARC −0.15 0.04 0.04 −0.18 −0.05 0.44 −0.10 0.04
Social Support −0.13 0.06 0.06 −0.19 −0.04 0.50 −0.11 0.05
Hopelessness 0.06 0.27 −0.07 0.25
CROPS 0.61 0.00 0.57 0.79
Model Description F(6, 270) = 0.84, ns; F(8, 268) = 2.38, p < .05; F(10, 266) = 19.22, p < .001;
R2 = 0.02 R2 = 0.07 2
R = 0.42
Δ R2 = 0.05, p < .01 Δ R2 = 0.35, p < .001

Bold signifies the statistically significant findings (< .05).

31
J. Lee et al. Children and Youth Services Review 94 (2018) 27–34

Table 4
Quality of life outcome variable.
Model 1 Model 2 Model 3

Beta Sig. 95% CI Beta Sig. 95% CI Beta Sig. 95% CI

(Constant) 0.00 82.52 90.26 0.00 42.68 59.97 0.00 58.48 83.01
Female −0.10 0.10 −4.19 0.35 −0.18 0.00 −5.71 −1.60 −0.13 0.01 −4.60 −0.56
White 0.01 0.88 −2.05 2.40 −0.03 0.56 −2.57 1.39 −0.03 0.56 −2.48 1.34
SPED 0.22 0.00 1.97 6.80 0.23 0.00 2.51 6.81 0.26 0.00 3.03 7.18
Non-Relative P −0.16 0.03 −6.06 −0.41 −0.12 0.06 −4.93 0.11 −0.15 0.02 −5.45 −0.59
Restrictive P −0.28 0.00 −9.49 −2.50 −0.23 0.00 −7.99 −1.77 −0.23 0.00 −7.96 −1.97
Restrictiveness −0.26 0.00 −1.86 −0.67 −0.15 0.01 −1.27 −0.18 −0.16 0.00 −1.30 −0.24
ARC 0.35 0.00 0.15 0.29 0.26 0.00 0.09 0.24
Social Support 0.19 0.00 0.07 0.23 0.13 0.02 0.01 0.18
Hopelessness −0.19 0.00 −0.43 −0.10
CROPS −0.15 0.00 −0.28 −0.05
Model Description F(6, 270) = 8.10, p < .001; F(8, 268) = 17.24, p < .001; F(10, 266) = 17.32 p < .001;
R2 = 0.15 R2 = 0.34 2
R = 0.39
Δ R2 = 0.19, p < .001 Δ R2 = 0.06, p < .001

Bold signifies the statistically significant findings (< .05).

by the CROPS, was a surprisingly powerful risk factor for mental health
(i.e., beta = 0.75 and 0.61 for internalizing and externalizing mental
health scores, respectively), more so than any other indicators.
4. Discussion
Findings confirm those of previous studies that youth with dis-
abilities are more likely to be placed in specialized placements and
report higher perceived placement restrictiveness around communica-
tion, movement, and community engagement compared to youth
without disabilities (Hill, 2012a, 2012b; McSherry, Malet, &
Weatherall, 2016). In contrast to previous research (e.g., Holtan et al.,
2005), study findings also indicate the type of foster care placement
does not matter in influencing a range of internalizing and externalizing
mental health outcomes (McSherry et al., 2016), but is associated with
reduced quality of life (Anctil et al., 2007; Wehmeyer & Schalock, 2001;
Wehmeyer & Schwartz, 1998). A similar trend was found with the
perceived placement restrictiveness that negatively affects internalizing
mental health alongside quality of life. In this context, it appears in-
ternalizing mental health indicators and quality of life may suffer more
among those youth with disabilities who are placed in specialized
placements, and experience higher perceived restrictiveness as well.
Study findings provide important insights for future intervention efforts
to build foster care placement environments where youth with dis-
abilities can exercise their autonomy.
Trauma associated with adverse childhood experiences is a con-
sistent risk factor for all internalizing and externalizing mental health
indicators, as well as for quality of life. On the other hand, self-de-
termination is a consistent protective factor for all outcome variables.
While there are many strongly motivated and skilled youth workers to
advocate for the well-being of this population, they cannot change
previous adverse childhood experiences that are associated with cur-
rently experienced trauma. However, well-designed intervention pro-
grams that enhance the feelings of hope and empowerment, which is
strongly embedded in the experience of self-determination, as well as
the support of more caring adults in their lives may reduce negative
mental health outcomes and improve quality of life (Ahrens et al., 2008;
Geenen, Powers, Hogansen, & Pittman, 2007).
Transition to adulthood is an overwhelming experience for all
youth, and it is especially challenging for youth with disabilities in the
foster care system. This regional population-based study and findings
contribute a comprehensive examination of the nature and associations
of known protective and risk factors on mental health outcomes among
children and youth in foster care with disabilities. Study findings pro-
vide important evidence regarding the efficacy of self-determination
enhancement among this population. These findings therefore not only
replicate previous studies concerning mental health outcomes among
foster care youth, but also extend to foster care youth with disabilities,
placement types and perceived placement restrictiveness, as well as
self-determination enhancement.
Several study limitations need to be acknowledged. This study uti-
lized the SPED involvement as a proxy to identify disability status.
Although school representatives and Developmental Disabilities
Program representatives cross-referenced that all participants who were
involved in SPED had disability status, different types of disability and
severity of functional limitations caused by such disabilities were not
considered in this study. In addition, this is a cross-sectional study that
examines the causal relationship between known protective and risk
factors on mental health outcomes. Future studies are encouraged to
longitudinally investigate these relationships.
Furthermore, future studies of foster care youth with disability need
to take into account the importance of early life adversity, and how it
can hinder or promote self-determination (Levenson, 2017). While
trauma-informed care was not a specific focus of this study, one of
SAMHSA's guiding principles of trauma-informed care (SAMHSA, 2014)
is empowerment, which is also a central focus of the self-determination
enhancement model. This enhancement model emphasizes the power of
individual-level decision-making, however, the necessity of building
responsive service systems that promote healing and recovery from
traumatic experiences need to be recognized (e.g., Bartlett et al., 2018),
and should be incorporated in future iterations of this model. Finally,
youth transitioning from foster care to adulthood are a highly vulner-
able population. However, youth with disability transitioning from
foster care to adult are at even greater risk of many negative outcomes
including poor mental health, and face elevated risks as a result of
negative attitudes about disability, and unequal access to services and
resources. No one approach is optimal. Only comprehensive efforts that
include a focus on individual decision-making, which embrace organi-
zational and community-based trauma informed care principles, and
which include legislative advocacy can equitably meet the complex and
ongoing needs experienced by this highly vulnerable population.
Conflicts of interest
The authors report no relationships that could be construed as a
conflict of interest.
Acknowledgements
None.

32
J. Lee et al.
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