Occupational Therapy in Mental Health Occupational ...

This article was downloaded by: [Florida International University] On: 17 June 2014, At: 06:30 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

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Occupational Therapy's Emerging Role With Transitioning Adolescents in Foster Care a

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Amy Paul-Ward , Carol Lambdin-Pattavina & Anna Haskell a

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Florida International University , Miami , Florida

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Comprehensive Outpatient Rehabilitation Services, Anne Arundel Medical Center , Annapolis , Maryland Published online: 21 May 2014.

To cite this article: Amy Paul-Ward , Carol Lambdin-Pattavina & Anna Haskell (2014) Occupational Therapy's Emerging Role With Transitioning Adolescents in Foster Care, Occupational Therapy in Mental Health, 30:2, 162-177, DOI: 10.1080/0164212X.2014.909651 To link to this article: http://dx.doi.org/10.1080/0164212X.2014.909651

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Occupational Therapy in Mental Health, 30:162–177, 2014 Copyright # Taylor & Francis Group, LLC ISSN: 0164-212X print=1541-3101 online DOI: 10.1080/0164212X.2014.909651

Occupational Therapy’s Emerging Role With Transitioning Adolescents in Foster Care AMY PAUL-WARD and CAROL LAMBDIN-PATTAVINA

Downloaded by [Florida International University] at 06:30 17 June 2014

Florida International University, Miami, Florida

ANNA HASKELL Comprehensive Outpatient Rehabilitation Services, Anne Arundel Medical Center, Annapolis, Maryland

The American Occupational Therapy Association’s Centennial Vision advocates for an emphasis on intervention and prevention services for children, young people, the aging, and those with severe and persistent mental illness. This article discusses mental health issues among adolescents in foster care, a population that would greatly benefit from occupational therapy services emphasizing skill development in the areas of independent living, vocation, and health. Additionally, current intervention modalities used by other disciplines with adolescents in foster care are explored. Finally, a pilot study demonstrating the opportunities for occupational therapists to influence the long-term outcomes of adolescents in foster care is described. KEYWORDS mental health, foster care, interventions, adolescents

INTRODUCTION Since the 1970s it has been recognized that occupational therapists have become increasingly more distanced from mental health practice (Bonder, 1987). According to the American Occupational Therapy Association’s 1985 Commission on Manpower Report, even though the overall employment of occupational therapists increased by more than 75% between 1977 and 1982, the number of occupational therapists in community mental health centers decreased by 50% (Bonder, 1987). Further, it has been reported that Address correspondence to Amy Paul-Ward, PhD, MS OT, Department of Occupational Therapy (AHC3, 422A), Florida International University, 11200 SW 8th Street, Miami, FL 33199. E-mail: [email protected] 162


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in 1986 only 8.5% of occupational therapists were practicing in mental health and by 2004 it had fallen to 2% (Norris, Bunger, Courchesne, Smith, & Willoughby, 2007). In order to better understand the significance of this decline and the importance of re-embracing mental health as a vital practice area, it is important to take a moment to retrace the profession’s roots. Occupational therapy grew out of the humanitarian-influenced Moral Treatment Era which changed the treatment of people with mental health issues by integrating the fundamental concepts of participation in everyday activities to attain functional skills and improve well-being (Kielhofner, 2004). For the first 30 years of occupational therapy’s existence, the discipline maintained a significant presence in the care of people with mental health disorders. During this time, occupational therapy approaches reflected the interrelationships of the mind, body, and environment and sought to influence motivation by engaging clients in occupation (Kielhofner, 2004). By the 1950s, however, with a transition to the medical model, occupational therapy involvement in the mental health field dwindled. As new paradigms and conceptual practice models evolved in response to the changing landscape of medicine, occupational therapy strayed from the moral treatment-based core concepts and practices that early occupational therapists established to distinguish the profession in the treatment of mental health disorders (Kielhofner, 2004). Several explanations have been identified for the more recent decline of occupational therapists working in the area of mental health including: Deinstitutionalization, limited work opportunities outside of acute mental health settings, lack of endorsement as qualified mental health practitioners, low pay, the changing nature of reimbursement policies, and increasing competition from other health professionals (Bonder, 1987; Wittman & Gibson, 1990; Paul 1996). Regardless of the reasons for this decline, in recent years, occupational therapy as a discipline has recognized the need to recapture mental health as an essential practice area. One of the driving forces for this renewed emphasis on mental health practice is the World Health Organization’s (WHO’s) identification of mental illness as a growing cause of disability worldwide. Significantly, WHO predicts that in the future, mental illness, specifically depression, will be the top cause of disability (AOTA, n.d.-a). This position is reinforced in the American Occupational Therapy Association’s Centennial Vision, with mental health being placed at the forefront of treatment and prevention services that should be carried out by occupational therapists (AOTA, n.d.-a). As part of this vision, AOTA has begun advocating for an emphasis on intervention and prevention services for children, young people, the aging, and those with severe and persistent mental illness. Additionally, the soon to be released standards for a Master’s-Degree level education program in occupational therapy developed by the Accreditation Council for Occupational Therapy Education (ACOTE)


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mandate that at least one of either a Level I or Level II fieldwork be in the area of psychosocial practice (ACOTE, 2011). In these rapidly changing times, with uncertain political and economic conditions reaching across the globe and increasing numbers of people experiencing psychosocial problems related to these challenges, it is increasingly more relevant for occupational therapists to reclaim their professional position in the world of psychosocial rehabilitation. Not only is there a significant need for occupational therapy’s unique approach to mental health in traditional mental health settings, but also there are new opportunities for working with other groups in need such as adolescents in foster care, a group significantly at risk for a variety of major mental illnesses. It has been argued that young people with serious mental illnesses need more than treatment to be successful in the adult world (Rosenberg, 2008). Importantly, the types of ‘‘things’’ that Rosenberg identifies as necessary for this cohort, namely, integration in the community, jobs that offer skills, independence, and dignity, resonate with the types of goals that occupational therapists assist their clients in achieving. Yet, a review of the literature identifies few, if any, occupational therapy-based programs that target the mental health needs of foster care youth. The purpose of this article is multifold. First, we will identify the diverse intervention modalities other professional disciplines are implementing among adolescents in foster care with mental health issues. Second, we will describe a five year pilot study of occupational therapy intervention with transitioning foster care youth. Finally, we will discuss the potential impact of occupational therapy for addressing the mental health needs of this vulnerable population.

OVERVIEW OF FOSTER CARE On any given day there are over half a million children in foster care in the United States (Bruskas, 2008). Current statistics by the Administration for Children and Families (ACF) reports that as of September 30, 2006, approximately 500,000 children between infancy and age 18 were in foster care (U.S. Department of Health and Human Services, 2008). Further, 52% of the 303, 000 children who were placed in foster care that year were children of ethnic and racial minorities, even though these children represented only 43% of the larger child population (US Department of Health and Human Services, ACF, Children’s Bureau, 2008). Of these, 26% were African-American and 19% were Hispanic (US Department of Health and Human Services, ACF, Children’s Bureau, 2008). The median age of children entering foster care was 10.2 years with the majority of children (52%) being male. In the past, children were placed in foster care because of illness, poverty, death of family members, and assistance with family financial needs. In 2001, over 50% of foster care situations were the result of abuse and neglect which in



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itself has led to numerous emotional and psychological disorders among children in foster care (DosReis, Zito, Safer, & Soeken, 2001). Studies conducted with young people after they have been emancipated from the foster care system suggest that this cohort suffers from mental health issues at higher levels than their non-foster care peers (Jones, 2011; Persi & Sisson, 2008). Specifically, researchers have reported that at least one-third of individuals formerly in foster care have a mental health diagnosis (Courtney, Piliavin, Grogan-Kaylor, & Nesmith 2001; Stein, Rae-Grant, Ackland, & Avison, 1994; Cook, 1994; Barth, 1990) in comparison to 19–23% of their non-foster care peers (Jones 2011, citing the Surgeon General, 2007). Based on what is known about the reasons for children entering into care, experiences in care (e.g., instability in placements as well as multiple placements), and lack of emotional support, it is not surprising that this group is vulnerable for developing mental health conditions (Persi & Sisson, 2008; Marsenich, 2002; Stein et al., 1994). These disorders include depression, substance abuse, oppositional defiant disorder, anxiety, adjustment, post-traumatic stress disorder (PTSD), learning disorders and attention deficit disorder. Often these disorders are accompanied by the need for numerous medications which require management and adherence in order to be effective (DosReis et al., 2001). In regard to the treatment aspects of mental health, it has been argued that there is no standard of care for foster care children with mental health issues. The result is that services are often recommended based on the perceived need of the adolescent and available treatment providers in the community (McClellan & Werry, 2003). The pervasiveness of mental health problems within this community has long term implications not only for young people in foster care but for society at large. As adolescents transition into adulthood in society in the United States, they are expected to finish school, gain independence from their parents, and become contributing members of their communities (Arnett, 2000; Hiebert & Thomlison, 1996; Chadsey-Rusch, Rusch, & O’Reilly, 1991). While it is federally mandated in the United States that all children in the foster care system participate in independent living programming, the literature documents that a significant number of foster children have not had the opportunity or training necessary to acquire and master the independent living and employment skills needed for successful community living (Barth, 1990; Blome, 1997; Mech, 1994; Rashid, 2004). Independent living skills are typically acquired gradually over time, in family environments, through observation, experience, and receiving guidance from nurturing adults (Goldschieder & Goldscheider, 1999; Settersten, Furstenberg, & Rumbaut, 2005). Children in foster care often do not have the opportunity to acquire these skills as they develop and the training offered is rarely occupation-based. It has been reported that only 42,600 foster care young people are receiving independent living services nationwide out of the approximately 170,000 children required to receive these services


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(Government Accounting Office 1999; Georgiades, 2005). For young people who are ‘‘aging out’’ of the foster care system, this process presents numerous challenges as they face young adulthood. As young people go through this transition from dependent ward to independent adult, they find themselves at risk for developmental disruptions and other negative outcomes such as low educational attainment, homelessness, employment, and financial difficulties, as well as increased rates of serious mental and physical health problems (Barth, 1990; Blome, 1997; Collins, 2001; Courtney et al., 2001; Lemon, Hines, & Merdinger, 2005). One national survey revealed that almost 40% of young people exiting the foster care system were diagnosed as emotionally disturbed and 50% were substance abusers (Cook, 1991). Eventually, this lack of independent living, vocational, and mental health maintenance skills results in many individuals formerly in foster care receiving services as adults through the criminal justice or the welfare systems (Casey Family Programs, 2000; Jonson-Reid & Barth, 2003; Needell, Cuccaro-Alamin, Brookhart, Jackman, & Shlonsky, 2002). This places a huge financial and public health burden on society, and results in negative life consequences for these young people. The negative outcomes experienced by young people who leave the foster care system, as well as the implications for limited performance in occupations, illustrates the need for appropriate interventions for this marginalized population, especially those interventions that address mental health. Thus, recent research has begun to attempt to identify factors contributing to successful transitions out of foster care for these youth (Clark & Davis, 2000; Lemon et al., 2005). In 1986, Congress enacted the Independent Living Initiative to serve as a framework for states to develop services for adolescents to prepare them for transitioning out of care (Reilly 2003; Stoner, 1999). A review by the U.S. Government Accounting Office (1999), approximately 15 years after implementation, found that the effectiveness of these programs was unclear. Recent national research reports from the Child Welfare League and Chapin Hall (available at http://www.chapinhall.org/; http://www.cwla.org) call for new intervention approaches to improve the development of habits and occupational behaviors leading to the mastery of independent living skills among adolescents in foster care. While the challenges and barriers to independent living skills development have been identified, no individualized, occupation-based, client-centered interventions have been developed to address this important need and none have been evaluated with controlled, experimental studies. The current foster care infrastructure, with variability across state-operated, privatized and communitybased systems, is not effectively creating the necessary programs to provide foster youth with the essential skills for successful transition to self-sufficient adulthood (Krebs & Pitcoff, 2004). Many independent living programs are one-size-fits-all, didactic, and classroom-based programs emphasizing transition planning and the provision of information on various independent



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living skills without providing opportunities to actually master skills (Collins, 2001, GAO, 1999; Paul-Ward, 2009). These programs are typically housed in office buildings where the physical space does not allow practice of real world skills such as learning how to cook in an actual kitchen. Additionally, these programs are not equipped with the appropriate staff to comprehensively assess each adolescent and provide client-centered services to address individual needs. The result is that the independent living staff frequently completes tasks for these transitioning youth rather than assist them in learning how to do these things for themselves (e.g., locating and obtaining affordable housing, arranging for assistance when utility bills are not paid and service is terminated). This pattern too often results in a cycle of learned helplessness.

REVIEW OF LITERATURE Mental Health Interventions Most of the existing literature on mental health and mental health interventions can be attributed to the following disciplines: Social work, psychology, psychiatry, nursing, and public health. In this literature, it is readily acknowledged by many that the diversity among children in foster care, the range of their mental health diagnoses, and the variation in their placement experiences makes it more difficult to evaluate the effectiveness of foster care-based interventions; however, there are two generally recognized approaches. These approaches include those that emphasize the treatment of specific symptoms and those designed specifically for the foster care system (Racusin, Maerlender, Sengupta, Isquith, & Straus, 2005). Given there are approximately 200 symptom-focused treatment approaches currently in use, the following discussion will focus on the most widely accepted system-focused interventions for addressing the mental health needs of adolescents in foster care. System-focused interventions, such as treatment foster care (TFC), multidimensional treatment foster care (MTFC), and the parent child interaction therapy (PCIT), were developed specifically to deliver mental health intervention within the context of foster care (Racusin et al., 2005). These approaches are often considered the least restrictive form of therapeutic placement for children with severe emotional disorders and involve placing them in private homes with specially trained foster parents. The combination of family-based care with specialized treatment approaches are intended to create a therapeutic environment within the context of a nurturing family home (Racusin et al., 2005; Sroul & Friedman, 1986). TFC programs are integrated service delivery systems that view foster parents as central members of the treatment team. Significantly, in TFC, the foster parent-child relationship is viewed as therapeutic. As such, foster


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parents receive specialized training and high levels of agency support, participate as treatment agents, and receive higher compensation than non-TFC parents (Racusin et al., 2005; Steib, 2002). In TFC, there are fewer children in the home and all therapeutic services (e.g., foster family and individual child therapies, school-based interventions, foster parent support) are coordinated by case managers with small caseloads. According to Southerland, Mustilo, Farmer, Stambaugh, and Murray (2008), evidence from randomized trials has shown that TFC reduces problematic behavior, increases positive social behavior, and leads to better post-discharge outcomes. One recent study posits that a strong therapeutic relationship is a necessary component in TFC programs for achieving better emotional and behavioral functioning among foster care young people (Southerland et al., 2008). MTFC programs evolved out of TFC programs. From the research on TFC programs, it was clear that there are several conditions that can be linked to adolescent antisocial behavior—poor adult supervision, inconsistent discipline, association with delinquent peers, and poor academic performance (Racusin et al., 2005; Chamberlain, Ray, & Moore, 1996; Chamberlain & Reid, 1994). MTFC uses a three pronged approach that includes: (1) substantial amounts of foster parent training, (2) family and individual treatment, and (3) school interventions (Racusin et al., 2005). This model, which is less restrictive than the available alternatives, has been systematically studied and shown to produce effective outcomes (for examples see Leve & Chamberlain, 2007; Chamberlain; Leve, & DeGarmo, 2007; Leve, Chamberlain, & Reid, 2005; Leve & Chamberlain, 2005). It is important to note that a significant number of the efficacy studies on MTFC have focused on the treatment of the most severely affected at risk young people in foster care, rather than the broad spectrum of children in foster care. Further, these intensive services are costly, requiring multiple individual and family therapies, behavior management at home and in the community, as well as high levels of case management support. PCIT, involves altering the dysfunctional relationship between the caregiver and the child in treatment (Timmer et al., 2006). This treatment approach includes separate child and parent directed interaction sessions followed by didactic treatment to instruct all participants in PCIT relationship enhancement and behavior management concepts. PCIT is a treatment option that allows therapists to work with children and their foster parents to show caregivers how to effectively provide guidance and emotional support to children with behavioral and mental health issues. Various studies on PCIT have shown effectiveness in helping parents deal with behavior problems in their children (Timmer et al., 2006). One of the most widely disseminated programs for transitional mental health service management is the Transition to Independence Process (TIP; Clark, Koroloff, Geller, & Sondheimer, 2008; Clark, 2004; Clark & Davis, 2002). While the TIP program was not designed specifically for use with



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adolescents in foster care, it is increasingly being used with this population. The TIP program calls for engaging young people in developmentally appropriate client-centered services. Moreover, the process seeks to give each adolescent a voice by acknowledging his or her choices, fostering responsibility and autonomy, and enhancing competencies. The program includes assessment, planning, coaching, and service coordination to assist young people in achieving goals. An important aspect of the program is that participants work with a transition facilitator whose responsibilities include coordinating services for the adolescents participating in the program. Although much of the language used to describe the program, such as, in the training manuals and research publications, is similar to that used to describe occupational therapy-based programs, there is no recognition of the significance of meaningful occupations to address participants’ deficits in performance areas. Moreover, the program assumes that because a system exists, and a professional is identified to assure that the services are coordinated and available, that adolescent participants will feel confident in their ability to both access and avail themselves of these services. Data evaluating the effectiveness of TIP programs on long-term outcomes of foster care youth are limited. One study provides comparative data on 43 people who completed a TIP-based program and a retrospective review of administrative data on young adults (Arun, Caproni, Sterner, Whitfield, & Clark, 2004). The researchers found that TIP completers had more post-secondary educational involvement and were less likely to be incarcerated than a matched group. The groups however did not differ on high school completion rates.

SUCCESSFUL TRANSITIONS In this section the authors report on an ongoing multi-year, multi-methods needs assessment and pilot intervention with a sample of individuals in foster care ages 13–23. The purpose of this pilot is (1) to allow for complete immersion in the South Florida foster care community, (2) to identify the challenges that adolescents face as they transition from foster care to independent adulthood, (3) to provide adolescents with an opportunity to voice their concerns about the future by reflecting on the skills needed to be a successful adult as well as identifying the most desirable and effective ways of acquiring those skills, and (4) to begin implementing an occupation-based independent living and vocational skill program for transitioning young people. Over the course of five years, participants were recruited with assistance from the staff at eight collaborating agencies in Miami-Dade County. Institutional Review board approval was obtained for all phases of the study as well as informed consent=assent from all participants. To date, 78 adolescents have participated in the study in one of three ways—as a participant in a focus group, as a participant in a one-on-one interview, or as a participant in an


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occupation-based independent living and vocational skill development program. The participants have ranged in age from 13–23. Additional participants included 34 community stakeholders (e.g., agency staff, local policy makers, advocates, guardian ad litem, etc.) and 8 foster parents. Data collection has been conducted by master’s occupational therapy students under faculty supervision and methods have included open-ended interviews, participant observations, and focus groups. Both the interview and focus group questions were developed to target areas of interest related to preparing to transition out of foster care to independent adulthood. Seventeen participants were interviewed one time with the interview lasting between 60–90 minutes. These one on one interviews were designed to deepen the understanding of the research team about issues related to the needs of adolescents as they transition from the foster care system to independent adulthood. The questions covered topics such as: Knowledge and skills needed to successfully transition out of care, perceptions of what it means to be an adult, availability of role models, and opportunities to participate in life activities. Thirty-seven participants attended one of six focus groups. These groups were used to confirm the data obtained in the face to face interviews as well as further inform the team regarding the ongoing skill development needs of this cohort. Findings indicated that adolescents preparing to exit foster care are not accessing existing independent living skills services. This lack of utilization is related to several factors including (1) lack of knowledge of available services, (2) lack of motivation and confidence to ask for such services, (3) perceptions that these services are not relevant to them, and (4) the didactic and un-engaging format of the services. Most adolescents leaving foster care do not have a bank account and most of the participants reported having difficulties with budgeting. In this study, similar to findings in the literature, a significant number rely on the independent living staff to solve all problems. The result is that staff are often reacting to emergencies, rather than working proactively with the young adults to ensure they have the opportunity to learn and master problem solving skills. From participants in both face to face interviews and focus groups, no consistency was found across agencies regarding the provision of information about availability of classes, resulting in poor attendance rates. From the adolescents’ descriptions of the classes, it was determined that the format of these programs was didactic, with paper and pencil exercises rather than opportunities for experiential learning. The results suggest a disconnect between perceived abilities and actual skills needed to become a successful adult. Moreover, it becomes apparent that adolescents in foster care are held to higher expectations than teenagers in more stable family situations, with an imposed expectation of self-sufficiency by age 18. The lack of young people engagement and the didactic format of current independent programming results in adolescents leaving the system with their skill needs unmet.



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The foster care system must move beyond the existing didactic models and implement innovative programs that are developmentally appropriate and provide opportunities for these adolescents to acquire the occupational behaviors needed to master independent living, vocational, and health maintenance skills. A critical piece is the inclusion of the target audience’s perspectives and ideas about what constitutes useful services. Therefore, the proposed study provides a unique opportunity to engage an entire community of experts including the adolescents themselves in the creation of a meaningful experientially driven program supporting the acquisition of skills needed to become successful, self-sufficient adults. The remaining 24 adolescents participated in 6 occupation-based group sessions. These sessions consisted of a series of activities addressing the development of independent living skills and included the following areas: Job training, educational performance, meal preparation, housing and finance, care of self and others, stress management, and occupational balance. Participants completed a baseline assessment developed by one of the authors that sought to identify areas of perceived strengths as well as areas (e.g., Activities of Daily Living [ADLs] and Instrumental Activities of Daily Living [IADLs]) needing improvement. This assessment was also administered at the end of the program to determine changes in both knowledge and skill. The results from this phase of the study were mixed as very few of the participants attended all six sessions and received the intervention as conceptualized. From the authors’ perspective, barriers to completion included lack of transportation, support from foster care parents and group home staff, and lack of intrinsic motivation of study participants. These barriers are reflective of the challenges of implementing innovative program models without the financial resources needed to support all of the program components.

DISCUSSION The pilot study described above seeks to reframe the way agencies interact with this population namely by teaching young people to be proactive rather than reactive in order to break this negative cycle. Further, by working collaboratively with the staff in community-based case management agencies to embed hands on experiential learning into their existing programs, we can improve their technical capacity to provide relevant independent living services for young people transitioning from foster care. If the aims of the Successful Transitions program are achieved, transitioning youth will be better prepared to deal with the real world issues of adult life. Intervention programs such as this, which emphasize occupation-based approaches to independent living and vocational skill building with an emphasis on mental health, will improve our scientific understanding of the importance of the use of meaningful occupations in the context of ‘‘learning by doing.’’


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There are clear implications for occupational therapy and ample support for the profession’s involvement in addressing the mental health needs of former foster care youth. In her 1987 article discussing the crisis of the declining occupational presence in mental health practice, Bonder noted that ‘‘change inevitably brings uncertainty, but it may also bring opportunity’’ (p. 498). Twenty years later, this statement remains true. Changes in the nature of society and ultimately in the way health services are provided, bring new opportunities for occupational therapists interested in mental health. As described above, adolescents in foster care are a group greatly in need of the services typically provided by occupational therapists. The development of such services may serve to eliminate some of the risk factors for mental illness by decreasing triggers for stress and depression. Occupational therapy practitioners have the requisite specialized knowledge and skills for addressing psychosocial and mental health issues. This specialized knowledge makes us well-positioned to provide a continuum of services aimed at social, emotional and mental health promotion, prevention of problem behaviors, early detection through screening, and intensive intervention (AOTA FAQ on school mental health, n.d.-b). In addition to working directly with adolescents in foster care, occupational therapists can provide professional development for foster care agency staff as well as collaborate with foster parents. As described above, there are significant opportunities for occupational therapists to address the mental health needs of individuals in foster care by working with agency staff in the delivery of independent living programming. The purpose of such programming is to ensure that adolescents have the necessary life skills to fully participate in their communities as students, workers, parents, etc. More importantly, these programs are federally mandated and every foster care agency is required to provide them. Unfortunately, to date, the literature evaluating independent living programs suggests a grim future for individuals formerly in foster care (Collins, 2001; Reilly, 2003; Courtney et al., 2001). Even though these programs are available, many young people have no access to them (Collins, 2001; GAO, 1999). There are several reasons why these programs are unsuccessful. First, most programs rely on self-reported assessments to determine an adolescent’s skill deficits rather than on observation. As adolescents are often reluctant to admit that they are not capable of performing a task, some requisite skill areas are measured unreliably and thus, go unaddressed. Second, many programs are classroom-based and didactic in nature. Often these types of programs are viewed by the adolescents as ‘‘too much like school.’’ Moreover, these classes are not perceived as relevant and meaningful to the target population. Therefore, the adolescents are unwilling to attend. There is an undeniable need for the expansion of existing programs to allow for the developmentally appropriate, experiential learning of skills (Fidler & Fidler, 1978; Cook 1988) in an innovative, engaging, meaningful, and fun manner (B. Delgado, personal communication, October 5, 2007; Paul-Ward, 2009).



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Most importantly, a significant reason why these interventions have not been effective is that occupational therapists have not been involved in their development or implementation. The authors believe that occupational therapists are uniquely qualified to incorporate occupation-based approaches within independent living programs for adolescents in foster care. Such an approach goes beyond current programming which is based on the notion that if a system of care is in place, adolescents will participate in the available services within that system. Unfortunately, this assumption does not take into account the challenges of operating within a system that is often bureaucratic in nature with professionals who frequently have differing service and program objectives, and desired outcomes. Incorporating an occupation-based approach would allow for programs that include a range of activities consisting of but not limited to: Baseline assessment, identification of perceptions of self-efficacy, short and long-term goal setting, activities for skill development and mastery, identification of mental health issues, and intense intervention leading to mental health stability and maintenance. Occupational therapists have the potential to bring to these programs therapeutic approaches that incorporate meaningful occupations relevant to foster care youth. It is important to remember that fundamentally they are just adolescents although unfortunately as a society we expect more from this cohort than from other adolescents. It is imperative that adolescents transitioning out of foster care have the opportunity to develop the necessary skills to successfully participate in their communities. Programs that incorporate key aspects of occupational therapy will fulfill a critical need, namely the implementation of independent living programs that recognize participants as people with specialized needs and emphasize opportunities for adolescents to develop and master skills through experiential learning. Specifically, by providing adolescents with an opportunity to master independent living, vocational and mental health skills, we may greatly reduce their risk of homelessness, unemployment, chronic illness, and long-term negative mental health and life outcomes.

CONCLUSION Emerging practice areas encourage occupational therapists to seek employment opportunities that allow them to provide services in new ways to new populations in non-traditional settings. Occupational therapy students spend several years being socialized into the profession. As part of this socialization process, students develop their professional identities and look forward to seeking employment as occupational therapists. There are, however, many job positions that would benefit from the knowledge, skills, and creativity of occupational therapists which do not have the title ‘‘occupational therapist.’’ While mental health practice is not an emerging practice


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area, the re-emergence of occupational therapy in this arena provides an opportunity for occupational therapists to seek employment in community based agencies that provide services for individuals in foster care. By working with the independent living staff in foster care agencies, occupational therapists can develop and implement occupation-based programs that reduce independent living and vocational deficits as well as promote recovery which is a critical component of intervention for people with mental illness (AOTA, n.d.-a). The long-term, negative outcomes associated with young people formerly in foster care who have untreated mental health disorders probably can be mitigated through interventions developed by occupational therapists that help these young people successfully transition into society and participate in meaningful occupations.

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