Adverse childhood experiences among foster parents: Prevalence and association with resilience, coping, satisfaction as a foster parent, and intent to continue fostering

Journal Pre-proofs Adverse childhood experiences among foster parents: Prevalence and association with resilience, coping, satisfaction as a foster parent, and intent to continue fostering Morgan E. Cooley, Bethany Womack, Jacqueline Rush, Kristie Slinskey PII: DOI: Reference:

S0190-7409(19)30754-6 https://doi.org/10.1016/j.childyouth.2019.104679 CYSR 104679

To appear in:

Children and Youth Services Review

Received Date: Revised Date: Accepted Date:

22 July 2019 7 December 2019 7 December 2019

Please cite this article as: M.E. Cooley, B. Womack, J. Rush, K. Slinskey, Adverse childhood experiences among foster parents: Prevalence and association with resilience, coping, satisfaction as a foster parent, and intent to continue fostering, Children and Youth Services Review (2019), doi: https://doi.org/10.1016/j.childyouth. 2019.104679

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© 2019 Published by Elsevier Ltd.

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Adverse childhood experiences among foster parents: Prevalence and association with resilience, coping, satisfaction as a foster parent, and intent to continue fostering Morgan E. Cooley, Bethany Womack, Jacqueline Rush, & Kristie Slinskey

Author Note Morgan E. Cooley, Phyllis and Harvey Sandler School of Social Work, Florida Atlantic University. Bethany Womack, Social Work Program, University of Tennessee at Chattanooga. Jacqueline Rush, College of Social Work, University of Tennessee. Kristie Slinskey, Phyllis and Harvey Sandler School of Social Work, Florida Atlantic University. Correspondence concerning this article should be addressed to Morgan E. Cooley Phyllis and Harvey, School of Social Work, Florida Atlantic University, 777 Glades Road, SO 303, Boca Raton, FL 33431. Email: [email protected]

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Abstract Foster parents provide substitute, primary care for children who have been removed from their primary caregivers due to abuse and neglect. Little is known about the experiences of foster parents prior to fostering, particularly whether they have experienced adversity themselves, such as adverse childhood experiences (ACEs). The purpose of this study was to examine the occurrence of ACEs among a convenience sample of foster parents and explore multiple relationships between foster parent-reported ACEs, resilience, and other indicators of foster parent function and well-being (parental stress, satisfaction as a foster parent, perceived challenges with fostering, intent to continue fostering). This study included a convenience sample of 150 non-relative foster parents from across the United States who were currently fostering. Authors utilized descriptive statistics to describe occurrence of ACEs, regression analyses to examine associations between study variables, and t tests to address differences in resilience and fostering outcomes based on experience of ACEs. Sixty-eight percent (68%) of foster parents in this sample experienced one ACE or more. Results indicated that there were no relationships between ACEs and foster parent outcomes, except that foster parents with at least one ACE reported more challenges with the foster care system. Parental resilience was associated with parental stress, satisfaction, and intent to continue fostering. The results of this study indicate that early adversity may be less important than foster parent resilience, particularly considering that resilience is both genetic and something that can be taught. Thus, researchers and child welfare practitioners or administrators should understand and integrate foster parent training and supports that can build foster parent resilience.

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Key words: foster parent; foster care; adverse childhood experiences; foster parent resilience; foster parent coping; foster parent outcomes; foster parent well-being.

An Exploratory Study of Foster Parent Reported Adverse Childhood Experiences, Resilience, and Fostering Outcomes Introduction There are approximately 437,283 children in foster care, and non-relative foster parents provide approximately 46% of placements (other placement types might include kinship homes, group homes, or other planned placements; USDHHS, 2019). Foster parents provide daily care for a child, as a biological parent would, such as transportation to school or appointments, preparing meals, and managing daily caregiving tasks (NFPA, 2017). However, there are some foster parents who provide medical or therapeutic foster care to children more vulnerable to physical or mental health diagnoses. On top of typical parenting or caregiving responsibilities, several unique stressors accompany the role of a foster parent. For example, low satisfaction with the services available to the foster child or family, difficulty navigating the child welfare system, managing complex family issues related to having a foster child in the home, or dealing with child behaviors (Author, 2015; Mullins, Hayes, & Lietz, 2013). Although foster parents may report both personal and systemic resources for managing these stressors (Author, 2015) and there is a growing body of research on foster parent risk and protective factors, there are still a number of underexplored areas in terms of understanding risks to foster parent well-being. Because the nature of risk and

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protective factors are greatly intertwined, this exploratory study focused on identifying the occurrence of adverse childhood experiences (ACEs) among a purposive sample of foster parents and associations between ACEs, resilience, and multiple factors related to foster parent wellbeing (referred to as “fostering outcomes” throughout the study). Adverse Childhood Experiences (ACEs) An area in which little is known is what foster parents’ experiences were prior to fostering, specifically whether they have experienced adverse childhood experiences (ACEs). ACEs can be categorized into three different groups: (1) abuse, (2) family/household challenges, and (3) neglect that all happened before the age of 18 (CDC, 2016). Approximately 64% of adults in the United States have experienced at least one ACE in their lifetime (CDC, 2016), and the impact of ACEs is well documented. People who experience ACEs are more likely to have multiple negative health outcomes later in life, including poor self-rated health, chronic diseases, functional limitations, premature mortality, and poorer mental health, particularly those who report four or more ACEs (Hughes et al., 2017; Monnat & Chandler, 2015). Individuals who experience ACEs can experience lifelong alterations to the central nervous system, which is associated with awareness, memory, thought, and other important bodily functions (Wu et al., 2013). Additionally, studies identify a dose-response relationship between the number of ACEs and adverse outcomes later in life (i.e., more ACEs are associated with more physical or mental problems later on; Edwards, Holden, Felitti, & Anda, 2003; Gilbert et al., 2015). At the point of preparation of this manuscript, there were no published studies identifying the prevalence or experience of ACEs among foster parents. However, this appears to be an important area of study given that parents in the general population have identified that childhood experiences of abuse, neglect, or trauma are associated with higher levels of parent

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stress or more negative parenting practices (Okado & Azar, 2011; Steel et al., 2016). In addition, exposure to multiple ACEs is associated with experience of childhood adversity in one’s own offspring (based upon a sample of parents from Head Start; Randell, O’Malley, & Dowd, 2015). Because of the potential risks to children who have a caregiver with ACEs, examination of ACEs in foster parents may be particularly important for creating a more supportive and safe environment for both foster children and parents. Further, the challenges of foster parenting may be compounded by the fact that children in foster care face higher risks to their mental and behavioral health than youth in the general population (Tarren-Sweeny, 2008). Child behavioral issues can create a particularly challenging context for foster parents (Author, 2015). However, a healthy and more functional family context can be protective for youth in biological families who are dealing with mental health issues (Balistreri & Alvira-Hammond, 2016). Although this particular study is focused on foster parents, more information about foster parent and family context may be helpful in developing more supportive homes for children in foster care. It is not the intention of the authors to imply that ACEs are insurmountable obstacles to effective and satisfying foster parenting, as many people are resilient and overcome adversity. However, the authors do recognize that resources are often stretched thin in human-serving agencies, and the authors approach this study with the intent to identify areas where additional supports and resources may be beneficial in improving foster parents’ outcomes. Foster Parent Resilience There is limited research on foster parent resilience (Author, 2017), however, it is important to continue exploring how foster parents deal with challenges, particularly given the unique stressors of fostering (Adams, Hassett, & Lumsden, 2018). Researchers have proposed

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looking at resilience in a number of ways. For example, Cicchetti and Garmezy (1993) proposed resilience as a trait that develops through exposure to stress and adversity, while others have agreed that resilience is more of a dynamic process than a stable trait (Chmitorz et al., 2018). This stance indicates that resilience may influence how one manages or deals with adverse experiences. Conversely, resilience has been defined more as a skill or ability to successfully navigate adversity and stress (Campbell-Sills, Forde, & Stein, 2009), which suggests that resilience may also be dependent on outside or additional factors. Researchers have also found resilience to be both a genetic component and noted that resilience can also be taught (Wu et al., 2013), which makes it relevant to foster parenting and this research. For example, due to the stressful situations that foster parents have experienced prior to or during their fostering experience, they need to both employ effective strategies and learn new ways to navigate the stressful context of the foster care system. There is evidence that resilience is associated with better outcomes for foster parents and even children in foster care. For example, Sinclair and Wilson (2003) found that the attribute of resilience in a foster parent is associated with providing quality care to foster children. Lietz and colleagues (2016) identified that foster parents develop resilience in different ways as they gain more experience as a foster parent and adapt to different challenges as a foster family. Another study identified similar findings in that foster parents reported growth and enhanced ability to manage challenges while fostering (Author, 2017). Despite a developing body of knowledge on foster parent resilience, more research is needed to better understand the context of resilience, risk (e.g., ACEs), and fostering outcomes. Foster Parent Stress, Challenges Associated with Fostering, Satisfaction, and Intent to Continue Fostering

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A complete list of important outcomes for understanding the function and well-being of foster parents has yet to be established. However, foster parent stress, challenges associated with fostering, satisfaction, and intent to continue fostering have been a key focus in previous studies. Research has identified that foster parent stress can be psychologically harmful to caregivers as well as to the foster children in their care (Jones & Morrissette, 1999; Storer, Barkan, Stenhouse, Eichenlaub, Mallillin, & Haggerty, 2014). Foster parents have reported specific stressors, such as difficulty balancing their personal lives while fostering, developing a relationship with their foster child, and working with the needs of the foster agency (Buehler, Rhodes, Orme, & Cuddeback, 2006). Mullins and colleagues (2013) identified similar challenges, specifically insufficient finances, dissatisfaction with the quality of services, difficulty navigating the system, and both individual and family issues resulting from the stress that was being put on the family. Conversely, researchers have made the argument that foster parent satisfaction is an important outcome, as it is associated with greater intent to continue fostering (Fees et al., 1998; Rodger, Cummings, & Leschied, 2006). Foster parent satisfaction has been negatively correlated with perceived challenges in dealing with children and caseworkers (see Brown, 2008; Fees et al., 1998; Rhodes, Orme, Cox, & Buehler, 2003; Whenan, Oxlad, & Lushington, 2009). Foster parents have also reported a higher likelihood of quitting when they perceive poor agency support or communication, low influence in decision-making related to their foster children's care, or difficulty managing foster children's behavior (Rhodes, Orme, & Buehler, 2001). Because of the importance of these variables and because this study marks an early attempt at examining the potential impact of ACEs on foster parents, fostering outcomes are examined in this manuscript. Purpose

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The purpose of this study was to explore the occurrence of ACEs among a convenience sample of foster parents, as the authors could not identify a study exploring adversity in foster parents in this way. In addition, authors examined the association between foster parent ACEs and parental resilience within the context of multiple relevant aspects of foster parent well-being. The authors also examined the potential contribution of ACEs on resilience and fostering outcomes. The specific research questions were: (1) Out of a sample of foster parents, what is the occurrence of ACEs in non-relative foster parents? (2) What is the nature of the relationship between (a) ACEs, (b) foster parent resilience, and (c) fostering outcomes (i.e., foster parent stress, challenges related to fostering, parent satisfaction, intent to continue fostering, years fostered, number of children fostered)? (3) How do groups of foster parents compare in scores of resilience, foster parent stress, challenges related to fostering, parent satisfaction, years fostered, or number of children fostered when comparing foster parents who report (a) no ACEs versus at least one ACE or more and (b) lower ACEs (0-3) versus more ACEs (4 or more)? Methods Sample This was a cross-sectional, quantitative study of licensed, non-relative foster parents from across the U.S. This sample was comprised of 150 foster caregivers age 21 and older. Originally, 188 potential participants entered the online survey and 33 participants did not complete any of the measures (e.g., the participant may have decided not to fill the survey after all, decided that they didn’t have the time, encountered Internet problems, etc.). Finally, five participants were excluded because they did not fill out the ACEs questionnaire, which was the basis of interest for

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the study. Because of the number of predictors and type of analyses, the sample size is adequate to perform the proposed analyses. Participants were primarily female (92.7%; n = 139), White (86%; n = 129), and married or partnered (74.7%; n = 112). Please see the demographic table for more complete demographic information. [Insert Table 1 here.] Foster parents must have been licensed to provide foster care in order to participate in this study. There was no cut-off for age. It was required that the foster caregiver be fluent in English to complete the measures in the study. Participants were given the opportunity to enter a raffle for one of three $50 gift cards. Winners were selected prior to data analysis, and gift cards were mailed at the conclusion of the study. Recruitment and Data Collection Institutional review board approval for the research was obtained from the first author’s university, and all participants were required to give informed consent to participate before completing the survey. A nonrandom sample was gathered using convenience and purposive sampling strategies. Specifically, participants were recruited via (1) foster parenting groups on social media (i.e., Facebook) and (2) word of mouth (i.e., foster caregivers were encouraged to invite other foster parents to participate). Data were collected on an ongoing basis over December 2017 through February 2018 via online survey using the Qualtrics platform. The researchers sent out four reminder announcements to two different foster parenting groups in two-week intervals. It is not guaranteed that all foster parents subscribed to alerts from the foster parent groups or that all foster parents were active in using the support group. Therefore, it is not possible to identify a response rate. Measures

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Adverse childhood experiences (ACEs). ACEs were measured using a 10-item scale that asks participants to report whether they had experienced abuse, neglect, family mental illness or substance abuse, domestic violence, parental incarceration, or family dissolution between the ages of 0-18 (CDC, 2016). This measure has been widely used and is well validated (CDC, 2016), with internal consistency of .806 among participants in this sample. Participants respond “yes” or “no” to whether they experienced each adverse event, and the “yes” responses are totaled as the final ACEs score. Parental resilience. Resilience was measured using the parental resilience subscale of the FRIENDS (2011) Protective Factor Survey. This subscale included five items measured with seven-point Likert-style questions (i.e., 1 = “never” to 7 = “always”), and it has demonstrated acceptable validity and reliability through multiple pilot tests (Counts, Buffington, Chang-Rios, Rasmussen, & Preacher, 2010; FRIENDS, 2011). Higher scores indicated more perceived resilience. Questions assessed whether foster parents were likely to address problems openly in their family and pull together during stress. The internal consistency for this study was .801, which is relatively consistent with other samples (.89 in Counts et al., 2010). Parent stress. The 18-item Parental Stress Scale (Berry & Jones, 1995), which has demonstrated acceptable internal consistency and validity, was used to measure positive (e.g., emotional benefits, personal development) and negative (e.g., demands on resources, restrictions) themes of parenthood (Haskett, Ahern, Ward, & Allaire, 2006). Questions included a five-point Likert scale (i.e., 1 = “strongly disagree” to 5 = “strongly agree”) with some items reverse scored. All items were combined in a total stress score, and higher scores indicate worse stress. The internal consistency for this sample was .861.

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Foster parent satisfaction, challenges, and intent to continue fostering. Foster parent satisfaction was assessed with two subscales from a revised version of the larger Foster Parent Satisfaction Survey (FPSS; Denby, Rindfleisch, & Bean, 1999; Rodger et al., 2006). One subscale assessed confidence and satisfaction as a foster parent (sum of four items). The second subscale assessed foster parent perceptions of challenging aspects of fostering (sum of 12 items) in order to summarize the degree to which parents have experienced challenges due to their role and involvement in the foster care system. The confidence and satisfaction subscale utilized a seven-point Likert scale (i.e., 1 = “strongly disagree” to 7 = “strongly agree”), and the challenging aspects of fostering subscale utilized a four-point Likert scale (i.e., 1 = “not at all” a challenge for the foster parent to 4 = “a great deal” of a challenge). The internal consistency for the confidence and satisfaction measure was .797. Although the challenges associated with fostering measure has been used in previous studies with an adequate level of internal consistency (α = .75 in Author, 2014; α = .95 in Rodger et al., 2006), the internal consistency for this study was marginal (α = .681) for the challenging aspects of fostering measure. After examining an item analysis and intercorrelations, there is no clear explanation for the lack of intercorrelation. Thus, due to the previous performance and the exploratory nature of the study, the measure was included. Foster parent intent to continue fostering was measured with one item that utilized a three-point Likert scale assessing how likely it is that the foster home will be a licensed foster home a year from now (i.e., 1 = Not At All Likely, 2 = Somewhat Likely, 3 = Very Likely). Intent to continue fostering was an ordinal variable, thus it was not included in the regression analysis. Covariates. Based on prior research (Edwards et al., 2003; Gilbert et al., 2015; Lietz et al., 2016), the authors included age, years fostered, and children fostered as covariates.

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Demographic variables. Demographic variables assessed for foster parents’ age, race/ethnicity, marital status, education, type of foster care (to ensure they were all non-relative foster parents), the number of years they have fostered, their best estimate of the number of children they have fostered, the number of children that they have asked to be removed from their home, and the number of children that their fostering agency has removed from the home. Data Analysis Authors used SPSS 26 statistical software to analyze data. Missing data were assumed to be missing at random (MAR), thus pairwise deletion was used (Kang, 2013). Before running further analyses, data were examined for normality and other indicators of quality and found to conform to acceptable standards (histograms, p-plots, scatterplots, skewness, kurtosis). Independent variables in this paper included ACEs and resilience, and dependent variables included parental stress, challenges with fostering, satisfaction as a foster parent, and intent to continue fostering. To examine research question 1, the occurrence of ACEs in foster parents, descriptive statistics were computed. In order to examine research question 2, first, Pearson r correlations were run to examine the relationships between each of the variables. Second, authors ran simple and multiple regression to examine the independent and combined associations between each independent variable (ACEs, resilience) and covariates on the dependent variables (parental stress, satisfaction, and challenges). Because of the ordinal nature of the one-item measure of intent to continue fostering, Spearmans rho was used to examine the relationship between the independent variables and intent to continue fostering. Research question 3 examined whether there was a significant difference in each of the study variables (i.e., foster parents’ resilience, foster parent stress, parent satisfaction, challenges related to fostering, years fostered, number of

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children fostered). A number of independent-samples t tests were run to compare the dependent variables (listed previously) to the independent variable (ACEs) based on the following groupings: (first round of analyses) group 1: no ACEs; group 2: at least one ACE; and (second round of analyses) group 1: 0-3 ACEs; group 2: 4 or more ACEs Results Occurrence of ACEs in Foster Parents After running descriptive analyses, it appeared that 102 (68%) foster parents reported experiencing at least one ACE or more. The most commonly reported ACEs were having: (1) parents who were divorced or separated (N = 62, 41.3%); (2) a household member who was an alcoholic or drug user (N = 57, 38%); and (3) a family member who was mentally ill or tried to commit suicide (N = 44, 29.3%). Participants reported the highest frequencies of either no ACEs (N = 48, 32%), one ACE (N = 24, 16%), or three ACEs (N = 21, 12%). Refer to Table 2 for additional details. [Insert Table 2 here.] ACEs and Parental Resilience on Fostering Outcomes Pearson r correlations indicated significant associations between some of the study variables. There was no substantial relationship between ACEs and any other study variables. However, there was a weak negative relationship between resilience and parental stress (r (146) = -.314) and a weak positive relationship between resilience and satisfaction as a foster parent (r (145) = .250). Please see Table 3 for more details on associations between covariates and dependent variables. [Insert Table 3 here.]

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Spearman rho correlations were run to examine the relationship between ACEs and intent to continue fostering (rho = .027, p > .05), as well as parental resilience and intent to continue fostering (rho = .242, p < .01). Foster parents who indicated higher resilience tended to report a greater intent to continue fostering in the next year, but there was no substantial relationship between ACEs and intent to continue fostering. A number of simple linear regression analyses were computed to examine the relationship between ACEs and each fostering outcome (parental stress, challenges with fostering, and satisfaction as a foster parent). There were no substantial relationships between these variables. Similarly, simple linear regressions were used to analyze relations between resilience and parental stress, challenges with fostering, and satisfaction as a foster parent. A significant relationship was found between resilience and parental stress (F(1,144) = 15.806, p < .001), with an R2 of .099. For each unit increase in resilience (constant of 66.791), the parental stress score decreased by .824. Resilience was also associated with satisfaction as a foster parent (F(1,143) = 9.527, p < .01), with an R2 of .062. For each unit increase in resilience (constant of 16.174), the satisfaction score increased by .273. Participants who reported higher resilience tended to report lower parental stress and greater satisfaction as a foster parent. Please see Table 4. [Insert Table 4 here.] A number of multiple linear regression analyses were computed to examine the relationship between ACEs, covariates, and each fostering outcome. There were no substantial relationships between these variables. Please refer to Table 5 for details. [Insert Table 5 here.]

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Similarly, simple linear regressions were used to analyze relations between resilience, covariates (age, years fostering, number of children fostered), and each dependent variable (parental stress, challenges with fostering, and satisfaction as a foster parent). The only significant model indicated that resilience and covariates significantly predicted parental stress scores (F(1,126) = 5.273, p = .001), with an R2 of .143. Although the overall model was significant, resilience was the only variable that significantly predicted parental stress. Please see Table 6. [Insert Table 6 here.] Researchers also examined the effects of both independent variables (ACEs, resilience) and covariates on the dependent variables. Similar to previous analyses, the only significant model indicated that the independent variables and covariates significantly predicted parental stress scores (F(1,125) = 4.188, p = .001), with an R2 of .143; however, resilience was the only variable that significantly predicted parental stress. Please refer to Table 7 for details. [Insert Table 7 here.] Differences in Foster Parents who Experienced ACEs and those who have not Experienced ACEs Multiple independent-samples t tests were run comparing the means of (a) resilience, (b) parent stress, (c) satisfaction, (d) challenges related to fostering, (e) age, (f) years fostered, and (g) number of children fostered when comparing foster parents who reported ACEs (group 1) to those who do not (group 2). A significant difference was found among only one variable, challenges associated with fostering (t(141) = -2.256, p < .05). The mean level of challenges for participants who reported at least one ACE (M = 22.83, SD = 5.758) was significantly higher than the mean for participants who did not report ACEs (M = 20.674, SD = 4.385). It appears

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that foster parents who reported no ACEs tended to report similar levels of resilience and fostering outcomes as those who reported at least one ACE or more. [Insert Table 8 here.] Similarly, multiple independent-samples t tests were run comparing the means of (a) resilience, (b) parent stress, (c) satisfaction, (d) challenges related to fostering, (e) age, (f) years fostered, and (g) number of children fostered when comparing foster parents who reported 0-3 ACEs to those who reported 4 or more ACEs. No substantial relationships were identified. Please see Table 9 for details. Those who reported lower ACEs and those who reported higher ACEs tended to report similar levels of resilience and fostering outcomes. [Insert Table 9 here.] Discussion The purpose of this study was to examine the occurrence of ACEs and potential impact of ACEs and resilience among foster parents. Within this sample, 68% of foster parents reported one ACE or more. There was no evidence of substantial relationships between ACEs and resilience, nor ACEs and foster parent outcomes. However, results indicated that there was a weak but significant positive association between parental resilience and satisfaction, as well as resilience and intent to continue fostering. Resilience was also negatively associated with parental stress. When covariates were added into the model, resilience emerged as the only significant predictor of parental stress. Additional analyses revealed that foster parents who reported at least once ACE tended to report slightly more challenges with fostering than those who reported no ACEs. However, in general, foster parents reported similar levels of resilience and fostering outcomes despite their experience of ACEs.

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When examining the occurrence of ACEs, participants in this sample reported similar numbers when compared to the national rate of Americans who have experienced at least one ACE (64%; CDC, 2016). Interestingly, there was no substantial evidence for a relationship between ACEs and any other study variables, except that foster parents with ACEs reported slightly more perceived challenges when dealing with the foster care system than those who reported no ACEs. This finding is somewhat difficult to contextualize as there was no published research on foster parents available to compare these results. However, ACEs have been found to be associated with stress among parents living in poverty (Steele et al., 2016). Particularly of note, there was no substantial relationship between resilience and ACEs in this sample, nor did resilience levels differ by foster parents with varied levels of ACEs. Perhaps these findings can best explained by understanding that although ACEs are negative and often associated with long-term health risks (Monnat & Chandler, 2015), research has also identified that many people are resilient and able to overcome adversity (Leitch, 2017). As indicated by Wu and colleagues (2013), resilience is both internal or genetic as well as malleable. It is possible that participants in this study who experienced ACEs have also developed higher levels of resilience and are able to manage the stressors associated with fostering. Another consideration is that foster parents in this study may represent a more resilient or tenacious sample. For example, turnover among foster parents is high, especially among newer and relative foster parents (Gibbs & Wildfire, 2007; Wulczyn et al., 2018); yet, researchers have identified that a small group of experienced foster parents tend to provide a disproportionate amount of foster care services (Cherry & Orme, 2013; Orme & Cherry, 2015; Orme, Cherry, & Brown, 2017). Although participants reported an average of 4 years of experience fostering, they may still represent a more experienced and/or committed group. Despite the lack of associations

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between ACEs and study variables, more research is needed to fully understand the context of ACEs in foster parents, particularly given the cross-sectional nature of this study. Resilience alone was associated with lower parental stress, higher satisfaction as a foster parent, and greater intent to continue fostering. Additionally, there were little to no differences in resilience or fostering outcomes when comparing foster parents with different amounts of ACEs. These findings indicate that there are potentially a number of other factors that may need to be considered when understanding foster parent resilience. For example, researchers have identified that going through adversity or trauma can enhance or lead to the development of resilience (Feder, Charney, & Collins, 2011; Russo, Murrough, Han, Charney, & Nestler, 2012). Perhaps foster parents who experienced ACEs have developed similar levels of resilience as individuals who have not experienced ACEs. Another factor to be considered is social support, which has been identified as a buffer against the negative impact of child behavioral problems on challenges with fostering (Author, 2018). Researchers have also identified morality, spirituality, willingness to take initiative, ability to set boundaries, flexibility, and ability to accept the stress the foster system and grow as indicators of resilience (Lietz et al., 2016). Training may also promote resilience. As indicated in the literature review, resilience can be both innate and taught, as researchers have identified that resilience can be strengthened by different training techniques (Wu et al., 2013). Foster parents are required to go through pre-service and in-service training, which may also bolster their resilience. Limitations This study contributed to the understanding of ACEs, resilience, and coping in foster parents, but it still has its limitations. The sample was rather small, the sampling method used electronic format and social media recruitment from foster parenting groups, and the ability to

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self-select as a participant may potentially cause voluntary response bias (i.e., selection bias). It is also possible that a longer data collection period may have produced a larger response; however, the researchers did send out four reminders to participants and ended data collection after the response rate continued to decrease with each reminder. Conversely, a potential strength is that the sample includes participants from across the United States, which may increase the generalizability of the findings. Another limitation with the sample is that it was also mostly female and included mostly White participants, demonstrating the results may not be applicable to males or people of color. Lastly, this is a purely correlational study and longitudinal research is necessary to draw any causal results. Implications and Recommendations The results of this study have some different implications for research, practice, and policy. This study is an initial step in understanding the occurrence and impact of ACEs among foster parents. Future research should confirm the prevalence and impact of ACEs among foster parents using more rigorous sampling methods and a larger sample size to increase generalizability. In addition to enhanced design, future research needs to consider and integrate the complex nature of foster parents’ internal and/or external context into analyses, as there may be other variables associated with ACEs or pertinent fostering outcomes. One example would be the inclusion of more variables measuring different aspects of foster parent and family function or well-being (e.g., self-care, coping, vicarious trauma, mental health/illness, child behaviors, couple and family functioning). The application of these variables may provide a more dynamic lens than this paper, which focused primarily on individual-level variables such as parent stress, challenges associated with fostering, satisfaction, and intent to continue fostering. Studies that use qualitative methods, mixed methods, or integrate mediating or moderating effects of both

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risk and protective factors may also provide a higher level of understanding for why or how ACEs influence foster parenting or not. For example, it would be helpful to examine whether foster parents perceive ACEs to impact their parenting – regardless of whether there is a quantitative effect or not. This study is relevant to clinical practice as well. Foster parents with ACEs reported slightly higher levels of challenges associated with fostering, which supports the need for ways of managing stress. Regardless of the experience of ACEs, it is possible that all foster parents could benefit from receiving training on how to develop coping skills, given the stressful context of the foster care system (Adams et al., 2018). Coping skills training has been related to enhanced resilience and better response to stress (Southwick & Charney, 2012). In addition, although it would not be ethical to screen foster parents for ACEs as a requirement for fostering, as this may lead to dismissing qualified foster parents, information about ACEs could be helpful in supporting or preparing foster families for the challenges of fostering. During pre-service and in-service training, agencies could encourage foster parents to reflect on their own childhood experiences and encourage or link foster parents to personal therapy or support groups, if needed. Although this is an initial study on ACEs and fostering, it provides some support for state or agency policies requiring foster parents to receive training on developing resilience and managing parental stress. As an example, some federal-level and state-level policies require school, first response, or mental health professionals to obtain training in suicide, mental health, or ACEs/trauma, particularly for those who work directly with children. Similar policies may be helpful for foster parents who are regularly exposed to stress. Conclusion

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Foster parents are important stakeholders within the child welfare system and appear to experience ACEs at similar rates to the general population. This study provides correlational evidence that ACEs are not substantially associated with function as a foster parent, yet resilience appears to be a potentially important. Future research should continue to examine ACEs and other contextual elements of foster care, such as parenting, family function, or coping behaviors, while also considering the role that resilience plays in creating more positive outcomes for foster parents. This study provided information on an initial, exploratory effort in better understanding ACEs and resilience among foster parents.

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References Adams, E., Hassett, A. R., & Lumsden, V. (2018). What do we know about the impact of stress on foster carers and contributing factors? Adoption & Fostering, 42, 338-353. doi:10.1177/0308575918799956 Author. (2014). Author. (2015). Author. (2017). Author. (2018). Balistreri, K. S., & Alvira-Hammond, M. (2016). Adverse childhood experiences, family functioning and adolescent health and emotional well-being. Public Health, 132, 72–78. doi:10.1016/j.puhe.2015.10.034 Berry, J. D., & Jones, W. H. (1995) The Parental Stress Scale: Initial psychometric evidence. Journal of Social and Personal Relationships, 12, 463-472. doi:10.1177/0265407595123009 Buehler, C., Rhodes, K. W., Orme, J. G., & Cuddeback, G. (2006). The potential for successful family foster care: Conceptualizing competency domains for foster parents. Child Welfare, 85, 523-558. Brown, J. D. (2008). Foster parents' perceptions of factors needed for successful foster placements. Journal of Child and Family Studies, 17, 538-554. doi:10.1007/s10826-0079172-z Campbell-Sills, L., Forde, D., & Stein, M. (2009). Demographic and childhood environmental predictors of resilience in a community sample. Journal of Psychiatric Research, 43(12), 1007-1012. doi:10.1016/j.jpsychires.2009.01.013

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Centers for Disease Control (CDC). (2016). About the CDC-Kaiser ACE study. Retrieved from https://www.cdc.gov/violenceprevention/acestudy/about.html Chmitorz, A., … Lieb, K. (2018). Intervention studies to foster resilience – A systematic review and proposal for a resilience framework in future intervention studies. Clinical Psychology Review, 59, 78-100. doi:10.1016/j.cpr.2017.11.002 Cicchetti, D., & Garmezy, N. (1993). Prospects and promise in the study of resilience. Development and Psychopathology, 5, 497-502. doi:10.1017/S0954579400006118 Cherry, D. J., & Orme, J. G. (2013). The vital few foster mothers. Children and Youth Services Review, 35, 1625-1633. doi:10.1016/j.childyouth.2013.07.001 Counts, J. M., Buffington, E. S., Chang-Rios, K., Rasmussen, H. N., & Preacher, K. J. (2010). The development and validation of the protective factors survey: A self-report measure of protective factors against child maltreatment. Child Abuse & Neglect, 34, 762-772. doi:10.1016/j.chiabu.2010.03.003 Denby, R., Rindfleisch, N., & Bean, G. (1999). Predictors of foster parents' satisfaction and intent to continue to foster. Child Abuse & Neglect, 23(3), 287-303. doi:10.1016/s01452134(98)00126-4 Edwards, V. J., Holden, G. W., Felitti, V. J., & Anda, R. F. (2003). Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: Results from the adverse childhood experiences study. American Journal of Psychiatry, 160(8), 1453-1460. doi:10.1176/appi.ajp.160.8.1453 Feder, A., Charney, D. S., & Collins, K. (2011). Neurobiology of resilience, in Resilience and Mental Health, eds Southwick S. M., Litz B. T., Charney D. S., Friedman M. J., editors. New York, NY: Cambridge University Press.

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Fees, B. S., Stockdale, D. F., Crase, S. J., Riggins-Caspers, K., Yates, A. M., Lekies, K. S., & Gillis-Arnold, R. (1998). Satisfaction with foster parenting: Assessment one year after training. Children and Youth Services Review, 20, 347-363. doi:10.1016/S01907409(98)00011-5 FRIENDS. (2011). Protective Factors Survey. Retrieved from https://friendsnrc.org/protectivefactors-survey Gibbs, D., & Wildfire, J. (2007). Length of service for foster parents: Using administrative data to understand retention. Children and Youth Services Review, 29, 588-599. doi:10.1016/j.childyouth.2006.11.002 Gilbert, L. K., Breiding, M. J., Merrick, M. T., Thompson, W. W., Ford, D. C., Dhingra, S. S., & Parks, S. E. (2015). Childhood adversity and adult chronic disease: An update from ten states and the District of Columbia, 2010. American Journal of Preventive Medicine, 48(3), 345-349. doi:10.1016/j.amepre.2014.09.006. Haskett, M. E., Ahern, L. S., Ward, C. S., & Allaire, J. C. (2006). Factor structure and validity of the parenting stress index. Journal of Clinical Child & Adolescent Psychology, 35, 302312. doi:10.1207/s15374424jccp3502_14 Holland, P., & Gorey, K. M. (2004). Historical, developmental, and behavioral factors associated with foster care challenges. Child and Adolescent Social Work Journal, 21, 117–135. doi:10.1023/B:CASW.0000022727.40123.95 Hughes, K., … Dunne, M. P. (2017). The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. Public Health, 2, e356-e366. doi:10.1016/S2468-2667(17)30118-4

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Jones, G., & Morrissette, P. J. (1999). Foster parent stress. Canadian Journal of Counseling, 33(1), 13-27. Kang H. (2013). The prevention and handling of the missing data. Korean Journal of Anesthesiology, 64, 402-406. doi:10.4097/kjae.2013.64.5.402 Landsverk, J. A., Burns, B. J., Stambaugh, L. F., & Rolls Reutz, J. A. (2009). Psychosocial interventions for children and adolescents in foster care: Review of research literature. Child Welfare, 88, 49-69. Leitch, L. (2017). Action steps using ACEs and trauma-informed care: A resilience model. Health & Justice, 5, 5. doi:10.1186/s40352-017-0050-5 Lietz, C., A., Julien-Chinn, F. J., Geiger, J. M., & Piel, M. H. (2016). Cultivating resilience in families who foster: Understanding how families cope and adapt over time. Family Process, 55, 660-672. doi:10.1111/famp.12239 Monnat, S. M., & Chandler, R. F. (2015). Long term physical health consequences of adverse childhood experiences. The Sociological Quarterly, 56, 723–752. doi:10.1111/tsq.12107 Mullins, J., Hayes, M., & Lietz, C. (2013). Should I stay or should I go? A mixed methods study examining the factors influencing foster parents' decisions to continue or discontinue providing foster care. Children and Youth Services Review, 35, 1356-1365. doi:10.1016/j.childyouth.2013.05.003 National Foster Parent Association (NFPA). (2017). History of foster care in the United States. Retrieved from http://nfpaonline.org/page-1105741

Okado, Y., & Azar, S. T. (2011). The impact of extreme emotional distance in the mother-child relationship on the offspring’s future risk of maltreatment perpetration. Journal of Family Violence, 26, 439-452. doi:10.1007/s10896-011-9378-0

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Orme, J. G., & Cherry, D. J. (2015). The Vital Few foster parents: Replication and extension. Children and Youth Services Review, 56, 33-41. doi:10.1016/j.childyouth.2015.05.019 Orme, J. G., Cherry, D. J., & Brown, J. D. (2017). Against all odds: Vital Few foster families. Children and Youth Services Review, 79, 584-593. doi:10.1016/j.childyouth.2017.07.019 Randell, K. A., O’Malley, D., & Dowd, M. D. (2015). Association of parental adverse childhood experiences and current child adversity. JAMA Pediatrics, 169, 786-787. doi:10.1001/jamapediatrics.2015.0269 Rhodes, K. W., Orme, J. G., Cox, M. E., & Buehler, C. (2003). Foster family resources, psychosocial functioning, and retention. Social Work Research, 27, 135-150. doi:10.1093/swr/27.3.135 Rhodes, K. W., Orme, J. G., & Buehler, C. (2001). A comparison of family foster parents who quit, consider quitting, and plan to continue fostering. Social Service Review, 75, 84-114. doi:10.1086/591883 Rodger, S., Cummings, A., & Leschield, A. W. (2006). Who is caring for our most vulnerable children? The motivation to foster in child welfare. Child Abuse & Neglect, 30, 11291142. doi:10.1016/j.chiabu.2006.04.005 Russo, S. J., Murrough, J. W., Han, M. H., Charney, D. S., & Nestler, E. J. (2012). Neurobiology of resilience. Nature Neuroscience, 15, 1475-1484. doi:10.1038/nn.3234 Sinclair, I., & Wilson, K. (2003). Matches and mismatches: The contribution of carers and children to the success of foster placements. The British Journal of Social Work, 33, 871884. doi:10.1093/bjsw/33.7.871

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Southwick, S. M., & Charney, D. S. (2012). The science of resilience: Implications for the prevention and treatment of depression. Science, 338, 79-82. doi:10.1126/science.1222942 Steele, H., … Murphy, A. (2016). Adverse childhood experiences, poverty, and parenting stress. Canadian Journal of Behavioural Science, 48, 32-38. doi:10.1037/cbs0000034 Storer, H. L., Barkan, S. E., Stenhouse, L. L., Eichenlaub, C., Mallillin, A., & Haggerty, K. P. (2014). In search of connection: The foster youth and caregiver relationship. Children and Youth Services Review, 42, 110-117. doi:10.1016/j.childyouth.2014.04.008 Tarren-Sweeny, M. (2008). The mental health of children in out-of-home care. Current Opinion in Psychiatry, 21, 345-349. doi:10.1097/YCO.0b013e32830321fa United States Department of Health and Human Services (USDHHS). (2019). Preliminary FY¹ 2018 estimates as of August 22, 2019 - No. 26. Washington DC: Children’s Bureau. Retrieved from https://www.acf.hhs.gov/sites/default/files/cb/afcarsreport26.pdf Whenan, R., Oxlad, M., & Lushington, K. (2009). Factors associated with foster carer wellbeing, satisfaction and intention to continue providing out-of-home care. Children and Youth Services Review, 31, 752-760. doi:10.1016/j.childyouth.2009.02.001 Wu, G., Feder, A., Cohen, H., Kim, J. J., Calderon, S., Charney, D. S., & Mathé, A. A. (2013). Understanding resilience. Frontiers in Behavioral Neuroscience, 7, 1-15. doi:10.3389/fnbeh.2013.00010 Wulczyn, F., Orlebeke, B., Hislop, K., Schmits, F., McClanahan, J., & Huang, L. (2018). The dynamics of foster home recruitment and retention. Chicago, IL: The Center for State Child Welfare Data, Chapin Hall. Retrieved from https://fcda.chapinhall.org/wpcontent/uploads/2018/10/Foster-Home-Report-Final_FCDA_October2018.pdf

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APPENDIX A Table 1. Demographic information (N = 150) Demographic Characteristic Frequency (%) Age Years fostered Number of children fostered Gender Female 140 (98.5) Male 2 (1.5) Missing 8 Race/ethnicity White 129 (91.5) Black/African American 2 (1.4) Hispanic/Latino 5 (3.5) Native American/Alaskan Native 2 (1.4) Asian 1 (.8) Other – Undisclosed 2 (1.4) Missing 9 Relationship Status Married 112 (78.9) Single 18 (12.7) Widowed 1 (.7) Divorced 7 (4.9) Partnered 4 (2.8) Missing 8

28

Mean (SD) 37.74 (9.5) 4.06 (5.2) 11.88 (18.8)

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Table 2. Descriptive statistics examining the prevalence of ACEs and number of ACEs reported by participants Yes No Specific Type of Adverse Childhood Experience N (%) N (%) Sworn at, insulted, or humiliated; felt threatened 38 (25.3) 112 (74.7) Physically abused 21 (14) 129 (86) Sexually abused 41 (27.3) 109 (72.7) Emotionally neglected; lacked closeness or support 42 (28) 108 (72) Physically neglected; worried about next meal, had dirty clothes 15 (10) 135 (90) Parents separated or divorced 62 (41.3) 88 (58.7) Witnessed domestic violence; seen mother threatened 20 (13.3) 130 (86.7) Household member was an alcoholic or drug user 57 (38) 93 (62) Household member was mentally ill or attempted suicide 44 (29.3) 106 (70.7) Household member went to prison 12 (8) 138 (92) Number of ACEs Reported N (%) 0 48 (32) 1 24 (16) 2 18 (12) 3 21 (14) 4 13 (8.7) 5 5 (3.3) 6 6 (4) 7 7 (4.7) 8 5 (3.3) 9 3 (2)

Table 3. Pearson r correlations of study variables Measure ACEs 1 2

3

4

5

1. Parental resilience

-.115

2. Parental stress 3. Challenges 4. Satisfaction 5. Age 6. Years fostered 7. Number of children fostered *p<.05, **p<.01 (2-tailed)

-.002 .163 -.099 .107 -.001

-.314** -.128 .250** -.060 .009

.244** -.419** -.042 -.130

-.293** .127 .195*

-.089 .038

.554**

-.030

.068

-.056

.163

-.021

.503**

6

.719**

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Table 4. Simple linear regression analyses of ACEs and resilience on dependent variables Variable B SE(B) β t Sig. (p) R2 ACEs Parental stress -.006 .338 -.002 -.019 .985 .000 Challenges .359 .184 .163 1.955 .053 .027 Satisfaction -.171 .143 -.099 -1.194 .235 .010 Resilience Parental stress -.824 .207 -.314 -3.976 .099 .000 Challenges -.177 .116 -.128 -1.524 .130 .016 Satisfaction .273 .088 .250 3.087 .062 .002 Significant associations are bolded.

Table 5. Multiple linear regression analyses of ACEs and covariates on dependent variables Variable B SE(B) β t Sig. (p) R2 Parental Stress (DV) ACEs .112 Age .025 Years fostered -.381 Children fostered .033 Challenges (DV) ACEs .387 Age .007 Years fostered .107 Children fostered .024 Satisfaction (DV) ACEs -.154 Age -.054 Years fostered .098 Children fostered -.009 Significant associations are bolded.

.346 .113 .261 .069

.029 .023 -.182 .058

.324 .221 -1.461 .481

.185 .061 .136 .036

.183 .012 .104 .086

2.090 .110 .783 .665

.138 .045 .105 .027

-.098 -.123 .116 -.039

-1.110 -1.185 .934 -.325

.664 .747 .825 .146 .631 .069 .039 .913 .435 .507 .499 .269 .238 .352 .746

.020

.067

.026

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Table 6. Multiple linear regression analyses of resilience and covariates on dependent variables Variable B SE(B) β t Sig. (p) R2 Parental Stress (DV) Resilience -.907 Age -.009 Years fostered -.409 Children fostered .058 Challenges (DV) Resilience -.157 Age .012 Years fostered .105 Children fostered .025 Satisfaction (DV) Resilience .230 Age -.051 Years fostered .107 Children fostered -.014 Significant associations are bolded.

.213 .106 .245 .065

-.354 -.008 -.195 .102

-4.262 -.086 -1.666 .902

.121 .062 .138 .037

-.114 .021 .102 .088

-1.294 .196 .763 .670

.089 .044 .103 .027

.224 -.117 .126 -.061

2.597 -1.146 1.036 -.512

.001 .000 .932 .098 .369 .191 .198 .845 .447 .504 .064 .011 .254 .302 .609

.143

.048

.067

Table 7. Multiple linear regression analyses of ACEs, resilience, and covariates on dependent variables Variable B SE(B) β t Sig. (p) R2 Parental Stress (DV) ACEs -.038 Resilience -.909 Age -.008 Years fostered -.409 Children fostered .058 Challenges (DV) ACEs .376 Resilience -.127 Age -.005 Years fostered .111 Children fostered .029 Satisfaction (DV) ACEs -.111 Resilience .222 Age -.046 Years fostered .106 Children fostered -.015 Significant associations are bolded.

.329 .215 .107 .246 .065

-.010 -.355 -.007 -.195 .102

-.117 -4.234 -.071 -1.660 .893

.187 .121 .062 .136 .036

.178 -.093 -.009 .108 .103

2.010 -1.051 -.084 .812 .794

.137 .089 .045 .103 .027

-.071 .217 -.106 .126 -.064

-.811 2.488 -1.033 1.030 -.541

.001 .907 .000 .944 .099 .373 .072 .047 .295 .933 .418 .429 .091 .419 .014 .303 .305 .589

.143

.078

.072

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Table 8. Independent samples t-tests comparing foster parents who reported no ACEs with foster parents who reported at least one ACE Variable Parental Resilience No ACEs ACEs Parent Stress No ACEs ACEs Satisfaction as a Foster Parent No ACEs ACEs Challenges with Fostering No ACEs ACEs Years as a Foster Parent No ACEs ACEs Number of Children Fostered No ACEs ACEs

n

Mean (SD)

48 101

28.69 (3.50) 27.68 (4.03)

46 101

45.02 (8.76) 43.21 (10.69)

45 101

24.53 (4.24) 23.50 (4.26)

43 99

20.67 (4.38) 22.83 (5.75)

46 95

4.63 (5.62) 3.79 (4.95)

44 96

11.75 (17.86) 11.94 (19.28)

Lower CI -.335

Upper CI 2.343

t 1.482

p .140

-1.747

5.374

1.007

.316

-.470

2.546

1.361

.176

-4.096

-.211

-2.192

.030

-.998

2.680

.904

.367

-6.973

6.598

-.055

.957

Significant associations are bolded.

Table 5. Independent samples t-tests comparing foster parents who reported a lower number of ACEs (0-3) with foster parents who reported more ACEs (4 or more) Variable Parental Resilience 0-3 ACEs 4+ ACEs Parent Stress 0-3 ACEs 4+ ACEs Satisfaction as a Foster Parent 0-3 ACEs 4+ ACEs Challenges with Fostering 0-3 ACEs 4+ ACEs Years as a Foster Parent 0-3 ACEs 4+ ACEs Number of Children Fostered 0-3 ACEs 4+ ACEs

n

Mean (SD)

110 39

28.20 (3.93) 27.46 (3.73)

108 39

43.56 (9.40) 44.36 (12.04)

108 38

24.03 (4.45) 23.21 (3.68)

105 37

21.66 (5.07) 23.65 (6.25)

103 38

4.13 (5.10) 3.89 (5.43)

102 38

12.75 (20.63) 10.03 (12.61)

Lower CI -.691

Upper CI 2.168

t 1.021

p .309

-4.544

2.956

-.419

.676

-.774

2.408

1.015

.312

-4.033

.050

-1.929

.056

-1.717

2.180

.235

.815

-4.528

9.613

.711

.478

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Highlights  This is one of the first studies examining adverse childhood experiences in foster parents (ACEs).  There was limited evidence that ACEs are associated with poorer foster parent outcomes.  Resilience was associated with parental stress, satisfaction, and intent to continue fostering.  This study supports that early adversity may be less important than foster parent resilience.  Foster parent training and supports should be focused on developing resilience in foster parents.

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Morgan Cooley, Conceptualization, Methodology, Formal analysis, Writing-Original Draft, Writing - Review & Editing, Project administration; Bethany Womack: Writing-Original Draft, Writing - Review & Editing;; Jacqueline Rush: Conceptualization, Writing-Original Draft, Investigation; Kristie Slinskey: Writing-Original Draft.