Trauma-Informed Photovoice for Adolescents and Young Adults with Child Welfare Involvement

Abstract

Youth who age out of foster care face a constellation of challenges associated with navigating the transition to adulthood and often do not have opportunities to express their perspectives. The purpose of this project was to partner with these youth to develop a trauma-informed photovoice program that can be freely utilized in child welfare programming. This youth participatory action research (yPAR) project engaged youth and young adults with child welfare experience in a long-term partnership to co-develop and pilot test a trauma-informed photovoice program called Photovoice for Change (P4C). P4C evolved into a three-meeting structure: (1) orientation and launch; (2) preparation for sharing; and (3) share back. Youth participants revealed photographs of “places and spaces” that impacted their lives, sharing their meaning with other youth and supportive adults in a group setting. The project concluded with a gallery showing, featuring a video highlighting the program participants’ experiences. Trauma-informed photovoice may be an important program to embed within the child welfare system, as it can provide youth with an opportunity to: (a) strengthen within-group relationships and (b) express important aspects of their lives in a supportive and safe environment.

1. Introduction

1.1. Older Youth in Foster Care: Salient Contextual Factors

In 2023, there were 368,530 youth in foster care in the United States [1]. Research shows that youth in foster care have higher rates of exposure to adverse childhood experiences, such as child maltreatment, parental intimate partner violence, and community violence, than same-age peers, which can result in long-term negative outcomes [2,3]. Additionally, youth in foster care often lack positive and consistent relationships with family members and other non-parental adults that are important to accessing and navigating economic, educational, and healthcare systems [4,5,6].

Youth who age out of foster care in late adolescence or early adulthood (approximately 17,736 youth in 2023 [1]) are also handling a constellation of challenges associated with navigating the transition to adulthood on their own. Compared to their same-age peers in the general population, these transition-age youth experience negative outcomes in several key domains, including education, employment, housing, and health [4]. They are notably more likely than their same-age peers without a history of child welfare involvement to experience psychiatric illness [7,8] and suicidal behavior [9]. Recent research has also suggested that older youth may need more support to prepare them to manage their own health, mental health, and housing needs once they have left the system [10,11].

The disproportionate exposure to traumatic events for children and families in child welfare [3], coupled with economic and racial disproportionality and disparity [12], has resulted in an increased focus on developing trauma-informed child and family service systems, described by The National Childhood Traumatic Stress Network [13] as:

“One in which all parties involved recognize and respond to the impact of traumatic stress on those who have contact with the system including children, caregivers, and service providers. Programs and agencies within such a system infuse and sustain trauma awareness, knowledge, and skills into their organizational cultures, practices, and policies. They act in collaboration with all those who are involved with the child, using the best available science, to maximize physical and psychological safety, facilitate the recovery of the child and family, and support their ability to thrive”.

In a formative publication on trauma-informed care, the Substance Abuse and Mental Health Services Administration outlined guiding principles of a trauma-informed approach: “safety; trustworthiness and transparency; peer support and mutual self-help; collaboration and mutuality, empowerment; voice and choice; and cultural, historical and gender issues” [14] (p. 10). Implementing a trauma-informed approach with youth in foster care includes an intentional focus on programs and practices that are culturally and racially responsive, strengths-based, and asset-based. In practice, this means identifying and addressing trauma on both the individual and systems level, creating inclusive and safe spaces for youth, providing opportunities for youth to develop relationships with peers and adults, partnering with youth in decision making, and providing strategies that promote wellbeing and positive coping mechanisms [15].

1.2. Photovoice: An Empowering Youth-Centered Approach

Community-engaged research (CEnR) is an approach that centers partnership between researchers and the individuals and/or communities the research findings aim to impact [16]. It promotes co-learning and recognizes the strengths of all parties involved, guided by principles calling for long-term sustained partnerships that are mutually beneficial [16]. Participatory research methods are central to CEnR; they highlight flexibility and the willingness to address power dynamics in the research process and challenge traditional research methods and norms [17,18]. Participatory research methods are particularly important for underrepresented groups, such as youth, whose voices are often not heard or prioritized in decision making that directly impacts them [19]. Participatory research methods have been found to have a positive impact on youth in terms of the development of skills and knowledge, a sense of agency and empowerment, and enhanced connections to social networks and social capital [20].

Photovoice is a community-based participatory research method that provides participants with an opportunity to visually represent their perspectives on their communities, their experiences, and their lives [21,22]. It amplifies “insider knowledge” on issues and/or topics that are important to a community or group of people, placing power into the hands of participants. Originally conceptualized as a research method or tool, photovoice has increasingly been used more broadly as an intervention [23,24,25]. Photovoice projects with underrepresented groups have demonstrated that the process provides an opportunity for participants to document their perspectives, engage in therapeutic dialogue, and experience empowerment and enhanced wellbeing [26,27]. This process has proven to be especially powerful with youth, whose perspectives are not always considered or understood [28,29,30]. Some youth-focused photovoice projects have explored the ways in which youth experience certain social issues, amplifying their ideas on prevention and treatment [31,32,33].

Photovoice is also considered an antiracist modality for working with racialized and marginalized youth [17,34,35], as it provides underrepresented youth the opportunity to critically reflect on their own experiences and circumstances, challenge dominant narratives and systems of oppression that uphold them, and develop counternarratives that are representative of their own experiences and perspectives [31,36]. It is also a modality of creative expression that has been shown to improve mental health and overall empowerment for youth [37,38]. Wang and Burris describe the goals of photovoice, which include allowing individuals to document the strengths and problems in their “community”, as an opportunity to facilitate dialogue and raise awareness about the community (concerns and strengths) through the discussion of photographs and the communication of emergent ideas to policymakers and other interested constituents [39].

Photovoice commonly follows a series of steps. The first step is often the identification of a topic or issue the community would like to focus on. Second, there is typically a training where someone introduces the topic and trains the participants on the method and the use of photography and cameras. Third, there are usually one or two steps which involve sharing back the photographs and analyzing them, either through discussion or coding of the photographs and accompanying text. Finally, there is a process of the participants identifying influential others (e.g., advocates, policymakers, and administrators) with whom they can share their work and messages, both images and words [40]. There are formal methods that can be used for the sharing of photographs, for example Shaffer’s SHOWeD technique, during which discussion facilitators would ask participants to reflect on a series of questions: (a) what do you See here?; (b) what’s really Happening here?; (c) how does this relate to Our lives?; (d) Why does this problem, concern, or strength Exist?; and (e) what can we Do about it? [41].

A growing body of research, including a report from the World Health Organization [42], suggests that creative arts initiatives, such as photovoice, can support the prevention and treatment of mental health conditions. This research highlights how creative arts can stimulate imagination, sensory activation, evocation of emotion, and attention [42]. Engaging in creative arts can provide a healthy outlet for youth to express emotions while also reducing stress and anxiety [42,43,44]. Photovoice has been used in the context of healthcare, and it has been shown to be a powerful tool to help youth gain knowledge and experience empowerment [45,46,47,48]. Golden proposed that photovoice, as an art-based intervention, promotes positive health outcomes, and that it provides a space for sharing, which creates increased safety and opportunity for safe disclosure amongst youth [35]. Furthermore, the use of photography for self-expression can facilitate the development of critical consciousness by encouraging adolescents to share their photos and perspectives on issues that are important to them and engage in critical dialogue about the issues.

Despite the clear benefits of photovoice, Golden recently highlighted some limitations around the approach, including the failure to include participants beyond data collection and the lack of providing multiple means for expression [35]. Further, our team recognized that practitioners and researchers may call on photovoice to amplify the voices of those with histories of trauma without making sure that their protocols are trauma-informed and safe for participants. In this paper, we describe a photovoice project called Photovoice for Change (P4C) that was created to address the unique experiences and needs of older youth in the child welfare system, while addressing these limitations. This protocol was developed in partnership with young adults who had lived experience in foster care, and each step of the protocol is trauma-informed, with the intention of keeping youth participants safe, healthy and connected.

1.3. Photovoice for Change (P4C)

Photovoice for Change (P4C) is a project that emerged during an inflection point in child welfare services in the United States, a period of time when many were calling for abolition and major systems change [12]. It emerged through conversations with a multidisciplinary team, described in detail below, and is uniquely situated to enhance mental health and empowerment while informing systems change with child welfare-experienced adolescents and young adults leading the way. This paper summarizes our process, while also sharing the trauma-informed protocols developed by the Investigative Team in consultation with our youth and adult advisory boards in service to increasing accessibility so other child and youth-serving organizations can freely utilize them in their programming.

1.4. Contextual Grounding: Family First Prevention Services Act & Trauma-Informed Care

Our program development was informed by the Family First Prevention Services Act (FFPSA) and Trauma-Informed Care (TIC). FFPSA centers the importance of mental health and wellbeing among youth in out-of-home care. FFPSA was enacted in 2018 (P.L. 115–123), shifting the prioritization of federal funding to support family-based foster care over residential care. It seeks to enhance family engagement by improving caseworker contacts, engaging families in empowerment programs, funding youth development initiatives, and outlining strategies for the amplification of youth and family voice in child welfare service provision. FFPSA also centers efforts around child mental health and youth wellbeing, which child welfare organizations traditionally have addressed through specialty mental health services (i.e., psychotherapy). P4C was created to enhance the wellbeing of child welfare involved youth, providing each participant with multiple opportunities to (a) cultivate leadership skills, (b) engage in artistic/creative expression, (c) connect with other youth who have lived experience of out-of-home care, and (d) make meaning of important places and moments in a safe environment. Beyond the group experience, each participant is also provided with an opportunity to connect with a trauma-informed adult who supports them through the photovoice process.

While some youth participatory action (yPAR) projects are generally developed with youth in mind, P4C was developed specifically by and for youth with extensive trauma histories. For this reason, developers repeatedly returned to the six guiding principles of a trauma-informed approach developed by the CDC’s Center for Preparedness and Response (CPR) and SAMHSA’s National Center for Trauma-Informed Care (NCTIC): (1) safety, (2) trustworthiness and transparency, (3) peer support, (4) collaboration and mutuality, (5) empowerment voice and choice, and (6) cultural, historical, and gender issues. Each of these principles was carefully considered as protocols were developed and as meetings were facilitated.

2. Materials and Methods

2.1. Study Design

The present study utilized a stepped youth participatory action research (yPAR) approach. yPAR methods use a collaborative model with youth and young adult participants co-leading decision-making and project processes [49]. Rodriguez and Brown proposed that yPAR is grounded in inquiry that is driven by youths’ lived experiences, that youth participants are genuine collaborators in the methods and learning, and that the project is transformative, aiming to change knowledge and practices to improve youth wellbeing and empowerment, while remaining open to systems change [50]. Our yPAR project engaged youth and young adults with child welfare experience in a long-term partnership to co-construct knowledge and co-develop a trauma-informed photovoice program (TIPP; [50,51]). These youth were integral members of our team, and the community-based child welfare agency with whom we partnered (The Children’s Village, based in Dobbs Ferry, NY, USA) was committed to better understanding the lived experiences of youth participants.

2.2. Stepped Approach to Co-Create Photovoice for Change

While P4C took place between July 2023 and June 2024, the project began in 2022 with a preliminary meeting with Youth Advisory Board members (described below). It involved a series of iterative steps that centered power sharing [52] and evolving an integrated project agenda, building alliances across constituent groups (e.g., researchers, program directors, youth advisory boards, youth participants), and working toward change (see Figure 1). The steps we took towards development are detailed below:

• Step 1. Developing a Youth Advisory Board for Photovoice for Change

Our first step was to develop a youth advisory board (YAB) with leadership from Court Appointed Special Advocates of New York City (CASA-NYC). The project leadership met multiple times with a group of YAB members to discuss the possibility of co-creating a photovoice project for child welfare involved youth. Each of these YAB members had lived experience in the child welfare system in New York City. Upon establishing mutual interest in moving forward with a photovoice project, investigators hosted a focus group with four YAB members where the project investigators led a conversation and then posed the question: “If you were us, and you were going to invite young people to engage in a ‘creative expression’ project, what might be something young people might want to focus on as a theme to create images/words/art around?” A rich discussion led to a set of three top themes that the YAB agreed were important topics for child welfare involved youth. The top themes included: (1) belonging and safety for LGBTQI+ kids in care, (2) mentoring, inspiration, and self-acceptance, and (3) the places and spaces that influenced the journey. Project investigators asked each YAB member to rank-order the three themes. Project leadership collated the rankings by each member, and the YAB decided on “the places and spaces that influenced the journey”, which focused on important physical spaces in the lives of child welfare involved youth. The YAB partnered with project investigators to write a foundation grant to create a trauma-informed photovoice project. Each YAB member was given a $100 gift card to Amazon for participating in this process.

• Step 2. Establishing Community-Based Partnerships: Children’s Village

Prior to the writing of the grant and any meetings, the investigators had multiple meetings with administrators at The Children’s Village to glean their level of interest in the program. It was also important to the team that the leadership at The Children’s Village recognized that, consistent with the practices and principles of CEnR, we all needed to remain open to the youth voices and feedback that emerged from the P4C project. Our colleagues at The Children’s Village were interested, and they were key partners in helping us to determine which programs would include youth who would be eligible for and potentially interested in P4C involvement. Four programs were identified, with each chosen program serving youth between the ages of 14 and 24, all of whom had been involved with public systems of care, including the child welfare system. The four programs included: (1) an aftercare program for young people who have recently left foster care, (2) an anti-trafficking program serving young people with a history or risk of commercial sexual exploitation, (3) a public school-based counseling and youth development program, and (4) a family foster care program.

• Step 3. Project Team

The P4C project was originally conceived of by two NYC-based researchers with extensive history working with child welfare-involved youth. These project investigators (the Investigative Team) developed a Leadership Team that met monthly to advise and partner on the project. The Leadership Team included the following members: (1) an administrator from CASA-NYC (the partnering organization where young adult participants with lived child welfare experience were trained as YAB members), (2) an administrator from The Children’s Village (the partnering community-based organization and site for P4C); (3) a research consultant with yPAR experience and lived experience in foster care, (4) a research consultant with photovoice experience and extensive knowledge of the child welfare system, and (5) a doctoral-level project coordinator. The Leadership Team was instrumental in creating project materials to utilize for recruitment and project meetings, including the creation of a project logo. The Investigative Team partnered with the Leadership Team to develop the three program protocols for the trauma-informed photovoice program. We refer to the full team (both the Investigative Team (n = 2) and the Leadership Team (n = 5)) as the Project Team.

• Step 4. Positionality of Manuscript Authors

The Project Team (including all members of the Investigative Team (n = 2) and the Leadership Team (n = 5)) is aware that our identities can shape our approach to program development, facilitation, and writing. As such, we wish to share information about gender, ethnic, and experiential positionality. All Project Team members (n = 7) are co-authors on this paper, as is one youth P4C participant; the positionality of all eight co-authors is included below.

Three authors identify as women of color: one as a Black Sierra Leonean American, one as Black, and one as Asian Guyanese. The remaining team members identify as white; four women and one man. Five team members have professional experience working in the child welfare system, six members have experience conducting or collaborating in research in the child welfare system, and two team members have personal experience in the child welfare system. Six team members have Master of Social Work (MSW) degrees, four members have doctorates, and one has some post-secondary educational experience.

• Step 5. Development and engagement of three photovoice protocols: What did we learn?

The Project Team developed an initial set of project protocols (described in detail below) and pilot-tested them throughout the project year. Over the project year, the team refined the project protocols and learned how youth experienced the program. Final versions of the program protocols are described in the Appendices below and may be further refined after completing research interviews with program participants (the next step of P4C).

3. Results

The Project Team developed a three-meeting structure for P4C that included: (1) orientation and launch, (2) preparation for sharing, and (3) share back. Each of these meetings played an important role in the P4C experience. Thirty youth participated in one of the “orientation and launch” meetings (our first meeting). Eleven youth participated in all three of the meetings.

3.1. Photovoice for Change (P4C): A Three-Meeting Structure

Meeting 1: Orientation and Launch. The first meeting was an orientation to P4C and an opportunity to recruit participants. At this meeting, the Investigative Team and the Project Coordinator met in person with youth being served by one of the programs at The Children’s Village. All youth in attendance (and The Children’s Village staff that provided support services for these youth) were engaged in an interactive presentation that explained photovoice and P4C in developmentally appropriate detail. Each P4C participant was offered $100 for the second and $100 for the third meeting, so they could earn up to $200 for participating in P4C. The Investigative Team and the Project Coordinator shared their own photographs depicting the “places and spaces that influenced the journey” in an effort to provide examples of how youth might attempt to engage in this project, and this prompt, on their own terms. Youth in attendance were then asked to participate in an activity during which they explored their own environments to encourage reflection on their own meaningful places and spaces that have impacted their lives. After the completion of this activity, youth who were interested in participating in the P4C program formally enrolled by sharing their contact information (Appendix A) and by consenting to protocols that outlined safe participation (“Guidelines for Participation”; Appendix B). These facilitators emphasized the importance of confidentiality and ensuring photos were not shared beyond the P4C group. The Project Team consulted with agency leadership and staff to make sure all of the documents shared with the youth were written in a way that was accessible to them, and then the Investigative Team and Project Coordinator explained each document in detail when they were meeting with the youth in person during the first meeting.

Meeting 2: Preparation for Sharing. The second meeting included a one-on-one virtual meeting between the Project Coordinator and each participating youth before the final presentation of photographs in a group context. This meeting is not customary in photovoice projects, but the Project Team felt it was critical to our trauma-informed approach to include an opportunity for each participant to process their experience of taking personal photographs that may be particularly emotionally evocative in nature, the content of the photos, and how they might want to share them (or not share them) with the group. In the meeting, the participants and the Project Coordinator went over their top three to five photos, which enabled them to process their photos and to come up with text to accompany the photos prior to the larger group meeting. It also encouraged rapport building with the Project Coordinator, who was able to query the youth about the supports they might need during the larger group share at the third meeting. In this way, the Project Coordinator gently prepared each participant to “present” these photographs to their peers. One of the ways the Project Coordinator helped each participant prepare was to ask them to think about the meaning of these photographs: what they would name the photograph?; would they put any words to the photograph? These meetings were very lightly guided by a protocol sheet developed by the Project Team (Appendix C), but each of these meetings was highly tailored to the needs, wishes, personality, and development of each participant. The Project Coordinator had met each of these participants in the first meeting and had interacted with participants over email and text in the planning of the second meeting, so she had a general sense of how to personalize each one-on-one meeting. The inclusion of Meeting 2 is central to the trauma-informed approach of P4C.

Meeting 3: Photovoice for Change “Share Back” Meeting. The third, and final, meeting was an opportunity for all P4C participants in the same program to come back together (either in person or virtually). These meetings were kept small and private, generally reuniting between three and five youth who were (a) engaged in the same program offered by CV and (b) willing/available to attend. The third meeting was facilitated by one Investigative Team lead and the Project Coordinator. Each P4C participant had an opportunity to share their photograph/s with the rest of the group, naming their photographs and offering any descriptions they were moved to include about these photographs. Group members were then provided with an opportunity to respond and offer feedback but were asked to keep everything they heard confidential. Sharing was encouraged but not required for the youth participants in attendance at the meeting. The third meeting was gently guided by a protocol (Appendix D).

3.2. Emergence of the Critical Role of Supportive Adults

Supportive staff members that work at The Children’s Village (most specifically, program directors and “youth coaches”) emerged as critical partners in the P4C protocol. Staff coaches work with the youth in a variety of ways, depending on the programs in which they are staffed and the youth that they are serving. Typical supports provided by coaches include (but are not limited to): accompanying youth to appointments; preparing for internships, job interviews, or other age-appropriate tasks; providing psychoeducation or support with processing peer and family interactions; and general mentoring. It is considered an asset for coaches to come from similar communities as the young people they serve, and many have lived experience with child welfare and related systems. For the first and third meetings, program directors and coaches helped the Investigative Team organize the meetings (providing physical spaces for the meetings to occur and, often, food for participants) and helped our team reach out to the youth, especially those who were not consistently responsive. These supportive staff members contributed meaningfully to creating safe and engaging spaces for youth and enhancing comfort with and acceptability of the program. Some of these staff members even shared their own photos in Meeting 3, walking alongside youth who may have felt nervous or unsure about their own sharing, celebrating youth when they shared, and redirecting youth when they needed some assistance. The decision to partner with these staff members is consistent with a trauma-informed approach, as it enhanced familiarity, comfort, and safety for the youth (who did not know the Project Team prior to this project).

3.3. The Photovoice for Change Gallery Showing

The Project Team brainstormed the best way to invite stakeholders across the community to see the youth’s photographs and accompanying text. After much deliberation, the team decided to ask the youth if they would be interested in a gallery showing. In preparation for this showing, the Project Team partnered with New York University TV to produce a short video featuring youth and coaches sharing their experiences. This process was chosen over a live panel because it would allow for the youth and supportive adults to prepare ahead of time (and for content to be edited ahead of time). Participation on a panel was ruled out because it could have required more extemporaneous sharing of difficult and sometimes emotional experiences in front of a live audience. This, too, was a trauma-informed decision. The P4C project culminated in a gallery showing with community members, the Project Team, adult supports, youth advisory board members, and youth participants showing their work. It was clear that images of important people, places, and processes and the words chosen to describe them were instrumental to the P4C participants’ experiences in foster care and in life. For example, one participant photographed a particularly meaningful building, while another photographed an area of the beach they loved. Each youth participant received their work in a custom frame, along with the accompanying text they wrote to express themselves.

4. Discussion

A Youth Advisory Board (YAB) member involved from the beginning of P4C summed up her experience of participating in P4C:

“Most of the time, I’m asked to share a story that’s kind of morbid or something horrible that I’ve gone through in my life or that relates to the foster care system or something that could be improved. Just sharing the photos that I chose to share [expressed] something beautiful about my life and something that I cherish”.

Guided by our participatory approach, young people with child welfare experience were at the center of this program from its conception. They chose the topic, were invited to choose photographs that were meaningful to them, and were invited to share their photos in a safe and empowering space with P4C staff, The Children’s Village staff, and their peers. In this space, they could discuss both their difficulties and successes while in the child welfare system, and importantly, share these experiences with supportive CV staff members. Many youth participants also shared that the relationships they had with CV staff members were meaningful to them.

A systematic review of photovoice projects with youth over a 10-year period found that that photovoice provides multiple benefits to participants, including individual empowerment [53]. While the project was not a research project, a P4C participant summed up the potential impact of this approach: “I had no idea it was going to affect me as much as it did… This program moved mountains inside of me. I had no idea I even had mountains inside of me that could move”. P4C provided transition-age youth with foster care involvement with an opportunity to share their personal stories and unique perspectives with others in a safe, supportive environment. Instead of illuminating their shortcomings, this project drew attention to their strengths and creative gifts. This outcome is in close alignment with those posited by FFPSA; it empowered youth participants, amplified their voices, and enhanced their wellbeing in a variety of ways, including providing each participant with an opportunity to forge or strengthen existing relationships with peers and caring adults. It is also consistent with the broader literature that conceptualizes yPAR as an intervention to support positive youth development across the lifespan [52].

Youth expressed to the Project Team that they felt safe throughout their participation in the P4C program, speaking to the importance of incorporating trauma-informed components into standard photovoice protocols. For example, the addition of a one-on-one meeting with a P4C staff member to help them prepare for their final peer presentations seemed to reduce anxiety and increase feelings of confidence. That said, the utility and effectiveness of this trauma-informed photovoice protocol would be bolstered by first-hand accounts of those who participated; formal data collection from those who participated in the P4C pilot program is an important next step. Should there be evidence to support the usefulness of a trauma-informed photovoice protocol for use with youth with histories of trauma, we hope that others who work with system-involved youth would consider integrating the trauma-informed components we have outlined in this manuscript and in the documents offered as appendices into their yPAR and photovoice programs, tailoring them to meet the needs of the youth with whom they are partnering.

Another important outcome of P4C, consistent with the yPAR literature [18,53], was raising awareness among community members and key stakeholders in terms of youth issues and priorities. Partnering with staff from The Children’s Village throughout the process provided them with real time information as to how youth describe and experience the places and spaces in theory journey. The photovoice gallery event and video was a powerful community forum that provided the opportunity for youth participants to share their photos, captions, and descriptions and hold intimate conversations, as appropriate, about their experiences in P4C.

5. Conclusions

Trauma-informed photovoice may be an important program to embed within the child welfare system, a program that provides an opportunity to focus relationships between staff and child welfare involved youth on important aspects of their lives in a supportive and safe environment. It is a program that can be intentional about centering youth expression and de-centering problems and/or pathology. This strengths-based and participatory approach has the potential to offer a new path forward for youth, by providing them with an opportunity to communicate their experiences and needs with those who are committed to caring about them.