Social relationships and their connection to mental health for young people who have been in the care system

The mental health of young people is a pressing concern in global development. However, there is little research on how young adults report their own mental health. The interview data gathered in this study ( n ¼ 74) explored young adults’ well-being during the transition period from care to independent living under an English local authority and in Finland. Participatory action research methods were employed. The interview schedule included 71 open and closed questions, and was analysed by content and summarised using the SPSS software application and Excel tables. The themes concerning mental health and social relationships were divided into three categories: ‘They have been there for me’, ‘My friends are the only ones’ and ‘They just guided me’. Participants who felt they had supportive social networks also felt their mental well-being and security to be better than those who did not. Overall, the findings demonstrated that good, significant social relations provided a sense of security but did not guarantee a positive mental outlook. Exploring young adults’ own evaluations of their social networks provides social work practitioners with sensitive information with which to find ways for young people to support their mental health in their own terms.


Introduction
Youth mental health and young adults leaving care Youth mental health is a pressing concern in global development (Stein and Dumaret, 2011;Trickey et al., 2012;Mokdad et al., 2016;Pedersen et al., 2019;Kelly and Coughlan, 2019). However, there is little research on how young adults leaving care report their own mental health status. This study examined how young adults who have been in the care system evaluate their social relationships and mental health and how these are interconnected. This study examines research that provides empirical evidence for mechanisms of family or peer social support lead a maltreated child to develop sustainable mental health outcomes or be relatively resilient (Bender and Lö sel, 1997;Ridley et al., 2016;Eisman et al., 2015;Hiller and St. Clair, 2018). Studies show that social ties affect physical and mental health and are correlated with lower mortality rates (Berkman and Syme, 1979;Houseet al., 1982;Orth-Gomer and Johnson, 1987;Antonucci, 2001;Antonucci et al., 2014;Kelly and Coughlan, 2019). Young adults leaving care need continuity and access to support from significant adult relationships during their transition to adulthood (Hö jer and Sjö blom, 2011;Stein and Dumaret, 2011;Ward, 2011;Stanleyet al., 2013;Tö rrö nen et al., 2018a). They are at a developmental stage of intimacy and distanciation where they are building their own identity and their reciprocal relationships to important people within their environment (Erikson, 1994;Marcia and Josselson, 2013). Intimate social relationships with peers and romantic partners can be experienced as new attachment relationships that adolescents can turn to in stressful situations if former significant figures have been unable to meet their needs (Thomas, 2000;Dubois-Comtois et al., 2013).
Outcomes of children and young adults living in care are often compared with those of other children, especially regarding their education, healthand well-being and usually show poorer outcomes for young adults ageing out of care (Steinet al., 2011;Kestilä et al., 2012). Homelessness, low educational attainment, inadequate employment and income, teen and single parenthood, mental health difficulties and lower overall wellbeing are also documented (Zeira and Benbenishty, 2011;Lee and Berrick, 2014;Hiller and Clair, 2018). Mental health difficulties may include posttraumatic stress disorder, conduct problems and attachment difficulties (Hiller and Clair, 2018). Harkkoet al. (2016) noted that 51per cent of all young adults who were in care in Finland during 2001-2010 received psychopharmaceutical drugs, compared with 21per cent of their age mates. While the number of those employed at age 26 was very small (15per cent), it was similar to that of other young adults at the same age with comparabledifficulties (28 per cent) (Harkko et al. 2016). Kalland et al. (2001) and Manninen et al. (2015) found that young adults who had been in care have higher mortality rates than the general population.
Children and young adults in care often have histories of abuse, trauma, rejection and neglect and may have limited familial support; furthermore, they may need healthcare and special education (Zeira and Benbenishty, 2011;Ward, 2016). The comparisons mentioned earlier suggest that young adults leaving care are in the same situation as other young adults leaving their childhood homes (Hö jer andSjö blom, 2010, 2011). According to Hö jer and Sjö blom (2011), but this view does not consider that young adults aging out often do not have support from their biological parents, and that substitute caregivers (for example, foster parents) are not supposed to take full parental responsibility. Still, young adults leaving the care system may remain in contact with their biological parents and even live with one or both of them (Tö rrö nen et al., 2018a).

Reciprocal relationships and holistic well-being
This study's understanding of young adults' mental health and their social relationships is based on the theoretical understanding of reciprocity, which reflects young adults as both subjective actors and as objects of the care system policy in society (Tö rrö nen et al., 2018b). This study comprehends well-being holistically, including physical needs and survival as well as social, emotional and existential factors (Hö jer and Sjö blom, 2010;Pinkerton, 2011;Lee and Berrick, 2014;Paget, 2016;Tö rrö nen, 2018a). It follows the idea that child welfare involves guarding young adults' health and safety as physical bodies and as whole persons (Paget, 2016). The United Nations General Assembly adopted the Convention on the Rights of the Child in 1989, and was the first legally binding international instrument to incorporate the civil, cultural, economic, political and social rights of children and young adults (Munro et al., 2011). The balance of material resources, health and sense of agency supports young adults' social, emotional and physical development. Existential well-being incorporates our mental and physical state, how we feel about ourselves and how we find our place in the world (Frankl, 1978;Tö rrö nen et al., 2018a). Reciprocity specifically illustrates the quality of social relationships. It signifies one's social status and ability to change one's life and integrate into society. Often, individual difficulties are linked to other people and communities as well as structural changes in local and global environments (Tö rrö nen, 2018a).
An examination of holistic well-being reveals the state of equality among people and the difficulties they face in everyday life. For instance, do they have food and shelter, caring social relationships and a feeling of agency in their own life? The review of well-being from this perspective builds on Bourdieu's (1990) idea that people cannot choose their social status, rights or freedom to act because there is ongoing competition for resources in society. Poverty has been found to correlate positively with mental health problems, drug abuse, increased suicide risk, negative body image and low self-esteem (Saarikallio-Torp et al., 2010;Woodman and McArthur, 2018;Pedersen et al., 2019). Poverty can be a severe barrier to the formation of social ties and limit participation in social networks (Offer, 2012). Poverty, discrimination and deprivation decrease the opportunity for mutual relationships. These issues also influence who can participate in a certain culture, what is prioritised, and what is permitted or valued (Bourdieu, 1990). Lee and Berrick (2014) examined how social visibility in the form of educational achievement, for instance, helps provide entry into advanced educational institutions, certain employment opportunities and socioeconomic status.

Data and method
This analysis is based on participatory methodology and peer interviews with young adults who were in the care system and have begun independent living in Finland and the UK. This research considers young adults' views (for example, Kellett, 2003;Thomas, 2007;Kilpatrick et al., 2007;Larkins et al., 2014;O'Brien, 2016;Fletcher, 2017). Berrick et al. (2017) described Finland as having a deregulated child and youth care system. They characterise the Finnish process as horizontal, where staff are likely to indicate a wider range of individuals involved in decision making, including co-workers, multiprofessional teams, parents and/or children. They claim that England has the most tightly regulated and highly proceduralised child protection system, which has been criticised for impacting staff confidence and morale. According to Berrick et al. (2017), English child protection services' focus on decision making is more heavily weighted towards notions of risk and safety, while Finnish child welfare services address children in need of help. Despite the differences, the similarities in the public discussion are surprising; for example, legislation and administrative regulations offer options that make a difference in the lives of young adults in care. However, in both countries, child and youth care services have financial difficulties, high staff turnover, stretched resources and difficulty ensuring that all young adults are given appropriate support time (Fletcher, 2017).
This research was based on the data from two projects, representing approximately two years of field work: 'Rights of Children in Alternative Care (RCAC), from Theory to Practice: Filling the Gap through Peer Research', coordinated by SOS Children's Village The research teams included young adults as peer researchers (n ¼ 16), practitioners of child and youth care services and nonprofit organisations (NGOs) (n ¼ 6) and academics (n ¼ 6). The peer researchers ranged in age from 18 to 32 years (5 males, 11 females). They had been in care themselves, including both foster families and child welfare institutions. In their respective countries, the peer researchers attended a two-day training session to learn basic skills in designing research, research ethics and conducting peer interviews. The English peer researchers were also trained in co-analysis, which took two additional days. The peer researchers were reimbursed for their travel expenses and food was provided. The Finnish peer researchers were paid for conducting the interviews, which was not allowed in England by the administrators. Largely, the peer researchers enjoyed participating in the project: The study used a participatory action research (PAR) approach and explored the experiences of young adults (n ¼ 74, aged 17-32) who had been in care in England (2016-2018, 24 interviews, 15 h) and Finland (2011-2012, 50 interviews, 34 h) with a wide variety of care experiences. PAR can be considered an approach whereby local perspectives, needs and knowledge are studied by collaborating with community members throughout the research process (Smith et al. 2010;Gardner 2018). This kind of action research attempts to provide shared investigations with people who traditionally may be oppressed and offer them tools to make changes in their lives (see O'Brien,2016). The study followed the same PAR process for each country. The researchers collaborated with peer researchers in the design of the interview schedule, data collection, analysis and dissemination of findings.
The interviews comprised 71 quantitative and qualitative questions. The interviews included 18 background questions, 28 open-ended research questions and 25 Likert-type questions with a 3-point scale. The interview questions were developed with young people using participatory research methods in RCAC projects in Poland, Finland, Albania and the Czech Republic (see Stein and Verweijen-Slamnescu, 2012;Tö rrö nen and Vauhkonen, 2012). The interview began with background questions, including departure from alternative care, financial situation and accommodation. The next section included questions about health and psychological well-being, leisure activities, and the nature of their relationships with friends and family. Finally, the interviewees were asked to describe their thoughts about the future. The outcomes of questions concerning health, psychological well-being and the nature of relationships with friends and family give valid and adequate data regarding the research phenomenon (see Silverman, 2011, Eskola andSuoranta, 1998). The questions used in Finland, including their phrasing and terminology, were discussed with the peer researchers to ensure the tool would be applicable to the UK setting. Their role was fundamental in the analysis process because it helped to clarify the interview content. Ethical issues were discussed and training exercises were provided on: sensitive issues and confidentiality, facilitating meaningful engagement and day-to-day support during field interviews (Tö rrö nen et al., 2018a).
A snowball approach was used to recruit interviewees in both cases because there are no registers of young adults who have been in care. In England, interviewees were recruited through youth centres in the county in the east of England. In Finland, interviewees were found through local authorities and child welfare organisations throughout the country (Tö rrö nen and Vauhkonen, 2012). The interviews, which lasted from 40 to 50 min, took place at the youth centres in the English local authority; only the peer researcher and the interviewee attended. Before and after the interview, the project researcher and one or two social care workers were available to answer questions and review the interviewers' feelings. In Finland, the venues for interviews varied from the interviewees' homes to public spaces such as libraries or coffee shops. Peer researchers were prepared before the interviews and were able to discuss their feelings afterward with the workers linked to the project.
All interviews were anonymised by the external transcriber. The English transcriptions comprised 504 pages of double-spaced text (including questions). The Finnish transcriptions comprised 317 pages of single-spaced text (excluding questions). The qualitative data were transcribed into RTF files and imported into the ATLAS.ti software for qualitative analysis. The closed questions were collated as tables in the SPSS programme. Excel tables were created for the multiple-choice questions (Tö rrö nen et al., 2018a). The interviews were separated with nicknames, including English or Finnish categorisation, the year of the interview and in the Finnish case, also gender.
The qualitative data were analysed in a two-(the Finnish case) and three-stage (the English case) process: initial content analysis, collaborative analysis with peer researchers and practitioners and synthesis of the themes. Because the collaborative analysis was developed in England (tape-recorded with permission), that stage was missing from the Finland analysis. The qualitative analysis included listening to the interviews and coding their content into 13 codes using the ATLAS.ti programme. In both cases, the content stressed young adults' departure from alternative care, their social relationships and feelings about future challenges. The 2016 report included both cases and described these themes in terms of social, practical and existential well-being based on the data analysis (Tö rrö nen et al., 2018a).

Results
'Interviewees expressed feeling lonely and depressed and struggling financially when living independently. They have struggled to keep connections with family and friends, and that is (I believe) a key part of developing social skills, besides keeping you physically and mentally well'. (Peer researcher, 11 March 2017) Social support networks Our data included information about a variety of social networks, personal relationships and mental well-being (see also Stein, 2008;Gibb and Edward, 2017). The young adults reported receiving the most help from their friends; other common sources of support were family, such as friends, siblings, parents, partner, grandparents, other extended family members and officials, such as teachers, social workers or other officers from social services or other organisations, foster carers and residential staff. (Tö rrö nen et al., 2018a). English interviewees reported receiving more support from authorities when starting independent living, whereas Finnish interviewees described receiving more support from their friends or family than from authorities.
Young adults described their relationships to their biological parents, other relatives or caregivers as Very good, Good enough or Poor, as shown in Table 1.
One young adult responded that his mental health was very poor but that he had a sense of security in his life. The interviewer asked the reason for that, and added a question asking if there were reasons for him to be to be unhappy with his life at the moment of the interview: The other example of a young adult who felt that her overall wellbeing and physical well-being were almost always good, and felt mentally good enough, shared what she desired from her future relationships: 'I believe that I will be married in five years and have my own family. . . The interviewees' answers indicated they found it very important that someone had taken care of them, that they were important to someone, and they had people who they could trust during and after their time in the care system. These kinds of priorities are related to caretaking and emotional connectedness, which are fundamental for children and young adults. The young adults mentioned their biological parents very often in their interviews but their perceived role and meaning in their lives seemed to vary.

Mental health and wellbeing
The interviewees' (n ¼ 71, 3 missing) evaluation of their mental wellbeing showed a variety of opinions. The data indicated that 27 (38per cent) of the interviewees evaluated their mental well-being as Very good, 35 (49per cent) as Good enough and 9 (13per cent) as Poor. The interviewees from both countries gave similar responses to questions addressing how they felt about themselves, physical and mental wellbeing and their level of security. Their overall well-being and security were estimated most frequently as Very good, and their physical and mental well-being as Good enough. There was some variation in the use of the Poor option, from 2per cent to 29per cent (see Table 2).
There was a proportional difference between the Finnish and the English cases in terms of how young people evaluated their mental wellbeing. In the Finnish case, the emphasis was on the answers Very good or Good enough (n ¼ 47, 94per cent), whereas in the English case the answers were divided between Very good and Good enough (n ¼ 15, 71per cent) and Poor (n ¼ 6, 29per cent). These numbers do not directly indicate the type of mental difficulty or diagnosis applicable to the interviewees. Rather, they express the variation in young adults' subjective views of how they feel.
One Finnish estimate is that as many as 20-25per cent of young adults have had mental health difficulties at some point during their youth (Finnish Institute for health and welfare, 2020). According to English authorities, up to 49per cent of children (aged 5-16 years) in care had 'normal' emotional and behavioural health, 13per cent had 'borderline' scores and 39per cent had scores that were cause for concern. Boys were more likely to have scores that were cause for concern (Department of Education, 2019).
Young adults' well-being and social networks can be divided into three categories: 'They have been there for me','My friends are the only ones'and'They just guidedme' (Stein, 2008;Shook et al.,2009;Tö rrö nen et al., 2018a). These categories are based on the phrases the interviewees themselves used. In practice, however, these categories may not be distinct but may overlap and vary over time.
They have been there for me 'They stuck by me and made me-I don't know-they made me feel normal, to be honest. Encouraged me, they encouraged me, to just get on with it now'. (Ann, English, 2017)  The positive experiences of the participants leaving care were linked to people-including family members, foster family members and friends-who helped and supported them during the transition period and with whom they had a constructive emotional connection. The first category, 'They have been there for me', indicates that the participants had several people they trusted and could get help, comfort and support from when needed (Tö rrö nen et al., 2018a). These significant persons were connected to their central decisions and life choices, and these relationships seemed to support the young adults' prosperity. The people in this category affirmed their well-being and the feeling that they were in balance. They mainly felt very good about themselves, were somewhat satisfied with their physical and mental well-being, and felt secure. Akister et al. (2010) concluded that young care-leavers who do well in terms of mental capital and well-being are those who progress to higher education, do not engage in crime and live independently with support. Stein and Dumaret (2011) found that successfully moving on from care is associated with a life history and a placement trajectory that support the creation of new attachments and models of identification. They noted the importance of young adults having a supportive adult during the placement and transition periods. This study found that if young adults evaluate their relationships positively, they usually evaluate their physical and mental well-being and security optimistically as well. The data show that good social relationships provide basic security to young adults leaving care.
My friends are the only ones 'Don't know, they [foster parents] were the only ones that helped me. . . . Supported me and give me guidance really, and still do now'. (Patrick, English, 2017) 'So what was connected to social and physical life, so [workers from an institution] . . . supported me a lot. I could talk to them about many things I had in my mind. They gave me information in a full sense. . . . If I needed more help, I searched it for myself, but I did not need any more help'. (Jonna, female, Finnish, 2012) The second category, 'My friends are the only ones', is similar to the first category. Here, there were fewer persons who were considered close or helpful by the participants. These young adults reported they mainly felt good enough about themselves and their physical and mental well-being and security. In this category, young adults had people they could trust and get help from, such as a mother, father, foster parents, caregivers, friend or fiancé . Their close relationships, although few in number, seemed to be enough for them to feel content.

They just guided me
'Really no person [can] I talk to when I'm unhappy' (Christian, English, 2017).
' [If I feel unhappy, I speak] perhaps to my best friend. . . . [that person] listens and gives his own opinion'. (Jouko, male, Finnish, 2012) The third category is similar to the second category. The young adults in the category 'They just guided me' seemed to have distant social relationships. In both the Finnish and English cases, some participants said they did not feel good about themselves, their health or their security. 'They just guided me' illustrates how young adults can be given authoritative advice yet not feel as if they matter. Feelings of loneliness, helplessness and nervousness were especially visible in these interviews. The participants seemed to be mentally or physically isolated, felt they were not important to anyone, and had difficulty in trusting anyone. Traumatic childhood experiences and various obstacles in youth could explain these feelings. The transition period increased the feeling of loneliness and loss of meaningful social relationships. When they had been placed geographically apart from their relatives, there were difficulties in rebuilding connections. These young adults were proud they could cope on their own, yet were sad they had to do everything on their own (Tö rrö nen and Vauhkonen, 2012; Tö rrö nen et al., 2018a).

Discussion
This study examined the interconnections between social support and mental health of young adults who have been in care system. This research found that young adults leaving care in Finland and in England generally feel good or good enough about themselves, both physically and mentally, and have people with whom they have a reciprocal relationship. Reciprocal relationships reflect that young adults in their living circumstances and social networks are understood as subjective actors and that their well-being is supported holistically, including physical needs, social, emotional and existential factors. The interviewees told us they felt their needs were met because they were, for instance, studying, working or engaging in a meaningful activity; they did not report economic difficulties. This finding reveals that these young adults have developed sustainable mental health or are relatively resilient.
At the same time, there were young adults leaving care who reported anxiety about an uncertain future and how to take care of themselves socially, economically and mentally. These young adults' well-being seemed to be almost the opposite of those in the first category. Their support networks were either fragile or non-existent. This finding gives support to De Salvo's (2017) conclusion that if people do not experience connectedness, it may create feelings of isolation, rejection, psychological distress and mental difficulties.
However, the evaluation of mental health varied by country and category. The interviewees in England used more often the extreme values (very good or poor) when describing their relationships or mental health, whereas in Finland the interviewees' answers were divided more equally between very good, good enough or poor. Good quality and significant social relationships give a certain sense of security to life but do not guarantee how the young person feels mentally. The participants' mental health and social relationships can be interpreted both positively or negatively: positively interpreted, more than half the young adults in this study said they felt good about themselves; negatively interpreted, only three in ten young persons in this study expressed that they felt sufficiently secure and good about themselves. One in ten claimed they did not feel mentally well. This tells us that child welfare and care system can have a positive impact. However, it also points out that the system is not perfect because there are still many young adults who describe their well-being as merely good enough or even poor. If we agree that mental health is the foundation for health, well-being and effective functioning (Finnish Institute for Health and Welfare, 2020), we must take this evidence seriously. Entering the care system is traumatic. It is important that young adults understand why they are entering the care system and express their feelings about it. Many young adults who have been in the care system need professional or peer support for mental health issues. Stein and Dumaret (2011) suggested that early assessment of children's and young adults' needs should be conducted, followed either by therapeutic intervention to assist them and their families or early removal from very damaging relationships. Additional services should also be provided to prevent gaps in services when young adults transition to adult services, if needed (Butterworth et al., 2017;Hiller and Clair, 2018;Tö rrö nen et al., 2018a). If young adults' complex needs when leaving care remain unmet, they will be likely be at greater risk (Butterworth et al., 2017). Manninen et al. (2015) suggested that effective treatment of mental problems and substance abuse is needed to avoid the most common causes of death, substance abuse and suicide. Stein and Dumaret (2011) and Hiller and Clair (2018) found that these young adults need support that gives them a sense of stability, compensatory attachments and continuity in their lives.
There is need for comprehensive services for young adults leaving care, such as early intervention from families, providing high-quality care and enabling gradual transition from care (Stein, 2006(Stein, , 2008Stein and Dumaret, 2011;Memarzia et al., 2015). Young adults need to be recognised, feel that they belong and have the possibility of action (Tö rrö nen, 2018a). As in the research noted, specific and most beneficial for young adults are the principles of empowerment, hope for the future, social support, meaning and purpose and connection to their caregivers (Kelly and Coughlan, 2019). Young people do not want only to be helped, but to be also important to someone, such as family, foster parents, other caregivers or friends. These kinds of relationships are reciprocal (Becker, 1986). They contain both advice and support via respectful dialogue about young adults' identity and self-esteem (Tö rrö nen, 2018b). According to Butterworthet al. (2017), this emphasises the importance of multi-agency cooperation, including young adults and their most important relationships and identifying who is responsible for mental health care and its coordination. This would also include effective, increased cooperation of social services and health care.
Although the study reached both peer researchers and young adults with experiences of the care system in two countries, it does not represent all the young people who have aged out of care. Although it is possible that this data collection did not reach the young adults who have experienced the most difficulty, it encompassed a variety of experiences. Some young people answered very briefly or sometimes even refused to answer some questions if they felt the interview theme was too personal, for instance when was asked about their livelihood and biological family. English youth seem to be more sensitive to these questions and sometimes actively declined to answer. Despite these methodological limitations, the collected data give good opportunities to observe young adults' own interpretations of their well-being.
The results of this study highlight the importance of caring relationships and social connectedness for young adults when leaving care that support their development and well-being, even though it does not guarantee mental well-being for each young person. As Gibb and Edwards (2017) concluded, sustaining progress is dependent on young adults having good networks and having their underlying needs met, especially regarding mental health.
Subsequently, improved health and well-being can lead to improved educational achievement, which may enrich the young adults' prospects of escaping poverty and the associated poor health and well-being (Fletcher, 2017). Exploring young adults' own evaluations of their social networks provides social work practitioners with sensitive information on how to find ways to empower young persons to support their mental health on their own terms.

Funding
This project received funding from the European Union's Horizon 2020 research and innovation programme under the Marie-Sklodowska grant agreement #702989.