To investigate the association of living in foster care (FC) with substance use and subjective well-being in a sample of secondary school students (11–16 years) in Wales in 2015/16, and to examine whether these associations are attenuated by the perceived quality of interpersonal relationships.Cross-sectional, population-based health behaviour and lifestyle questionnaire.Wales, UK; young people who took part in the 2015/16 School Health Research Network (SHRN) questionnaire (n=32 479).Health behaviours among young people in FC were compared with those from private households.The prevalence of all adverse outcomes was higher among young people in FC. Those in FC were significantly more likely to report mephedrone use , multiple substance misuse behaviours , poorer relationships with peers  and teachers , having experienced bullying , dating violence  and poor well-being . The association between FC and substance use remained significant, though was attenuated after accounting for relationship variables. The association between FC and subjective well-being became non-significant after adjustment for relationship variables.Young people living in FC experience significantly worse outcomes than young people not in care, likely due to a range of care and precare factors, which impact adversely on subsequent social relationships. The analyses are consistent with the hypothesis that the associations of FC with substance use and life satisfaction are partially explained by poorer quality social relationships. Large scale, longitudinal studies are required to investigate the relationship between being in care and health, educational and social outcomes. Mental health interventions and interventions to reduce substance use and improve well-being in FC should include a focus on supporting healthy social relationships. This study included a large sample size, which facilitated a robust modelling approach.School-level self-report data are not sufficient for understanding the trajectories of children. Strategic plans for data linkage would facilitate an understanding of the long-term impacts of health behaviours on outcomes.This study highlights a need for development and evaluation of interventions to improve outcomes among children in care, specifically those targeting relationship formation and maintenance.This cross-sectional design does not identify cause and effect.In 2015, there were around 1.8%A range of precare factors have been shown to be more common among young people who enter care than those who do not. A 2011 reviewMany of these adverse experiences, which are disproportionately experienced by LAYP, are linked to poorer health outcomesThis paper draws on a large school-based survey of the health and well-being of young people aged 11–16 in Wales. First, we examine associations of living in FC with substance use , subjective well-being and relationships with teachers, peers and romantic partners. Subsequently, we test the hypothesis that young people in FC will report poorer relationships with peers and teachers, and will be more likely to report experiences of bullying and dating violence. Finally, we examine the extent to which the associations of living in FC with substance use and poorer emotional well-being are attenuated by differences in the quality of social relationships.This study uses data collected from the School Health Research Network (SHRN) student health and well-being survey in Wales in 2015. At the time of the survey, network schools represented just over half  of all secondary schools in Wales (N=212), with representation in all 22 local authority areas. Schools were recruited to the network through three mechanisms. First, those participating in the Welsh Health Behaviour in School-aged Children (HBSC) survey in 2013/14et al69Questions on the use of mephedrone were adapted from the drugs questionnaire used in the Avon Longitudinal Study of Parents and Children (ALSPAC).Students were asked who they lived with, with options of mother, father, stepmother, stepfather, foster mother, foster father or other. For the purposes of these analyses, a ‘living arrangements’ variable was created whereby students were classified as living with both parents, a single mother, a single father, in a stepfamily or in foster arrangements. Young people who lived in other unspecified arrangements were excluded from analysis.Frequency of current smoking was measured by asking young people how often they smoked tobacco at present, with five response options: ‘I do not want to answer’; ‘I do not smoke’; ‘Less than once a week’; ‘At least once a week, but not every day’ and ‘Every day’. Young people were categorised as non-smokers, occasional smokers and weekly smokers.Alcohol use per drinking session was measured by asking young people ‘How many drinks containing alcohol do you have on a typical day when you are drinking?’ with response options of; ‘I never drink alcohol’; ‘Less than one drink’; ‘1 drink’; ‘2 drinks’; ‘3 drinks’; ‘4 drinks’; ‘5 or more drinks’ and ‘I do not want to answer’. These options were combined to produce a three-category ‘alcohol use per occasion’ variable . ‘Binge drinking’ was defined as five or more drinks per drinking session.Students were asked; ‘Have you ever taken cannabis in the last 30 days?’. They were then asked to indicate frequency of use with response options of; ‘Never’; ‘1–2 days’; ‘3–5 days’; ‘6–9 days’; ‘10–19 days’; ‘20–29 days’; ‘30 days or more’ and ‘I do not want to answer’. For analyses, a three-category past-month cannabis use variable was also examined  as a marker of current use.Students were asked ‘In your life have you ever tried mephedrone ?’ with response options of; ‘Yes’; ‘No’; and ‘I do not want to answer’. For analyses, a binary variable (‘mephedrone ever use’) was produced.To measure subjective well-being, students were asked to indicate on a scale of 0–10 how satisfied they were with their life, with a score of 0 indicating the ‘worst possible life’ and 10 the ‘best possible life’.Students were asked on a 5-point Likert scale (strongly agree to strongly disagree) whether they felt (1) that their teachers cared about them as a person and (2) that teachers at their school took pupils' ideas seriously. Both items were highly correlated (r=0.63) so summed to form a single item. Students were also asked the extent to which they agreed that they could count on their friends on a 7-point scale from strongly agree to strongly disagree. Finally, students were asked how often they had been bullied in the past couple of months in school .Young people were asked if they had ever been ‘seeing someone’. Those who said yes were asked if a partner had ever (1) made hurtful comments about them, (2) pushed, shoved or slapped them or (3) punched, kicked or beaten them up. Response options were never, once or twice, two or three times, 2–3 times a month, weekly or several times a week. When subjected to factor analysis, these items all indicated loadings of >0.5 on a single factor, and were hence summed to form a total ‘dating violence’ scale.Students indicated their sex, year and month of birth. To measure SES, participants completed the Family Affluence Scale (FAS).Schools returned a registration form indicating their intention to participate in the study. Schools informed parents about the survey using two of three methods  and parents had the option of withdrawing their child from data collection (‘opt-out’ consent procedure). The survey was voluntary and completed anonymously. The first question asked students for their consent to participate and if they said no, the survey automatically closed. Schools were provided with information and slides to share with students in advance of the survey.Reponses where the pupil did not wish to answer were excluded from analyses. Percentages for each level of substance use, life satisfaction and relationship quality are presented, broken down by living arrangements. Percentages are weighted to account for over-representation of minority ethnic groups within the sample. For ease of interpretation of subsequent regression analyses, the living arrangements variable was collapsed into a binary ‘non-foster care’  versus ‘foster care’ variable. Regression analyses were then used to examine the association of living in FC with substance use, relationship variables and life satisfaction. Owing to the small number of FC and the low prevalence of substance use, in order to maximise power, substance use variables were condensed into binary variables and subjected to binary logistic regression analysis. Subsequently, a combined substance use variable was created scored 0–3, indicating the number of risk factors  and subjected to ordinal regression analyses. For teacher relationship quality, ability to count on friends and life satisfaction, frequencies indicated substantial polarisation, with young people in FC at the higher or lower end of the distribution by comparison with peers. Hence, for these variables, multinomial regression models were constructed with three ordinal variables, with the middle category set as the reference. As associations for bullying were linear, the odds of being bullied were analysed using ordinal logistic regression. All models were adjusted for clustering at the school level, and adjusted for age, sex, ethnicity and SES. Finally, all models were rerun with the addition of relationship variables as mediators, to examine the extent to which associations of FC with these outcomes were attenuated by relationship variables. Following the hypothesis that the association of FC with substance use and well-being is partially explained by poorer quality interpersonal relationships, it was anticipated that the ORs and risk ratios for the FC would fall in the second set of models by comparison with the first.A total of 87 schools (77% of the 113 network schools) took part in the 2015 SHRN survey. Mean free school meal (FSM) entitlement (a marker of socioeconomic deprivation) was 16.9% within these 87 schools . Schools were also representative of schools in Wales according to academic attainment and school size. Thirty-six parents and 1137 children opted out of the survey. We did not capture information on the demographics of this group. A total of 32 479 young people within the eligible age range (11–16 years) completed the survey. Young people who provided sufficient data to categorise their current living arrangements were included in the analyses . Optional questions on drug use were completed within 76 of the 87 participating schools; there were no significant differences between schools which did or did not complete these items in terms of socio-demographic characteristics. Socio-demographic characteristics, and substance use outcomes, among young people included in analyses are presented in By comparison with young people living in private households, young people in FC reported higher rates of weekly smoking, binge drinking and recent cannabis use see . Young pRegression analyses, comparing young people in FC with participants in other living circumstances , indicated that those in FC were significantly more likely to be regular users of tobacco, alcohol and cannabis, and to have tried mephedrone ; Model 1As indicated in Model 2, where relationship variables are included in all models, experiences of dating violence and quality of teacher relationships were significantly associated with substance use outcomes and life satisfaction. Reports of having been bullied were significantly associated with all variables, other than cannabis use. Ability to count on friends was associated only with life satisfaction and with binge drinking. However, associations operated in inverse directions; young people who reported being better able to count on friends reported poorer life satisfaction, but were more likely to be binge drinkers. Once associations of relationship variables are accounted for in final models, the association of FC with subjective well-being was no longer statistically significant. In these models, there remains a significant association of FC for all substance use variables, but the association of FC with all outcomes is attenuated, in most cases by 20–30%. Hence, the analyses are consistent with a hypothesis that the associations of living in FC with substance use and life satisfaction are partially explaining by poorer quality social relationships.Consistent with international literature, this paper found that young people in FC in Wales had higher rates of use of substances  and poorer subjective well-being than those from private households.Associations of peer relationships were, however, more variable; while a higher perceived ability to count on friends was associated with significantly improved subjective well-being, it was not associated with most substance use outcomes. The clearest association was for alcohol, with a higher ability to count on friends associated with a higher risk of binge drinking. This is perhaps unsurprising given an extant literature demonstrating the roles of alcohol in social bonding and friendship formation, and the socially contagious nature of substance use during adolescence.To the best of our knowledge, this study is the first to examine the role of social relationships experienced by LAYP in attenuating associations with substance use and subjective well-being. After adjusting for relationship variables, the association of FC with subjective well-being diminished to below significance. Although there remained a significant association of FC for all substance use variables, ORs for all outcomes were reduced substantially. Hence, the findings are consistent with a hypothesis that poorer substance use and subjective well-being outcomes for LAYP are partly explained by difficulties in social relationships.The cross-sectional design of this study means that causality cannot be established. Notably, the research team plans to include unique identifiers in future rounds of the survey, which will enable longitudinal analyses of trajectories in care among secondary school-aged children. The sensitivity of some of the topics, for example, intimate partner violence and substance use, may have led to under-reporting. The paper involved secondary analyses of a data set not designed explicitly for this purpose, and while most of the measures are adopted from previous surveys, some (such as measures of novel psycho-active substances) have not been widely used previously. All models were adjusted for SES; however, we are uncertain of the validity of this measure, based on family affluence, for use among young people in FC since they have been exposed to more than one household. The indicator for living in care was a crude measure of care status. The survey question may have been confusing for children living at home under placement with parent regulations, or for children living in kinship care, neither of which may have acknowledged they were under care orders. This may have led to children with care experiences being in the comparator group. We measured only current FC status rather than histories of care: the survey did not assess duration and number of placements, which have been associated with poorer outcomes among young people in FC.Nevertheless, the study signals some important future directions for research. There remains a range of potential mechanisms underlying the associations observed, which could be usefully tested in future research. For example, disentangling the contribution of dimensions of the care experience to outcomes, such as placement instability, from precare adverse experiences, is an important future direction. The development of more high-quality data infrastructure for monitoring outcomes among young people in care longitudinally is an important potential future direction. At present, national cohorts are incomplete,The study has important implications for policy and practice. First, intervention approaches to improve well-being and reduce substance use among young people in foster care should include a focus on supporting LAYP in the development of healthy interpersonal relationships. This may, for example, require appropriate therapeutic interventions such as counselling and other psychological therapies on entering care in order to mitigate the effects of precare ACEs on the formation of future relationships. School-based interventions to reduce bullying, promote healthy romantic relationships and positive teacher–student relationships in the school setting may play an important role in mitigating the tendency for already disadvantaged young people experiencing further difficulties in social relationships with teachers, peers and romantic partners. Finally, changes to service and research infrastructure, including data collection, sharing and analyses systems among local authorities, hospitals, general practitioners and other services that come into contact with young people in care are required to facilitate large-scale interdisciplinary studies that can provide a mechanism for outlining epidemiology, and for monitoring and informing new and existing interventions.


What if many of the commonly performed surgeries were no better than placebo and surgeons performing them were no better than practitioners of alternative medicine?That is the tantalizing message that Prof. Ian Harris has put forth in his latest book, a thought-provoking, well-researched and informative book addressed to a specialized audience within surgery and medicine but also of value to a general audience.The book covers three topics throughout: the placebo effect , evidence-based practice (namely Chapters two and seven), and examples of contemporary and historical sham surgery . However, from the start (Introduction), the book already sets the basic contrast between placebo and evidence-based practice. The latter is identified with labels such as good science, evidence-based, experiment-based decision making, empirical, reality-centered, objective, and attending to specific therapeutic effects. The former is identified with labels such as bad science, tradition-based, assessment-based decision making, observational, perception-dependent, subjective, and biased by perceived therapeutic effects. The Introduction also contains the disclaimer that not all surgery is sham nor that surgeons intentionally perform sham surgery, and in so doing also sets the main focus of the book, which is on placebo surgery rather than on all surgery. The last chapter (Chapter nine) wraps up with recommendations for patients, doctors, researchers, funders, and society, in general.What I find most compelling is that this is a book borne out of the professional experience of the author (Harris himself being an orthopedic surgeon) and reflects on the author’s own discovery of the evidence, or lack of thereof, behind his training and expertise. This makes the book a manifesto for science in medicine, in general, and for the use of the scientific method in surgery, in particular.when to operate, but the best surgeons know when not to operate (p. 186); “largely, surgeons believe that they are doing the right thing” (p. 2); while “the proponents of any particular operation usually have a scientific explanation to justify the treatment” (p. 22)—and of the multiple opportunities and limitations that influence a surgeon’s ultimate decision whether to operate or not—“To a man with a hammer, everything looks like a nail. Surgeons operate – it is what they do” (p. 256); plus the plethora other reasons behind the persistence of ineffective surgery (Chapter 7).Indeed, because Harris is a trained surgeon, he knows first-hand the ins and outs of how surgeons are trained— “Medical  training. . . is too much of an apprenticeship” (p. 198); and “surgeons tend to dwell on the technical aspects of surgery” (p. 31)—, how they think—“There is a saying in surgery: any surgeon can operate; a good surgeon knows Above training, thinking, and decision-making mean for Harris that surgeons are very well-trained and capable technicians but not necessarily versed in the science that supports their trade. For the technical aspects of surgery “may be relevant, but they are not necessarily aligned with a measurable clinical benefit for the patient” (p. 31); surgeons thinking (or assuming) they are doing the right thing does not imply they are “aware of the strength (or weakness) of the supporting evidence” (p. 2); and “a scientific plausible explanation is no guarantee that the treatment works” (p. 22). Thus, it is here where Harris own inroad into the scientific method, the scientific debunking of non-scientific beliefs, and into evidence-based medicine provides value to surgery.Ultimately, science and the practice of medicine are two separate worlds with different ethical standards. “Science takes a global, societal perspective in which the risk to the individual is balanced against the potential good to society. The practice of medicine tends to concentrate on the individual, avoiding harm or risk wherever possible” (p. 81). That is, while science researches populations, anonymizing the individual in favor of group statistics, surgeons necessarily decide at the individual level, where idiosyncrasies occur. And although Harris’s book shows awareness of both worlds, it far too readily dismisses the latter in favor of the former. Furthermore, the science that Harris portrays is one based on frequentist statistics, on ascertaining the probability of surgery effectiveness when assuming that it is not going to be different than placebo. But surgical practice implies a Bayesian mindset, of ascertaining the probability of making a difference  if performing surgery (successfully). Ironically, even the science that Harris proposes is based on the simpler tests of statistical significance, where only a difference can be tested but nothing is warranted otherwise . Despite those shortcomings, however, Harris makes a good attempt to bridge both worlds by book’s end, making it a worthwhile reference in a surgeon’s library.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


N = 37 RHY). Data were analyzed with a theory-driven and inductive systematic content analysis approach. Half of participants (54%) were female; almost half (49%) identified as non-heterosexual; and 42% were African American/Black, 31% were Latino/Hispanic, and 28% were White/other. Results indicated that because RHY are a uniquely challenged population, distrustful of service settings and professional adults and skilled at surviving independently, the population-tailored approaches found in RHY-specific settings are vital to settings’ abilities to effectively engage and serve RHY. We found the following four major themes regarding the positive effects of settings: (1) engaging with an RHY setting was emotionally challenging and frightening, and thus the experiences of safety and services tailored to RHY needs were critical; (2) instrumental support from staff was vital and most effective when received in a context of emotional support; (3) RHY were skilled at survival on the streets, but benefited from socialization into more traditional systems to foster future independent living; and (4) follow-through and aftercare were needed as RHY transitioned out of services. With respect to gaps in settings, RHY highlighted the following: (1) a desire for better management of tension between youths’ needs for structure and wishes for autonomy and (2) lack of RHY input into program governance. This study advances our understanding of RHY, their service needs, and the ways settings meet these needs, as well as remaining gaps. It underscores the vital, life-changing, and even life-saving role these settings play for RHY.Runaway and homeless youth (RHY) comprise a large population of young people who reside outside the control and protection of parents and guardians and who experience numerous traumas and risk factors, but few buffering resources. Specialized settings have developed to serve RHY, but little is known about their effects. The present cross-sectional qualitative descriptive study, grounded in the positive youth development approach and the Youth Program Quality Assessment model, addressed this gap in the literature. From a larger sample of 29 RHY-specific settings across New York State, RHY ages 16–21 from 11 settings were purposively sampled for semi-structured in-depth interviews on their transitions into homelessness, experiences with settings, and unmet needs ( Runaway and homeless youth (RHY) comprise a large and growing population of highly vulnerable adolescents and young adults in the United States . RHY emeOver the past few decades, a set of specialized settings has evolved to provide services to this population of young people. These include outreach programs, short-term emergency shelters, and long-term programs such as drop-in centers (DICs) and residential facilities called transitional living programs (TLPs). Yet to date, relatively little research has focused on understanding these settings, their effects on youth, and gaps that remain. Some past studies have been conducted on single behavioral interventions for RHY, such as HIV prevention programs , 18, andThis study was guided by the positive youth development (PYD) approach , the accGiven the high prevalence of abuse and maltreatment in the lives of RHY, the settings that serve RHY commonly draw on a trauma-informed care approach , 26. TraN = 29) across a large but discrete geographical area, New York State  and with regard to location (upstate/downstate) and setting type . We sampled 11 settings, described in Table Study activities were carried out by a team of experienced master’s and doctoral level researchers from diverse disciplines including anthropology, social work, and psychology with expertise in RHY, qualitative methods, and organizational structures. Research team members made on-site visits lasting 1–2 days each to each of the 11 selected settings. Program administrators informed RHY in advance that study visits would be taking place, and RHY were directly recruited by research study staff in the settings. Each in-depth interview lasted 60–90 min and was audio-recorded and professionally transcribed verbatim.Participants were (1) age 16–21 years; (2) active client of the setting ; (3) approval of an appropriate child advocate if aged 16 or 17 years ; and (4) not currently in foster care . Note that youth enrolled in foster care are not commonly found in settings for RHY.Runaway and homeless youth aged 18 years or older gave signed informed consent for participation in the in-depth interviews. We obtained a waiver of parental consent from the Institutional Review Board for RHY ages 16 or 17 years. These young people provided signed informed assent, and we also elicited the approval of a child advocate in the setting in the form of a signature on the assent form, before the youth’s participation.Runaway and homeless youth clients were compensated $30 for their participation in the in-depth interviews.We used a semi-structured interview guide grounded in the YPQA model. The interview guide explored RHY clients’ backgrounds and paths to homelessness (for context) and perspectives on the offering- and organizational-level characteristics of the setting. With respect to background factors and the path to homelessness, the semi-structured interview guide included questions on the participant’s concept of “homelessness,” first experiences out-of-home, relationships with family, and experiences with and perspectives on RHY service settings, beginning with the RHY client’s first experience with such settings. Regarding offering-level characteristics, the interview guide focused on the setting where the RHY client was recruited for this study and probed for his/her perspectives on strengths and weaknesses in the setting, striving to go beyond the socially desirable response and also to elicit emergent and unexpected themes. Grounded in the YPQA model, the guide included questions on the extent to which the setting provided an emotionally and physically safe environment; the extent to which RHY clients felt supported in the setting, and how that support was provided (including relationships with staff and other RHY clients); aspects of interactions with and relationships between RHY clients and staff; and the extent to RHY clients’ involvement in their own goals and future plans. Thus, the YPQA model is positioned to document the use of a trauma-informed care in settings, as the model attends to relational/attachment aspects of settings. Some organizational-level characteristics may not be apparent to clients in a setting, but some indices on the YPQA are expected to directly affect clients. Thus, the interview guide posed questions about organizational-level characteristics such as staff members’ expectations for RHY clients, whether RHY clients have influence over programmatic activities and/or governance of the setting, and factors pertaining to access. Specific examples were elicited from participants where appropriate. Sociodemographic information  was collected for each participant.We analyzed the qualitative data using an approach that was both theory-driven and inductive using the Dedoose platform , taking a systematic content analysis approach . The anaNext, emphasis shifted from coding to identifying larger themes. The full analytic team comprised of the two data analysts and senior research staff formed an “interpretive community” , which eWe attended to the methodological rigor of the data collection process through periodic review of transcripts and process memos written at the time of each setting visit to attend to fidelity to the interview guides and quality of data and thereby ensure consistency across interviewers. Furthermore, the senior team members conducted regular debriefing with the research field team, and a review of transcripts was conducted by an expert in RHY settings . MethodoAs shown in Table As detailed in the analysis below, RHY clients identified a number of meaningful ways in which RHY-specific settings cultivated a sense of optimism, resilience, and feelings of wellbeing, as well as enhancements in behavioral functioning. Moreover, these young people provided their perspectives on some ways in which settings, even higher-quality settings, could improve. Overall, we found the specialized nature of RHY-specific settings was critical to the effectiveness of their work with RHY. Particularly, from the perspectives of RHY, a population-specific approach tailored to their specific needs was apparent in these settings, from the physical environment, through a particular skill set of staff, and the theoretical approaches informing services and treatments. This tailored approach reflected the fact these highly vulnerable youth typically presented to settings with a great sense of distrust of both professional adults and social services. This distrust complicated RHY clients’ processes of engaging in settings, as well as their ongoing experiences with settings. Indeed, we found RHY had experiences with various types of settings over their lifetimes, some RHY-specific and some not, and reported the greatest benefits from RHY-specific programs, as described below.With respect to the primary specific positive effects of RHY-specific settings on these young people, analyses revealed four main themes. (1) The process of first engaging with an RHY setting was experienced with trepidation and was fraught with emotion and meaning, and the experience of safety within RHY settings was critical to facilitating young peoples’ transition out of acute crisis and into service provision. (2) Instrumental support; that is, tangible help and services, was seen as vital and was most effective when received within the context of emotional support. (3) RHY clients showed a high level of skill related to survival outside of the home, on the street, and away from the guidance of their family of origin. Yet, competencies to thrive in other settings were less evident. Therefore, RHY settings were critical for RHY to build resilience, optimism, and confidence regarding the possibility of future successful engagement with the larger society. (4) Follow-through and aftercare were seen as vital as RHY clients transitioned out of service provision.Regarding RHY’s perspectives on gaps in services and needs for program improvement, the main themes in this analysis were (1) the need for settings to better address the tension between RHY’s perceived need for structure and their desire for autonomy and (2) a lack of understanding of and input into program governance among RHY in many settings. Names used below are pseudonyms, and some identifying details have been changed to protect the confidentiality of both RHY clients and the settings. For context, in the sections below, we provide a number of sociodemographic characteristics describing participants who are quoted, including age, sex at birth or gender identity if transgender, and race/ethnicity. (RHY were cis-gender unless otherwise noted.)Runaway and homeless youth typically described their past circumstances, and in some cases, their current situations, whether they thought of themselves as “homeless” or not, as characterized by chaotic and unstable environments that disallowed the physical or emotional space needed to adequately reflect on their current situation, and consequently, impeded their abilities to imagine a different, and perhaps more desirable, developmental trajectory.  In particular, many RHY described that before engaging with RHY-specific settings, they existed crisis-to-crisis, attending only to survival and basic needs. For most, this overall sense of living in chaos and instability stemmed from the experiences of multiple and overlapping traumas perpetrated by families, individuals they encountered in the street, and police and other authorities; this sense of chaos was often complicated by poverty and the need to cope with these experiences to survive. Specifically, these traumas were described as common in both their earlier and more recent lives. Traumas reported ranged from experiences of physical, emotional, and sexual abuse; physical and emotional neglect; non-acceptance of their sexual orientations and/or transgender gender identities; extreme scarcity of resources ; mental health and substance use problems; legal and immigration issues; and police targeting and/or harassment.The process of becoming homeless and engaging with RHY-specific settings was typically complicated and fraught for RHY. A substantial proportion of RHY gradually but perceptibly transitioned from residing with their families to either street homelessness or unstable housing. For example, RHY typically left and then returned home a number of times or were forced to leave home a number of times, before finally realizing they could not or were not permitted to return. Yet, we found these young people typically did not connect emotionally to that reality. Nor did they fully understand they were, in fact, engaged in a process of becoming disengaged from the care of their families, leading to the state of being homeless. Most RHY described the initial realization they were actually out-of-home or homeless as “a complete shock.”Runaway and homeless youth’s initial reactions to homelessness were particularly important as youth first began to experience various aspects of RHY-specific settings. A lack of emotional connection to the process of becoming homeless often contributed to a situation wherein the young person’s experiences, needs, and treatment goals were both difficult for them to articulate to RHY settings and highly variable. This, in turn, complicated the engagement and treatment efforts of RHY settings and created a need for programmatic flexibility to assist RHY to set goals and understand expectations, whether on a more micro, immediate interpersonal/behavioral level or on a more macro level, dealing directly with a youth’s long-term life trajectory. Indeed, a deep understanding of RHY’s backgrounds and the effects traumatic life experiences was critical for staff within RHY settings to provide a sense of physical and emotional safety and to build relationships with individual youth.I honestly (at first) felt more safe in the street than I felt in one of those shelters … I did an intake asking for all my problems, and I’m like no, no, no you’re not going to get me anywhere. Just like, the atmosphere. It was brand new to me. I’d never been to that. So, coming to that environment was like … I’d rather be on the streets because I know the streets. I don’t know the shelters.When reflecting on their initial engagement with RHY-specific programs, RHY typically reported feeling trepidation, resistance, and fear, and anticipated being treated poorly or even being in physical danger upon entering these settings. Many RHY had preconceived, negative views of social service settings in general, and often conflated any type of program dealing with homelessness, either for youth or adults, with stereotypical warehousing of people into dangerous situations. Indeed, many older RHY already had some experience with adult treatment settings and family shelters in their very early lives. This, and the fact that many programs were seen as a poor substitute for a loving and supportive family, made making the transition into even RHY-specific settings particularly challenging for RHY. Olivia was a 21-year-old African American transgender woman. She described,When I thought (about) a shelter, I thought of like a big room with bunk beds that people sleep in at night. That’s what I thought. And I didn’t want to do that. But when my guidance counselor had told me about [the RHY-specific TLP], and told me it was a house setting, I went for the intake, which is like an interview. And they accepted me. And I came. And from there I stayed.Thus, particularly early in their transition into homelessness, RHY clients commonly reported strong, often ambivalent, or even negative, feelings about social service settings, which served as an impediment to their engagement with RHY-specific settings, even those that could provide vital housing services. As Kayla, a 21-year-old White female notes,A lot of people, they think of a shelter and they probably immediately think of this really dark, dreary kind of place. And it’s true for most places, but [this RHY] shelter is set up like a home. So it’s really a fun, welcoming environment that really helps you, and supports you, and listens to you. So it’s really awesome.We found that RHY clients did not, in fact, experience RHY-specific settings as at all comparable to adult shelters or service settings. Instead, RHY generally experienced RHY-specific settings, particularly DICs and TLPs, as safe, and in many cases, “homey.” This was vital because RHY clients, as would be expected, felt the loss of their families and homes acutely. Indeed, before their initial engagement, RHY-specific programs were often associated with the emotional chaos RHY were experiencing as they transitioned to homelessness, the loss of their families, and then the realization they were officially out-of-home, resulting in initial hesitancy to engage with programs. In this context, RHY clients prioritized the need for a physically and emotionally safe environment in which they could begin to assess their current situations and to better manage the transition from homelessness to engagement with other types of services and/or into transitional housing. For example, Olivia, mentioned earlier, compared her initial apprehension with her actual experience with an urban TLP:Within this context youth noted they were able to work with staff and even other youth to take the time to gradually identify and address their individual issues, and that this time and space were instrumental in this transition from the streets to an RHY setting. Indeed, we found young people repeatedly distinguished between RHY-specific programs and other types of shelters and group homes, such as foster care settings, consistently reporting that RHY-specific programs were better able to understand them and meet their needs. Thus, we found RHY’s experiences with and knowledge of various both youth and adult shelters and service settings provided a useful contrast to their perspectives on RHY-specific settings, and thereby highlighted the benefits of RHY-specific settings such as crisis shelters, DICs, and TLPs.Yeah, you know, like [RHY programs] help you become more independent. It’s … more like a process. It takes time. And it’s actually, it’s time that you can actually deal with and you can actually handle … Once you get kicked out of your house, … you’ve got to develop that mindset, to survive. At least here, at [this RHY program] it’s like you have time to actually think about stuff, whereas on the street or at [an RHY crisis shelter], it’s more like you’re in survival mode. So, … it’s good to actually have some space to actually breathe. Sometimes I’m just here, just thinking about life in general. You know, like how the world works and why people think the way they think … So, it’s like being in this [RHY program] environment, it’s possible to think about those things … [Here] it’s more of a peace of a mind. You’re just quiet.Runaway and homeless youth clients almost universally viewed RHY-specific programs as unique in their abilities to provide a safe and at least relatively stable environment, in stark contrast to RHY clients’ experiences with abusive families, street homelessness, and to some degree with adult shelters. For example, Ronald was a 20-year-old African American man with past experiences with street homelessness in a large urban environment, adult and youth crisis shelters, and with RHY-specific programs, which he compared and contrasted:Yes, it’s actually really nice there. At first, I was really hesitant to go ’cause I been in the shelter since June of last year, and I was kind of getting sick of shelters. And once I got here—it’s better than a shelter. It’s more homey … They’re more considerate and understanding. I thought it was going to be like, I’m gonna have to watch my back 24/7, watch my things. But here I can leave something out and it won’t disappear. I can talk to any of the (staff) and they won’t get an attitude or get mad. It’s just a friendly and welcoming environment, and I didn’t think it would be … It’s better than a (youth) shelter. It’s more homey … Not only is their food way better, but they’re more welcoming. More of a homey environment.Similarly, Jessica, an 18-year-old pregnant Latina woman living in a TLP that serves pregnant RHY and youth mothers, contrasted her experiences in youth shelters with the “family-like” environment of long-term RHY programs that were characterized by a sense of safety and warmth.Thus, RHY clients stressed that the tailored environments and modes of engaging in RHY-specific settings were critical to their willingness and ability to transition from crisis and chaos into receiving services. However, youth crisis shelters were challenging environments for many because of the large numbers of RHY in a state of crisis and chaos, the short-term nature of placements, and the lack of stability to allow newer RHY to find peer role models and guides. Yet, crisis shelters were the vital bridge to the next step for RHY, whether that was to return home or enter a long-term facility such as a TLP.Once youth had made the transition into receiving RHY-specific services in DICs and TLPs, they reported benefiting greatly not only from the safety and security there, but also from the various resources and programs these settings provided. In these RHY-specific settings, RHY clients received basic necessities such as food, clothing, and housing, and staff also helped them prepare to apply for jobs, continuing education, housing, and other programs for which they might be qualified. For most RHY clients, simply having staff to assist them in navigating the otherwise daunting world of non-RHY social services was vital. For example, RHY clients typically needed help obtaining state-issued identification required for applications for school, employment, and public assistance benefits, all of which are essential to transitioning out of homelessness and becoming more self-sufficient. While obtaining identification is a relatively straightforward task for adults and adolescents generally, RHY clients typically had no access to needed documents such as birth certificates, and they often lacked familiarity and comfort with large bureaucracies designed to provide services to adults. Indeed, RHY clients commonly described themselves as well socialized into the norms of the street, but as less able to navigate more conventional settings.I came into this program with basically nothing. No clothes, no food, no money. And I didn’t basically have anything to fall back on. And they made sure that by the time I got to where I am now that I have everything that I need to make sure that I’m independent, an independent youth. And being at a young age like 14, 15, 16 years old, not a lot of kids survive. And [they] would usually have nothing if they went through something that I’ve been through. And I just can say it’s been a blessing to have them support me through it all. They’ve helped me get back in school to get my GED. They’ve helped me find jobs. Helped me become more independent with myself, and be comfortable in my community. They’ve helped me find apartments. I don’t think I’d have made it this far on my own if I never knew about them.Notably, many RHY clients reported that emotional support was a critical complement to instrumental support. This emotional support helped them overcome bureaucratic obstacles and to prepare for potential rejection. RHY clients commonly referred to RHY-specific programs as operating as a type of surrogate family, and youth repeatedly cited benefiting from such instrumental support as transportation costs, referrals to other programs such as vocational training and mental health services, and programs that catered to RHY clients’ individual interests , always within the context of emotional support and one-on-one guidance. As Maya, a 20-year-old Latina transgender woman with multiple years of experience in both DICs and TLPs noted,Throughout interviews with RHY clients in both DIC and TLP settings, RHY consistently highlighted the ability of RHY-specific programs to provide the thoroughly integrated instrumental and emotional support that distinguished these programs from non-RHY programs, and which they ultimately said provided the greatest benefit to them through their transition out of homelessness.Before I became homeless, I was never the type of person to ask for anything. I was so shy I would never ask. I would never ask, I barely listened, and I was just the type of person that liked to do things on my own. But when it comes down to it, my mom would do whatever I didn’t know how to do. So, I decided to take a different route and go out of my comfort zone and do what I had to do to get myself up there in the world … [In our groups in the TLP] I feel like I could talk about anything around them, like, we’ve got so much in common. But I’ve always thought [groups] were weird until I moved into the [RHY setting] and now I’m just ready to ask questions. Questions popping up in my mind, I ask, and I tell them experiences I’ve had or things I’ve heard, and I’m looking for answers and I’m asking questions.Fostering resilience, confidence, and optimism among RHY clients, within the context of their past and ongoing traumatic experiences, was a key function of RHY-specific settings. As many young people noted, months or even years of nearly uninterrupted trauma and relative social isolation left them suspicious and distrustful of others. For example, RHY clients often described themselves as feeling unbearably anxious, confused, or “shy” in unfamiliar settings. For many RHY clients, and especially those who reported a lengthy history of abuse, developing confidence in their abilities to succeed outside of the streets and RHY-specific settings often translated into the capacity to simply have the courage to ask for assistance when necessary. For most, this was made possible by the ability to have prolonged interactions with other RHY clients and with staff in a safe and supportive environment wherein self-expression was valued, and de-escalation of conflict and positive communication were actively taught. Jessica, mentioned earlier, described her experience as follows:Because in life, you know, you’re always gonna have questions. So you have to learn how to ask questions, when to ask questions. Even if it’s something that you think is the most obvious thing—ask the question.”Similarly, Ronald the 20-year-old man described earlier, stated: “It’s fun and kind of brought me out of my comfort zone. I was always nervous meeting people. I was always too shy. I really like staying in my room, reading stories, writing, and stuff like that. But [my boyfriend] brought me here and kinda made me come out more and meet new people and things like that. Well I started to talk more and stuff like that. I started feeling not so shy and stuff like that. I started talking, doing more active and stuff like that … Um, maybe like I wanna walk out more and go places and stuff like that … Probably meeting new people and Like seeing how some people are nice and stuff like that.For others in DICs in particular, simply being able to interact with similarly experienced peers in a relatively stable environment was enough to allow social skills and confidence to begin to develop. Tabatha, a 21-year-old White female who frequented a rural DIC, noted,So one thing I learned right off the back is never tell myself no. Before I even moved to New York State, I had a long history of homelessness with my mother as a young child … Another thing I did to assess my life was [to stop] speaking negatively about myself to myself. I didn’t so much focus on the outside at first, but I really looked at me on the inside and how I really felt about myself. And that’s where I started to change my life. In [the TLP].Again, citing the negative psychological effects of chronic homelessness, others reported the emotional space provided by TLPs led even more directly to developing self-confidence and resilience. Angeleae was a 19-year-old African American woman who described,I’m at the last part of it all. So, they’re still gonna help me, and they’re not gonna stop until I reach my goals. And I like that about the (RHY setting).” Similarly, Aisha, a 21-year-old African American woman living in a TLP noted,Once you leave one of their programs, they’ll still check in with you, even if it’s through text or they’ll give you a call or e-mail you. They’re trying to reach out any way they can and ask you, how’s it going? What’s going on? Are you guys getting along? Just different things along that nature. Do you need any money for food or anything like that. So, they’re still there for you in a capacity they can be. And I do believe they have a program, like within the [RHY setting] and that’s like their whole goal. I think it’s called Aftercare or something like that.Finally, RHY clients who were considered to be “graduated” from a TLP expressed a strong sense of appreciation of knowing that they had the ability to reach out to RHY staff even after having “aged out” or “timed out.” Youth and staff alike repeatedly stressed the importance of having a clear understanding that the instrumental and emotional support that characterized the RHY client’s time with the program would never completely terminate. As Madison, a 20-year-old transgender woman at a semi-urban TLP described, “Given the paucity of long-term supports in RHY clients’ lives, the support of understanding and caring adults, even after they age out of services, was comforting for RHY clients and increased their sense of confidence that they could survive in their post-RHY-service world. Just as families provide support to their emerging adult offspring, RHY settings maintained connections with former clients as they moved to the next developmental level.In the following section we describe RHY clients’ perspectives on ways settings could improve. One of the most influential factors in RHY settings was the successful navigation of the complex tension between young peoples’ needs for structure and their desires for autonomy. Yet, this balance was not easy to achieve, and the mechanisms through which this balance came about were not always apparent in youths’ statements. While many RHY clients were eventually aware that this tension between support and autonomy was perhaps inevitable in these settings, many youth, and particularly those who were still adjusting to life in an RHY-specific setting, indicated some of the ways staff could do more to help RHY clients understand and benefit from a structured environment. For example, youth commonly recalled that as they began to develop confidence to question the conditions within which they were living, they gradually began to feel a need for increased autonomy, which, in turn, provoked a sense of unease related to their previously identified need for structure and security.They run it like they’re your parents and you’re supposed to tell them where you’re going, how you’re going, when you’ll be back. Like those are parenting things. That’s what they do. [But] I shouldn’t have to come back and have to tell you guys like, oh, I was here with this, this, and this. That’s what my parents are for.This was particularly evident in statements made by youth in TLPs. RHY clients in TLPs frequently moved fluidly back and forth between statements indicating extreme gratitude for the emotional and instrumental support of the staff on the one hand, and slight contempt for what they often described as overbearing and unnecessarily strict guidelines on the other. This tension is evident in how Evelyn, a 16-year-old White young mother at an urban TLP, described being supervised by TLP staff.You know [some RHY] wish they had [a room in a TLP], you know, what we have, because not everybody has it. But, I tell the people that it’s good, but then it’s not, because people want to be able to be on their own and do things on their own, instead of having to be in here. I like it, but then I don’t, because I want to be able to be on my own, and I have to be in a group program, where I’m still being watched because I kind of feel like I’m in my parent’s house. But I mean, other than that, the program is perfect. They help you with your GED classes, they try to make goals for you. Because if I don’t get on top of the goals, they’ll try to push you to gain that enthusiasm to go do those things even if you don’t want to.This tension was exacerbated in many cases by young people’s ambivalent feelings about being supervised within an RHY-specific setting by someone other than their parents, and, in many cases, caused ambivalent feelings about wanting to reunite with their parents. As Nathan, a 19-year-old White man in a semi-urban TLP pointed out,They see that [living in the TLP is] good because you get to [have a home], and use free electricity and all that other stuff. But that’s not the way that I look at it as. I look at it as, it’s an alright thing. But then it’s not. [Some] people want to be out on their own, and there’s people that don’t. I’m one of those people that want to be on my own. I mean, it’s not a good thing to me that I use the [electricity] here. And that, you know, I put nothing into [the TLP] moneywise because, of course, [electricity] cost money. After a while of you being in here, you feel like you’re not doing nothing for [the TLP]. I mean besides doing what they ask you do to. That’s just not enough … I want to feel like a normal person that is out on their own. I don’t feel like I’m doing enough, or giving enough.Many RHY clients also expressed this tension between the need for autonomy and support in terms of a frustration with other TLP residents who they perceived as less determined to meet their stated goals, and therefore as less deserving of equal services, and sometimes even less deserving of autonomy. One common theme was the tendency for youth to locate themselves and one another along a continuum of maturity that seemed dependent on how they viewed themselves and others engaging with the program in an earnest and purposeful manner. One of the ways that youth attempted to comparatively locate themselves along this continuum was through articulating a clear desire for self-sufficiency, in contrast to behavior that was referred to as “freeloading” or “taking advantage” of what the program had to offer. Indeed, for some, being perceived as genuinely desiring of self-sufficiency, which was equated with “normality” by many, might even be seen as a way of beginning to truly distance themselves from the stigma of “homelessness;” however, this term or situation might be conceptualized. As Nathan, described earlier, noted,The only thing that I didn’t like was that we had to be back at certain times for meetings, like, at five o’clock or four o’clock, and then we can leave again. But curfew times were, like, 10 and 11. But once I ended up going there, I decided to give it a chance. I had about a month left till I was having my baby, and the [RHY-specific setting] was pretty much my only option left.Nonetheless, given the gratitude that most youth showed for even the most basic services and support, many noted they were willing to capitulate to what they considered to be inconvenient or even unreasonable demands rather than face the street or a shelter again. As Jessica, the young pregnant woman mentioned earlier, noted,If you’re not working or at school or we’re not in groups, we can go out and do what we want, but there’s only like certain times. Like say I was out for probably an hour and a half, two hours. And then they told me I had come back and then I have to do chores and stuff like that. I used to live in group homes. I didn’t realize it was so much of a group home [here] in that we had to do things along that nature. In a homeless shelter you don’t do things like that. [In shelters] you come and go as you please. And [here] you’re so tired.Runaway and homeless youth client input into governance is a core tenet of the YPQA model that guided this study and a strongly held value in many RHY settings, consistent with the PYD approach. Yet, we found, aside from a small number of examples, youth input was limited to mundane household rules and decisions, making chore assignments, talking out interpersonal problems among residents, and settling disputes over issues such as internet access and usage. Moreover, and closely related to the internal and interpersonal debating over exactly what balance of structure and autonomy is appropriate for youth transitioning out of homelessness, one of the most notable areas for program improvement regarding youth’s psychosocial development had to do with the youth’s own understanding of the ways in which programs operated on an institutional level. In fact, a lack of understanding of the reasoning behind the perceived “strictness” of basic rules and regulations at times even lead to misunderstandings between staff and RHY. For instance, despite having an overall appreciation for the TLP in which she resided, Evelyn, the 16-year-old young mother described earlier, expressed such a degree of frustration over what she regarded as unnecessarily prohibitive requirements that she began to compare the TLP to non-RHY-specific homeless shelters or group homes:Indeed, a lack of RHY’s awareness and understanding of the reasoning behind many DIC and TLP rules and regulations was a recurring theme that pointed to a lack of communication between youth and staff regarding the institutional decision-making processes.we just comment.” However, it is unclear from many of the youth’s comments how this ambivalence relates simply to a lack of effort on the part of program staff to engage with youth at this level, or whether the lack of ownership over programs is something in which youth simply are not interested, or both.Most strikingly, throughout the majority of interviews, even when explicitly asked about the degree to which they were able to genuinely contribute to decision-making on this level, youth were frequently confused or needed time to respond, and the vast majority seems to have never considered themselves in this role. Indeed, most RHY clients did not seem to understand that their input could be something valuable to the setting. As one youth tellingly put it, “The study of the ways RHY-specific settings influence the lives and developmental trajectories of RHY and the mechanisms by which settings achieve those objectives, have received little attention in the research literature to date, particularly from the perspectives of RHY clients themselves. This study, guided by the YPQA and the PYD model, takes a descriptive qualitative approach to address these important research questions and thereby extends past research on RHY and RHY-specific settings. In addition to uncovering settings’ positive effects on RHY, as we discuss below, we further identify some specific organizational characteristics and services that RHY need, but that are lacking in settings. We also uncovered youths’ perspectives on ways in which RHY-specific settings, even those demonstrating higher quality, can improve. Importantly, we focus on youth in a diverse set of RHY-specific settings, which varied with respect to geographical location, type, services provided, and quality, which, we found during analyses, fostered the validity of study findings and their utility.The challenges RHY face throughout their lives, and resultant complications these create for locating, engaging, and serving them, are well documented in the research literature. Indeed, some of the most concerning effects of maltreatment and trauma experienced by RHY are distrust and fear of professional adults and service settings, which causes RHY to avoid presenting to or engaging with settings , 44. We First, we found settings are positioned to build positive, developmentally appropriate, and professional relationships with RHY. This emphasis on the centrality of relationships is consistent with attachment theory . In a paIn sum, this study findings suggest the utility of an integrated service approach and philosophy focused on relationships, the sequelae of trauma, engaging RHY in their own goals, and identifying and fostering strengths to address the needs of this complex population of young people. RHY experience these RHY-specific settings as purposively designed to address the barriers they face to service engagement and psychosocial change. Indeed, RHY experience these settings as uniquely positioned to engage and serve them, and as a result, as more useful to them overall than general adult or non-RHY youth settings. This specialized, tailored approach encourages RHY to engage with services they otherwise would very likely never come into contact with or would avoid and allows for the receipt of integrated instrumental, emotional, instructional, and quasi-familial support critical for transitioning out of homeless and into a safer, healthier, and more satisfying life trajectory. This study identified the ways settings assist RHY and also the mechanisms by which settings do so; for example, providing instrumental support integrated with emotional support and helping RHY build skills to interact with the systems they will need to master to function independently when they age out or time out of their present placements.As noted earlier, the YPQA was developed for youth after-school settings, and this study provides some support for the utility of the YPQA model for the study and evaluation of RHY-specific settings. With respect to offering-level characteristics of these settings, RHY highlighted the importance of a sense of physical and psychological/emotional safety they experience in RHY settings, particularly in the long-term settings. RHY view setting environments as supportive, and in particular note the positive effects of encouragement and skill building. They value settings as being home-like, and staff for standing in for family. Finally, engagement is evident in RHY clients’ involvement in their own goals and plans. In past research, we studied these offering-level characteristics using quantitative coded observations of programs within RHY-specific settings . The YPQOrganizational-level characteristics are generally assessed from the perspectives of staff, and may not always be evident to RHY . Yet, in this study, RHY did have some insights into organizational-level characteristics and highlighted both strengths and gaps. Findings reflect the salience and importance of youth-centered policies and practices in settings, an important component of PYD. While RHY note this philosophy in practice, for example, with respect to flexible goal setting, they also experience tension between their needs for autonomy and structure; for example, with respect to rules and regulations in some settings. In fact, balancing adolescents’ and young adults’ needs for autonomy with support and guidance is a challenge for all youth-serving settings, as well as in families , 48. ThiRunaway and homeless youth highlighted a general lack of youth involvement in the governance of settings; that is, they do not typically have input into the settings’ policies and practices. Yet, youth involvement is a key feature of the PYD approach and may be one critical aspect of fostering a sense of autonomy and engagement among youth and reducing frustration and tension between staff and RHY clients in settings. Furthermore, youth involvement/youth governance may be a potential solution to addressing another gap in settings identified by RHY clients; namely, the challenge of balancing RHY clients’ needs for autonomy with rules and expectations in settings. Thus, RHY clients and staff could work together to create rules and policies, which may, in turn, be more acceptable to RHY clients than those they experience as imposed upon them. Moreover, RHY express trepidation about aging out or timing out of services before they are ready for independent living, suggesting that program constraints may not always align with youths’ needs.The study focused on long-term RHY settings in a single geographic area in the United States, which may limit its generalizability. Furthermore, the non-random sampling method of RHY within settings was a potential limitation, as it may have introduced social desirability and other biases; for example, if only RHY with uniformly positive views of the setting were recruited. The triangulation of findings of youth within and across settings was used as a strategy to reduce such biases. Furthermore, as we described earlier, African American/Black and Latino/Hispanic young people and/or those with transgender gender identities and/or lesbian, gay, bisexual, and other non-heterosexual sexual orientations are overrepresented among the population RHY compared with the general population , 29, andThis study advances our understanding of the population of RHY, their service needs, the ways in which settings meet these needs, as well as gaps that remain. As such, it underscores the vital, life-changing, and even life-saving role these RHY-specific settings play in the development and wellbeing of this complex population of multiply challenged young people.The protocol was approved by the IRB at NYU. All subjects gave written informed consent in accordance with the Declaration of Helsinki.MG conceived of the overall study concept and design and writing the manuscript. RF planned the qualitative data collection effort, collected the data, led the effort to analyze and interpret data, and helped write the manuscript. AK collected data and played a leadership role in analyzing and interpreting data, as well as reviewing the manuscript. ES collected data and played a leadership role in analyzing and interpreting data. AR planned the data collection effort and played a leadership role in analyzing and interpreting data. CC, NL, AS, JP, and JB played a leadership role in analyzing and interpreting data.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This paper examines a constellation of ethical and editorial issues that have arisen since philosophers started to conduct, submit and publish empirical research. These issues encompass concerns over responsible authorship, fair treatment of human subjects, ethicality of experimental procedures, availability of data, unselective reporting and publishability of research findings. This study aims to assess whether the philosophical community has as yet successfully addressed such issues. To do so, the instructions for authors, submission process and published research papers of 29 main journals in philosophy have been considered and analyzed. In light of the evidence reported here, it is argued that the philosophical community has as yet failed to properly tackle such issues. The paper also delivers some recommendations for authors, reviewers and editors in the field. Optics an account of visual perception , usually encompasses concerns over falsification, fabrication, plagiarism, and the treatment of human and animal subjects, although some researchers have also argued that there are many other ethical considerations that researchers have to deal with in their work and which are not captured by RCR  Journals, a collection of open access journals, specifically states that open access applies to both the scientific literature and the supporting data. Arguably, data sharing benefits numerous research-related activities: reproducing analyses, testing secondary hypotheses, assessing novel statistical methods, teaching, meta-analysis and, possibly, preventing error, fraud and selective reporting.Further, on top of deciding whether replication studies can be considered for publication or not, journals also need to decide which policies should be adopted to make research outputs more replicable. It is crucially important that researchers state clearly the details of the experimental procedure that has been followed. In scientific disciplines, the “The issues that have been discussed above are “new” in philosophy and, at the same time, have clear bearing on experimental philosophy’s growth. As it turns out, the growth of an experimental philosophy movement raises a whole new set of editorial issues. Notably, issues that deal with experimental philosophy’s replicability are especially important, as some failed attempts to replicate key findings in the experimental philosophy literature have already been published  based on the information contained there. Hence, important information concerning ethical approval of the experimental study, contributorship and informed consent should ideally be contained there and accessible through a targeted keyword search. Second, it is possible to consider journals’ instructions for authors or submission guidelines. Instructions for authors are arguably the main way of communication between researchers, publishers and journal editors. They serve as a readily available tool for reaching potential authors. Clearly written instructions may provide assistance throughout the whole process of manuscript preparation and, as a consequence, it is a journal’s obligation to update instructions, inform authors about editorial policies, peer review policies, code of publication ethics, manuscript preparation preferences and requirements of accompanying documents for each submission , which is the most common measure of a journal’s impact and quality, although its flaws are also well-known and oft-cited  review articles. In light of the overlap between the two lists, the sample eventually included 29 journals, which are listed here below:NousPhilosophical studiesPhilosophy and Phenomenological ResearchMindAnalysisSyntheseMind and languagePhilosophers’ ImprintAustralasian journal of philosophyErkenntnisReview of Philosophy and PsychologyErgoPhilosophical ReviewPhilosophical QuarterlyCanadian Journal of PhilosophyPhilosophical PsychologyEthicsJournal of PhilosophyPhenomenology and the Cognitive SciencesJournal of Consciousness StudiesPhilosophical PerspectivesRatioJournal of Philosophical LogicPacific Philosophical QuarterlyAmerican Philosophical QuarterlyStudies in Philosophy and EducationEuropean Journal of Political TheoryProceedings of the Aristotelian SocietyEuropean Journal of PhilosophyIn light of this state of affairs, two other classifications of journals were considered. One quantitative ranking is provided by the h-index metric, and it is possible to find a ranking of philosophy journals based on this last metric.Journal of Experimental Psychology: Language, Memory and Cognition (IF 2.862)Journal of Experimental Psychology: General (IF 5.929)Psychological Science (IF 4.940)Cognition (IF 3.479)Journal of Personality and Social Psychology (IF 5.031)Frontiers in Psychology (IF 2.560 and Open Access)A group of psychology journals that could be used as benchmark for a comparison was also identified. Different rankings are popular in psychology and philosophy. Notably, in psychology, unlike philosophy, impact factors are typically calculated and often taken into account when choosing whether one particular outlet is better than another. In establishing the sample, those psychology journals that had been considered for the recent investigation of the reproducibility of psychological studies  were considered.The 4589 research articles published in the past 3 years in the 29 philosophy journals in our sample were accessed and analyzed, isolating experimental/empirical papers using a broad search strategy. Review articles, book reviews, errata, editorials, and corrigenda were not considered when looking at the research articles published in the past 3 years. The PDF version of the articles was accessed and the coder searched for the keywords ‘experiment,’ ‘empirical,’ ‘subject(s),’ ‘participant(s),’ ‘sample,’ ‘test,’ and ‘statistic.’ Also the words ‘interview’, ‘poll’, ‘case study’ and ‘survey’ were considered, to detect qualitative research articles: as stated in the previous sections, an assumption of this paper is that experimental philosophy includes qualitative research.Google Scholar as database: whilst this database is not necessarily the most accurate, as it is rather  liberal, other databases such as PhilPapers, Scopus, Web of Knowledge or PubMed are inadequate for this analysis as they either miss many citations outside the field of philosophy (Philpapers) or within the field of philosophy . The average number of citations per article can be used to shed further light on the impact and relevance of the sub-field of experimental philosophy. Finally, a search for the terms “Mechanical turk”, “M-turk” and “turk” was also conducted to determine whether the studies constituting the sample had relied on such a tool. Since similar crowd-sourcing services that are not offered by Amazon cannot be detected through this keywords based search, the estimate to be obtained is conservative.At this point, the 122 experimental philosophy articles were considered to determine whether the authors had addressed the issues of ethical approval and informed consent by searching for the terms ‘ethic’, ‘board’, ‘approved’, ‘Helsinki’, ‘committee’, ‘informed’, ‘consent’. The coder then searched for studies using the terms ‘contribut(ed),’ ‘authorship,’ ‘collected,’ or ‘analysed/zed” to look for mentions of authorship and authors’ contributions. The same was done with the 64 experimental psychology articles to obtain a benchmark against which to compare the results obtained in the case of philosophy papers. For the experimental philosophy articles the number of citations received so far was checked by referring to Philosophy and Phenomenological Research and Nous) or required submission fees (Philosophers’ Imprint). The following 15 questions were also considered when looking at the evidence:Is the journal a member of COPE?Does the journal inform authors of whether experimental papers can be submitted?Does the journal inform authors of whether replication studies could be submitted?Do the instructions for authors address the topic of justified authorship?Do the instructions for authors address the topic of ethical approval?Do the instructions for authors address the topic of informed consent?Do the instructions for authors address the topic of falsification or fabrication?Do the instructions for authors address the topic of data availability?Do the instructions for authors provide indications on article’s suggested sections and structure?Do the instructions for authors provide indications on fair and accurate reporting?Are the authors asked to provide statements of authorship and contributorship upon submission?Are the authors asked to confirm ethical approval upon submission?Are the authors asked to confirm that informed consent was obtained upon submission?Are the authors asked to confirm that their reporting of the experimental study is accurate upon submission?Are authors asked to upload data sets upon submission?Besides analyzing the research outputs published in philosophy journals and comparing them against psychology ones, further evidence was also considered by reviewing the instructions for authors of these journals, as well as the information provided to authors during the submission process. Whilst previous studies (e.g. Asai and Shingu http://publicationethics.org/members) was also considered, as not all journals that are members of COPE do list that information on their website.Notably, to answer question (1) the COPE webpage  and relevant variables. They were also used to explore whether there was a relationship between whether or not a philosophy journal belonged to COPE and whether the journal addressed responsible authorship, ethical approval, and informed consent in the instructions for authors.Point-biserial correlations were used to assess the relationship between number of citations and presence of author statement, ethical statement and reference to participants’ informed consent, and between number of authors and author statement, ethical statement and reference to participants’ informed consent. All analyses were performed using SPSS for Mac v.20.To ensure that idiosyncratic biases and coding errors did not affect the assessment of articles and journals, a second coder also coded articles from a random 23% of the experimental philosophy papers and 23% of the psychology papers considered by the primary coder (the author), as well as journals from a random 24% of the philosophy journals and 33% of psychology journals considered by the primary coder.Of the 122 experimental philosophy articles, 16 (13%) included ethical statements and 8 (7%) mentioned informed consent by participants. Also, 4 (3%) included authorship statements. In addition, 48 of them (39%) referred to use of Mechanical Turk. Finally, the average citations for these experimental papers was 8.65, and 32 (26%) of the 122 experimental articles had more than 10 citations.Erkenntnis, which lists a non-trivial number of traditions favorably considered by the journal, avoids referring to experimental philosophy and experimental studies:Erkenntnis […] concentrates on […]:EpistemologyPhilosophy of science, foundations and methodology of science in general and of natural and human sciences such as physics, biology, psychology, economics, social sciences in particularPhilosophy of mathematicsLogic, philosophy of logic, and all kinds of philosophical logicsPhilosophy of languageOntology, metaphysics, theory of modalityPhilosophical psychology, philosophy of mind, neurophilosophyPractical philosophy, i.e. ethics, philosophy of action, philosophy of law, etc.Further, of the 29 philosophy journals examined, 18 (62%) were members of COPE. Five of them (17%) seem to clarify whether they welcome empirical and experimental work but none of them addressed whether replication studies could be submitted. Interestingly, even the journal Synthese, whilst explicitly mentioning that formal approaches are accepted, fails to mention whether experimental work is welcome:Synthese is a philosophy journal focusing on contemporary issues in epistemology, philosophy of science, and related fields. More specifically, we divide our areas of interest into four groups: (1) epistemology, methodology, and philosophy of science, all broadly understood. (2) The foundations of logic and mathematics, where ‘logic’, ‘mathematics’, and ‘foundations’ are all broadly understood. (3) Formal methods in philosophy, including methods connecting philosophy to other academic fields. (4) Issues in ethics and the history and sociology of logic, mathematics, and science that contribute to the contemporary studies Synthese focuses on, as described in (1)–(3) above.Moreover, the journal Analysis, for instance, only writes that “in case of longer papers, it can be helpful to divide the piece into numbered sections, and the sections may also be given headings”.Further, 10 (34%) of these journals addressed in their guidelines the topic of responsible authorship, 7 24%) referred in their guidelines to ethical approval and informed consent. Also, 8 (28%) of the journals addressed in their guidelines the issue of data availability and 7 (24%) addressed the topic of data fabrication or falsification. Yet, none of the journals gave indications on fair reporting of procedures and results or on manuscript’s suggested sections. Notably, whilst philosophy journals do sometimes offer guidance on sections’ formatting, they fail to suggest a particular structure for articles or to demand that they include particular sections such as a “% referrep = .044; Odds Ratio (OR) = 10.00] and included reference to ethical approval . On the other hand, there was no statistically significant correlation between number of citations and whether authors addressed the topic of responsible authorship  and included reference to ethical approval , although a statistically significant correlation was found between number of citations and reference to participants’ informed consent in the paper . The correlation between the number of authors and whether authors addressed the topic of responsible authorship was statistically significant . There were no statistically significant correlations between number of authors and whether authors included reference to ethical approval , and whether articles included reference to participant’s consent .The results reveal a statistically significant association between COPE membership and whether journals’ guidelines for authors addressed the topic of responsible authorship , reference to informed consent  and authorship statement , to those that did not, differed significantly between philosophy and psychology articles (Table Chi square tests of independence were performed to explore the association between subject type (i.e. philosophy and psychology) and relevant variables as outlined below. The results of the Chi square tests revealed that the proportion of articles containing ethics statement [X2 , N = 186p < .001; ORadj = 57.91) and replications , as well as whether they referred to ethical approval , informed consent , availability of data , and indications on manuscript’s sections  in their instructions for authors. Further, there were statistically significant differences between the field of the journal and whether or not the journal referred to ethical approval , informed consent , responsible authorship , and fair reporting  during the submission process. On the other hand, the percentage of journals that are members of COPE compared to those that are not was not significantly different between philosophy and psychology journals . Also the proportion of journals addressing responsible authorship , data fabrication and falsification , and fair reporting  in their guidelines did not differ significantly between philosophy and psychology journals. There was also no statistically significant difference in the percentage of journals requesting authors to upload their data sets during the submission process between philosophy and psychology , and substantive in the case of information regarding informed consent (Cohen’s k = 0.78). Further, in the case of the random 23% of psychology articles examined also by a second coder, inter-rater reliability was perfect (Cohen’s k = 1) for the assessment of information concerning authorship statements, ethics statements and participants’ informed consent. With regard to the assessment of the instructions for authors and submission processes of the random 24% of the philosophy journals and 33% of the psychology journals that were also analyzed by a second coder, the agreement between raters was also extremely high. In particular, in the case of philosophy journals, reliability was perfect (Cohen’s k = 1) for the assessment of journals’ COPE membership as well as of information in the guidelines concerning need of ethical approval and informed consent, availability of data, responsible authorship, acceptability of empirical/experimental work, and data fabrication/falsification. Cohen’s k could not be computed due to lack of variability in codes for at least one of the raters for the assessment of instructions on manuscript’s structure, acceptability of replications and fair reporting, as well as for the analysis of requests of raw data upload and ethical approval, confirmation of fair reporting, responsible assignment of authorship and participants’ informed consent upon submission. Still, in all of these cases there was full agreement between coders, except in the case of the assessment of requests of ethical approval during the submission process, where there was disagreement on just 1 out of 7 journals examined. In addition, in the case of psychology journals reliability was perfect (Cohen’s k = 1) for the assessment of information on COPE membership as well as of instructions on data fabrication/falsification, manuscripts’ structure, responsible authorship, acceptability of replication studies, and fair reporting. Cohen’s k could not be computed due to lack of variability in codes for at least one of the raters for the assessment of guidelines on responsible authorship and participants’ informed consent, ethical approval, data availability, acceptability of experimental work and fair reporting, as well as for the analysis of requests of ethical approval, participants’ informed consent and upload of raw data during the submission process. Still, in all of these cases there was full agreement between coders, except in the case of the assessment of instructions on responsible authorship, where there was disagreement on 1 journal. Finally, the count of citations provided by the two coders was not analyzed statistically because their coding did not take place at the same time, and discrepancies were therefore expected.Finally, considering the assessment provided by the second coder, the reliability of coding was extremely high. Specifically, in the case of the random 23% of experimental philosophy papers scrutinized by a second coder as well, inter-rater reliability was perfect for the assessment of information concerning use of Mechanical Turk, authorship statements and ethics statements  is indeed impressive if compared to the impact factor of the few philosophy journals that have such number available, and even to the impact factor of psychology journals. For instance, the journal This work provides evidence for insufficient reporting of ethical and research integrity issues in experimental philosophy papers. Quite worryingly, this was the case also for the “most influential” papers: articles with a higher number of citations were not more likely to have authorship and ethical statements and to refer to participants’ informed consent than those with fewer citations. Notably, whilst experimental philosophers have declared that they wish to import the methods and tools of psychologists, it seems that they have not as yet followed in psychologists’ footsteps when it comes to adherence to research integrity and ethics issues.n = 8)The fact that research outputs do not provide relevant information concerning ethics and research integrity is consistent with a scenario in which philosophy journals have updated and well-informed guidelines and authors fail to follow the advice and instructions. But it is also consistent with a different scenario in which journals fail to provide authors with relevant information and instructions. Notably, this study also sheds light on which of these two scenarios best describes the current situation of philosophy journals. On the one hand, it turns out that most scientific journals have made important efforts to provide authors with accurate guidance on ethics, research integrity and good scholarship. But philosophy journals have not properly updated their instructions and requirements yet. These, again, are worrying outcomes. Failure to update journals’ instructions could be read as signifying that these journals and, in turn, the philosophical community, do not regard these as serious issues. A more encouraging result, however, is that, as predicted, COPE members have so far implemented more accurate and detailed guidelines and requests for authors. It should be noted that, in part, poor control of submissions’ adherence to standards of ethics and research integrity could be explained also by the fact that many philosophy journals  implies that certain requests that were elaborated in detail in some instructions for authors and just briefly mentioned in others would be equally scored. Similarly, articles’ statements could also vary significantly in their quality and accuracy. Fourth, the keyword-based search for information is clearly a non-perfectly reliable way to obtain information. At the same time, accuracy/efficiency trade-offs seem to strongly justify its use. To maintain acceptable levels of accuracy, however, the coders reviewed the texts themselves, compensating with some more careful reading when the keyword-based search was ineffective, instead of simply resorting to unsupervised automated methods for exploiting the information available in the papers  subjects, ethicality of experimental procedures, availability of data, unselective reporting and publishability of research outputs. This is in turn a problem for journals’ referees, who are research gatekeepers but cannot find in the journals’ guidelines clear advice on fundamental aspects of research integrity and quality. In light of this it seems that philosophy might not have the best practices in place when it comes to review papers that use empirical methods.Still, this exploration of conformity to principles of ethics, research integrity and good scholarship in the philosophical community does license a verdict that is at the same time quite clear and rather worrying. It seems that the philosophical community has so far failed to properly address the new constellation of ethical and editorial issues that philosophy’s experimental turn has raised. In particular, Mind states on its website that “the review at MIND is ‘triple-anonymous’—the identity of authors is not revealed to editors or referees unless and until a paper is accepted for publication”. Importantly, the philosophical community has devoted a lot of its attention to issues of fairness in review, but somewhat neglected the other crucial issues that have been explored in this paper, which might nevertheless be interfering with the quality of knowledge communication and that have long been addressed by other empirically-oriented research communities.Notably, this result might look particularly striking if we consider how much attention philosophers have devoted to some other sets of issues potentially affecting the transmission of knowledge. More precisely, journals have tried to find ways to fights biases in peer-review. There have long been complaints that peer review can be unfair. For instance, in the common ‘single-blind’ system, there are concerns about bias, knowing or unknowing, on grounds of sex, race, nationality, or field of study. Philosophy journals have typically looked at double-blind review systems as ways to tackle this problem. In some cases, even triple-blind peer review. For instance, the journal Psychdisclosure (http://psychdisclosure.org) is an open-science initiative that provides a platform for authors of recently published articles to disclose methodological design specification details that are not typically required under common reporting standards but that are at the same time critical for accurate interpretation and evaluation of reported findings. All in all, it seems that carefully reflecting on these aspects will be an important initial step towards the development of a more informed and considerate empirically-minded research community.The situation can be changed, obviously. It is recommended that journal guidelines and instructions in philosophy journals be accurately and promptly updated. Editors should clarify their policies, perhaps publishing editorials to discuss their in-house handling of such issues. Yet, until this is done, authors might also want to consider submitting experimental philosophy papers to psychology journals , which have proven to be better equipped to deal with empirical work. Notably, some psychology journals such as Frontiers in Psychology  and Theoretical and Philosophical Psychology explicitly welcome philosophical contributions.