Child Welfare and Children’s
Mental Health Services:A Decade of Transformation
By Ken Olson, LCPC, Executive
Director, KidsPeace National Centers of New England
The line between “child welfare services” and “children’s
mental health services” has never been particularly clear. In general, policy
makers, bureaucrats and service providers all agree that there is substantial
overlap among the populations of children and families that need these
services. Common sense and research both tell us that children who are victims
of abuse or neglect are more likely to have mental health needs than those who
are not. Similarly, children with mental health problems often live in family
situations that can benefit from a range of child welfare prevention and
intervention programs. It might not even be too glib to say that deeming a
program to be a “mental health service” or a “child welfare service” is
sometimes determined as much by the nature and requirements of the funding
source as anything else. In the most recent decade, both of these have undergone
significant transformations: Underlying philosophies have been questioned, and
new paradigms have emerged. Providers of these services to children and
adolescents have scrambled to adapt, to differentiate “fad” from “trend” and to
remain true to organizational mission, vision and values. The changes have
been, at times, tumultuous, with mature agencies going out of business and new
agencies and new models of care growing and disappearing rapidly. Other new
models have become a new standard of excellence, with long-standing providers
of one service in one location adapting and diversifying into multi-service,
multi-state and multi-regional providers. While there has been loss, there has
also been a real opportunity to better serve children and families with new and
more effective strategies and interventions.
Child Welfare
Approximately 500,000 children in America live in foster
care – counting foster homes, residential treatment and other group care
settings. Despite the best efforts of many mental health professionals,
“graduates” of the foster care system have higher incidences of mental health
problems, lower levels of academic achievement, higher incidences of substance
abuse and legal system involvement, etc. While there are many exceptional
individuals who have grown up in this system (Steve Jobs, Eddie Murphy, Alonzo
Mourning, Malcolm X, John Lennon and Superman to name a few), the system itself
has often failed to produce the desired outcomes for children.
Clearly, even casual observers of America’s child welfare
system cannot help but notice the sea of change that has occurred in this field
in the last decade. Loosely called “child welfare reform” by some and “a
cynical ruse to save money” by others, these changes include major reductions
in the numbers of children and adolescents being served in residential
treatment and group care settings, increases in the number and types of
programs that provide care in community-based settings, a preeminent priority
of serving children in their own community whenever possible and a near
prohibition on sending youth to programs located out of state or, in some
cases, out of county.
These evolving trends have
altered our nation’s approach to dealing with problems associated with child
abuse and neglect. Long-held assumptions about the kind of help children and
families need have been called into question. The goal of providing stability,
for example, has been superseded by the belief that it is more important to
provide permanency. From a practical standpoint, this means that a teenager who
formerly might have been allowed and encouraged to “age out” to independence in
a stable group home setting may now be moved to live with a long-lost relative
in the interest of finding a permanent family for that child. The advantage of
remaining in a stable, but impermanent group care setting is now trumped by an
opportunity, even when presenting some risk of failure, at a permanent family.
Other assumptions are similarly being questioned. For example, the value of engaging
birth families and kin in the lives of children residing in foster or group
care settings has been reassessed and found (often) to be critical to achieving
positive outcomes. Assumptions about which set of behaviors or mental health
problems MUST be treated in an institutional setting are questioned, reassessed
and, ultimately, re-engineered. Debates among mental health professionals rage
regarding the exact meaning of the term “treatment” and its underlying active
ingredients. The “side effects” of a treatment or child protective service
model that separates a child from his or her family, even a neglectful one, are
being newly considered in the calculus that weighs the risks and benefits of
that self-same treatment or service.
So what happened? Why did the field of child welfare
undergo this transformation? Is it reform? Or is it funding? The answer lies,
at least in part, in the public policy decisions of the 1990s.
Federal Funding, Desired Outcomes and
Oversight of Child Welfare
Titles IV-E and IV-B of the Social Security Act (SSA)
provide states with significant sources of funding
for their child welfare systems. These 1994 Amendments
authorized the US Department of Health and Human Services (HHS) to review
states’ compliance with the requirements of Title IV-E and IV-B. These reviews,
in the 1990s, looked closely at case file documentation, and little else.
On March 25, 2000, however, all that changed and new rules
for these reviews became effective that provided a clear set of desired and
required outcomes (see textbox)
for children receiving child welfare services. The outcomes, debated as a
matter of public policy and described in the Adoption and Safe Families Act of
1997, are broken into three now familiar categories: Safety, Permanency and
Well-Being. The Children’s Bureau of HHS administers the reviews, known as
Child and Family Services Reviews (CFSRs).
7 CFSR Outcomes
|
Safety
Outcome 1: Children are first and
foremost, protected from abuse and neglect
|
Safety
Outcome 2:Children are safely
maintained in their homes whenever possible and appropriate
|
Permanency Outcome 1: Children
have permanency and stability in their living situations
|
Permanency
Outcome 2: The continuity
of family relationships and connections is preserved for children
|
Well-Being Outcome 1: Families have enhanced capacity to provide for
children’s needs
|
Well-Being
Outcome 2: Children receive
appropriate services to meet their educational needs
|
Well-Being Outcome 3: Children receive adequate
services to meet their physical and mental health needs
|
Child and Family Service Reviews
CFSRs, conducted first for all states between 2000 and
2004, are now completing their “second round.” The process of the review itself
allows the state to compare itself to other states on certain safety and
permanency measures (called the Statewide Assessment). In the second stage, an
onsite team consisting of a Federal reviewer and a person from the state
reviews case records, interviews children and families being served and
interviews community stakeholders such as the courts, foster families and
service providers. If states are found to be out of compliance with the federal
standards (meeting 95% or less of
criteria for each outcome measure), the state is required to prepare and file a
Performance Improvement Plan (PIP) designed to bring the state system into
conformance with the federal requirements.
By 2004, all 50 states, the District of Columbia and Puerto
Rico had completed their first review. Notably, no state was found to be in
substantial conformity in all of the seven outcome areas or in seven systemic
factors. In fact, the nationwide average percentage achieved for Permanency
Goal 1 was a meager 40% (the lowest rating of all seven goals). It should come as no surprise, then,
that improving permanency outcomes in child welfare – what has become known as
a search for the “forever family” for each child in care – has become a
particularly high priority.
Also notable: No goal, on average,
achieved the desired 95% threshold across all states. Nonetheless, some states did better on some measures than
others, and the elements that contributed to that success can be identified. For example, common findings across
states with higher performance include1:
• Concept of wrap-around
as a way of coordinating and delivering services
• Strong connections to
community-based organizations
• Access to independent
funding streams to address gaps in service array
• Use of Family Group
Decision-Making
• Prevalence of specialized
services to address domestic violence, substance abuse and adolescent
populations.
Thus, it is not surprising that the thirteen states that
are operating with approved PIPS are using strategies to improve that include:
• Develop and implement practice
models
• Adopt evidence-based
assessment tools
• Strengthen worker
contacts with families to engage, assess and provide services
• Implement processes like
family team meetings to facilitate engagement, assessment and service provision
• Enhance supervision and
QA/CQI processes.
Children’s Mental Health
Research studies find that
between 5 and 9 percent of children suffer from serious emotional disabilities2.
In 2001, President Bush empanelled The President’s New Freedom Commission on
Mental Health, a group of distinguished professionals and policy makers,
charged with undertaking a year-long study of America’s mental health service
system. The Commission studied the research literature and took testimony from
thousands of professionals and stakeholders in the mental health system in an
effort to determine what worked, what didn’t and what practices and
philosophies of care seemed to hold the most promise for the future.
The findings of this Commission, released in final form in
2003, provided a blueprint for policy makers that has driven legislative
priorities and reform efforts across the country ever since. Not since the
passage of the Americans with Disabilities Act has there been such a clear
statement of public priorities pertaining to the government’s role in meeting
the needs of these children and their families. This report, titled “Achieving
the Promise: Transforming Mental Health Care in America,” affirms the
groundwork and philosophy first identified in the 1980s as the “System of Care”
approach.
New Freedom Commission Findings and
Recommendations of Importance to Children’s Programming
While the New Freedom Commission focused on both adults and
children with emotional disabilities, their fundamental conclusion was that the
mental health service delivery system was “in disarray” – particularly citing
“fragmentation and gaps in care for children.” They further reported that there
was an over-reliance on institutional care for both adults and children: “The
nation must replace unnecessary institutional care with efficient, effective
community services that people can count on.” While these were hard words for
agencies and organizations with many years commitment to providing high quality
residential treatment services, they affirmed the strategic plans of those same
organizations that saw this trend developing and had diversified and expanded
their array of services to include therapeutic foster care and new models of
home and community-based services. Institutional settings (residential treatment
and psychiatric hospitals) were reserved for only the most challenged children
and, even then, with a new focus on crisis stabilization and short-term
treatment models.
Successfully transforming the mental health service
delivery system rests on two principles:
• First, services must be
consumer and family centered, geared to give consumers real and meaningful
choices about treatment options and providers – not oriented to the
requirements of bureaucracies
• Second, care must focus
on increasing consumers’ ability to successfully cope with life’s challenges,
on facilitating recovery, and on building resilience, not just on managing
symptoms.
Executive Summary of the Final Report of the
President’s New Freedom Commission
Also critical to understanding how this commission’s report
has impacted mental health care for children is the explicitly stated goal that
“Mental Health Care is Consumer and Family Driven.” This is a fundamental
philosophical shift from a system that was formerly driven by mental health professionals
and administrators, not “consumers and families.” Mental health professionals,
accustomed to being treated as the “expert professionals” are, under a family
driven model, asked to assume a more consultative than authoritative role –
allowing the family, and, whenever possible, the youth him- or herself, to
direct the priorities of treatment.
Lastly, with respect to children’s programming, the
Commission recommended accelerating research to promote recovery and
resilience, in particular through the development, support and enhancement of
evidence-based practices. These practices (treatment models) are those that are
supported by research into the efficacy of particular treatments.
Systems of Care
The professional literature describing the values and
principles of a “System of Care” for children and adolescents with emotional
disorders and their families dates back to a seminal article by Stroul and
Friedman in 19863. It is not a program model, per se, but, rather, a
philosophy of mental health service delivery that emphasizes a system that is
individualized to the needs of a particular child and family, strengths based,
coordinated through intensive case management, culturally and linguistically
competent and based on strong partnerships with families and family involvement
in treatment.
Further, the system of care philosophy goes beyond the
individual purviews of the “mental health system” or the “child welfare system”
to encompass a framework that includes all life domains of children and their
families. As such, the philosophy holds that to most effectively treat mental
health issues, overlapping dimensions of education, health, recreation,
vocation and other social services must also be considered and coordinated in
the plan for any individual child.
It is not difficult to see, given the transformation noted
above in child welfare and mental health, why the concepts of the System of
Care philosophy are affirmed by these other systems’ changes. As a result,
policy makers at the national, state and regional levels have embraced these
concepts. The fact that they offer the promise of improved outcomes at
potentially lower cost than “higher end” services such as residential treatment
and hospitalization is a further “accelerant” promoting these systems changes.
The Challenge
How then, do mission-driven agencies, many with years of
valuable experience in meeting the needs of troubled youth and families, adapt
their programs, philosophies, treatment modalities and values to meet the
challenges posed by these larger system transformations? It’s simple, really.
Social workers have, for years, understood the concept of “parallel process”:
the phenomenon that systems have a propensity to duplicate characteristics of
interaction between system elements: Cursed at by his boss, Jim goes home,
curses at his son, who curses at the dog. Not to oversimplify, but in words of
one of my first clients, “you be nice to me, I be nice to you.”
With this lesson, it is clear: Agencies must similarly
transform their thinking and practices; a parallel process. No one can argue
with motivation to achieve better outcomes for our clients. No one can argue
that much of the reform effort prompted by the CSFRs and President’s New
Freedom Commission is not driven by a desire to use these data to improve these
outcomes. This does not, however, mean that the hard-won knowledge and
experience of foster care, residential or hospital providers are
invalidated. Rather, it means that
their place in the system is evolving and that the system itself is evolving to
have many more “places” within it. The system is recalibrating.
Yet, there are risks in these transformations. How far is
too far? When does safety trump permanency? When does the work that can only be
done in a residential treatment setting trump the desirability of services
being community based? When does the youth/family NOT know what’s best, and,
therefore, a seasoned professional needs to be empowered to make a decision
about treatment priorities?
There are further risks that ideologues will attempt to
co-opt the systems changes to eliminate necessary services that have, at times
in the course of implementing these reforms, been demonized. There is a risk
that, under budget constraints, services and service models will be adopted not
because of better outcomes but, rather, because of lower cost. There is a risk
that, before we have fully developed alternative treatment systems, old systems
will disappear, leaving an already fragmented system with even larger “cracks”
through which people will fall.
What is simple is not always easy. In this case, simply,
responsible agencies, public and private, must form the necessary partnerships,
hold the necessary debates and identify the opportunities to meet the needs of
the children, adolescents and families that it is our privilege to serve.|
Ken
Olson is a past President and current Public Policy Committee Chair of the
Foster Family-based Treatment Association, a North American Association of over
400 agencies providing therapeutic foster care. He is a Licensed Clinical Professional Counselor, a former
treatment foster parent, and he speaks frequently to national audiences
regarding public policy, child advocacy, and children’s mental health. Ken is
currently the Executive Director of KidsPeace National Centers of New England,
where he oversees a state-wide range of community based and campus based
programs for Maine’s youth and families.