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.