Family First Act: no funding for important drug treatment and mental health services

Passage of the Family First Prevention Services Act as part of the Bipartisan Budget Act early in 2018 was hailed as a game changer in child welfare.  For the first time, according to the celebrants, Title IV-E funds could be used to pay for services to keep families intact rather than place children in foster care. But the more we learn about Family First and how it is being implemented, the less cause for celebration there seems to be. In my last post, I discussed the problems caused by the decision to make Title IV-E the payer of last resort for foster care prevention services. In this post, I discuss the surprising omission of important mental health and drug treatment programs from the list of programs that have been approved or proposed to be paid for under Family First. The paucity of useful programs in the clearinghouse certainly will detract from the utility of Family First in preventing foster care placements.

In expanding the use of federal IV-matching funds beyond foster care through Family First, Congress wanted “to provide enhanced support to children and families and prevent foster care placements through the provisions of mental health and substance abuse prevention and treatment services, in-home parent skill-based programs, and kinship navigator services.” Family First allowed federal Title IV-E matching funds to be used for programs in these categories that meet criteria for being “evidence-based” as defined by the Act.

The categories  of mental health, drug treatment and parenting programs make sense in light of what we know about why children come into foster care. Anyone who has worked in foster care knows that parental drug abuse and mental illness are two of the major circumstances behind child removals, while a third major factor, domestic violence, was inexplicably left out of the Act. The inclusion of parenting programs makes sense because abuse in particular is often related to parents’ lack of knowledge about child development and appropriate disciplinary practices.

Family First established a Title IV-E Prevention Services Clearinghouse, which is being developed under contract by Abt Associates, to review and approve programs for reimbursement using Title IV-E foster care prevention funds. So far, the clearinghouse has approved nine programs for inclusion and is in the process of considering 21 more. A careful look at the programs that are included, under review, and not on either list raises some questions.

Take substance abuse treatment, the most common single factor behind child removals according to federal AFCARS data, which indicates that drug abuse was a factor in 36% of the child removals that took place in Fiscal Year 2018. The opioid crisis, often cited as a reason to pass Family First, seems to have peaked in most areas but is still wreaking havoc in many states and their foster care systems. Medication-assisted treatment is often called the “gold standard” for treating opioid addiction and is vastly underutilized. But strangely that Abt Associates chose to include in the clearinghouse only Methadone Maintenance Therapy and not the newer buprenorphine treatment, which is not even on the list of programs to be considered for clearinghouse listing.  According to the National Institute on Drug abuse, “Methadone and buprenorphine are equally effective at reducing opioid use.” And there are reasons to prefer the newer medication. As the federal Substance Abuse and Mental Health Administration (SAMHSA) states, unlike methadone treatment, “which must be performed in a highly structured clinic, buprenorphine is the first medication to treat opioid dependency that is permitted to be prescribed or dispensed in physician offices, significantly increasing treatment access.”

Let’s turn to mental health. It is clear that mental illness is the major factor behind many removals into foster care. AFCARS data indicate that 14% of child removals are associated with a “caregiver’s inability to cope,” but that percentage sounds small to this former social worker. It is likely that many more removals where other factors (like child abuse and substance abuse) are cited are also related to parental mental illness. Parents suffering from untreated depression, bipolar disorder, post-traumatic stress disorder (PTSD), and other mental health disorders often have difficulty providing appropriate care to their children. So it is not surprising that mental health was included as a category of services to prevent foster care under Family First.

What is surprising is the nature of the services that have been chosen so far. The clearinghouse has approved four mental health programs: Functional Family Therapy, Multisystemic Therapy, Parent Child Interaction Therapy, and Trauma-Focused Cognitive Behavior Therapy. All of these programs are geared at addressing the issues of children–not their parents. It is very odd that the clearinghouse did not include any services to address common mental disorders, such as depression and PTSD, that afflict many parents who come to the attention of child welfare agencies. After all. the California Evidence-Based Clearinghouse for Child Welfare (CEBC), the leading repository of evidence practices in child welfare, lists nine programs meeting Family First criteria as well supported, supported or promising  for treating depression and 11 programs meeting those criteria for trauma treatment for adults. Even odder, among the six mental health programs being considered for inclusion in the Title IV-E clearinghouse, only one (Interpersonal psychotherapy) could be used to treat adults although there is also a version for adolescents and the clearinghouse does not specify which one is under review.

Among the evidence based practices included in the CEBC and not included or under review by the Title IV-E clearinghouse are some well-established programs known to be effective, such as Cognitive Behavioral Therapy for adult depression and  Mindfulness Based Cognitive Therapy.  Both of these have the top rating of “well-supported” from CEBC for treatment of depression in adults. Another mindfulness-based treatment called Mindfulness Based Stress Reduction is becoming increasingly popular and supported by research for treatment of depression and anxiety. Because it is not generally covered by insurance, using Family First funds could make this treatment available to parents who could not otherwise get it. Eye Movement Desensitization and Reprocessing (EMDR), a popular trauma treatment, is also given the top rating from the California clearinghouse and not included or being reviewed by its Title IV-E counterpart.

On the other hand, the inclusion of two out of three “in-home parent skill based” programs in the Title IV-E Clearinghouse is somewhat surprising. The inclusion of Healthy Families America (HFA) raises questions because it has not yet been able to demonstrate an impact on the prevention of child abuse and neglect. There is one study with a promising result but this study was criticized by CEBC due to a very small sample size, limitation to one region, reliance on parent self-report and other factors. CEBC gave HFA as a rating of “4” (“evidence fails to demonstrate effect”) for the prevention of child abuse and neglect.

Another home visiting program, Nurse Family Partnership (NFP), has limited potential to prevent foster care among the Title IV-E eligible population. NFP is the only home visiting program given the top rating for prevention of child abuse and neglect by the CEBC; however it is approved only for first-time teenage mothers. It cannot by definition be used to prevent a recurrence of abuse or neglect. NFP can be provided under Family First in jurisdictions, like the District of Columbia, that have defined all children of teens in foster care as foster care candidates. But it is not applicable to most families eligible for prevention services under Title IV-E.

In sum, the list of programs that have been cleared by the Title IV-E clearinghouse as well as those that are being reviewed contains some disconcerting omissions and surprising entries. While some of the most exciting and promising mental health and drug treatment programs are not included, some home visiting programs with very limited applicability to the purposes of the Act have been included. When added to the decision to make Medicaid the payer of last resort, these decisions by the clearinghouse make the utility of Family First as a vehicle of foster care prevention even more dubious. Those who agree should join me in requesting that the Title IV-E Clearinghouse review and approve some of the effective practices mentioned in this post.