Around the country, states face shortage of placements for youth with greater needs

Around the country, young people in foster care–especially those with greater needs– are being housed in facilities not designed for them because appropriate placements are not available. Children who are already traumatized by abuse or neglect are being warehoused in agency offices, hotels, emergency shelters, out-of-state facilities, and even detention centers, resulting in further harm to these most vulnerable children and high present and future costs for taxpayers.

Many youth in foster care have serious emotional and behavioral issues. Many have endured years of trauma, including physical and sexual abuse, severe neglect, and living in dangerous and chaotic conditions. Some have cognitive or neurological issues caused by drug exposure in utero or severe neglect. Some have violent outbursts, many are verbally aggressive, and many have difficulty in making attachments. Around the country, these youths are being placed in inappropriate settings because the right ones are not available.

• In the letter accompanying his annual budget request, The head of Washington‘s Department of Children Youth and Families has acknowledged the scarcity of “therapeutic group home and facility-based placements for children with severe behavioral issues that don’t enable them to be successful in private foster homes.” As a result, he states, children are being placed in foster homes that are unequipped to handle them, resulting in further damage to the child and often a loss of the foster parent to the system. The lack of appropriate placements also led to over 2000 instances last year of children staying overnight in a hotel or office accompanied by a caseworker; and “excessive use of expensive one-night placements at extraordinary cost and detriment to the child.”
• In 2016, the discovery that some Oregon children were sleeping in hotels or offices due to a lack of other options resulted in a public outcry and a class action lawsuit. In response, the state drastically reduced its practice of sending foster kids to hotels. But at the same time, according to an investigation by Oregon Public Broadcasting (OPB), the state began sending more foster kids requiring a higher level of care to out-of-state residential treatment facilities.  The majority of these children were housed in facilities run by one for-profit company called Sequel, as reported by OPB in a second installment of its investigation. After reports of abuse and neglect by staff resulted in the closure of five Sequel Facilities, Oregon began bringing its children home. There are now 30 children (down from 84 in February 2019) at out-of-state facilities, all of them run by Sequel, according to OPB.
• Texas has projected that by 2021 it will have only 90% of the foster homes or other facilities it needs for youths with “specialized” or “intensive” needs (including 24-hour supervision from specially trained caregivers. ) And in some regions of the state the shortages will be much more severe, meaning that children will have to be sent far away if a spot can be found at all..
• Illinois has had a longstanding problem of children being left in psychiatric hospitals after they have been cleared for release, a practice labeled as  “Beyond Medical Necessity (BMN). The Inspector General for the Department of Children and Family Services has reported that there were approximately 308 episodes of BMN during FY 2019 involving 297 individual youths. Such long stays in such an inappropriate setting result in further damage to children’s mental health. Moreover, the state cannot receive Medicaid reimbursement for such hospitalizations, leaving the state to foot the bill. In FY 2019, children left in psychiatric hospitals BMN ranged in age from 3 or 4 to 19 or 20 with the largest number being between 14 and 16. In FY 2019, 94 youths were hospitalized between 31 and 60 days and 154 youths were hospitalized from 61 to 120 days. The longest BMN hospitalization involved a fifteen-year-old who was hospitalized for 279 days.
• As I discussed in an earlier post, an alarming report last March indicated that New York City children with behavior problems or mental illness were staying for months at an intake center where they are supposed to be no longer than a few hours until a real placement can be arranged. Instead they were staying as long as a year in this center, where social worker have described an atmosphere of chaos, violence, weapons in plain sight, feces-smeared walls, overcrowding and “a dangerous mix of babies and young children with special needs living alongside troubled teens and even adults straight out of jail.”
• In my own jurisdiction of the District of Columbia. a special hearing was recently held in a longstanding class action case to discuss the current placement crisis. The Judge, referring to a letter that is not available to the public, reported that 31 children, including seven children between eight and ten years old, experienced a total of 60 overnight stays at the Child and Family Services Agency between April and November of 2019. All of these children had challenging behaviors that excluded them from existing placements. The agency director acknowledged that the District needs more therapeutic placements (either in family or group settings) for these children. The District is in the process of developing some new therapeutic placements but it is not clear that they will be enough to meet the need.

As many are already beginning to do, states must expand their array of placements for the young people with the most serious needs. There is increased interest in developing a cadre of highly trained professional foster parents for whom caring for hard-to-place youths is a full-time job. This may be the best option for many children, but these programs, where they exist, are very small both due to cost and to a small pool of people willing to take on this difficult job. So there will still be a need for more therapeutic group settings. In states including California and Florida there have even been calls for secure therapeutic settings to be established for the most disturbed youths. Child welfare agencies should coordinate with other agencies serving the same youths. such as developmental disabilities, mental health, and juvenile justice agencies, to develop a continuum of appropriate residential placements for all the youths who need them.

Leaders from Washington State to Washington, DC have already begun increasing budgets for therapeutic options including professional foster care and therapeutic group homes. But unfortunately the task of expanding the placement array to accommodate foster youth with greater needs will be made more challenging due to the new Family First Prevention Services Act. This Act was based on a false narrative that nearly all children can succeed in foster homes and that congregate (or non-family) care is always harmful to youth. Believers in this narrative combined with legislators who supported the law because it would reduce government spending. Family First makes it more difficult to place children in congregate care facilities and requires these facilities to meet a number of criteria, such as accreditation, a trauma-informed model, and 24-hour nursing staff in order to be eligible for funding under Title IV-E.

California is one indicator of what might happen under Family First because it is deep into a similar state-level reform called Continuum of Care. So far, many group homes have been closed or have been denied a license to care for foster kids. One veteran service provider in California writes that “there are fewer kids in group homes, but only because there are fewer group homes and counties have inappropriately been pushing challenging, difficult-to-manage youth into lower levels of care.” Family First will result in a replication of the California situation around the nation. At a time when we need more therapeutic facilities, Congress has made it more difficult for those in existence to continue and for new ones to be established.

As in many other areas, America has been penny-wise and pound-foolish in its reluctance to spend money on therapeutic placements for the most damaged young people in the foster care system. The new federal funding framework makes it even more difficult to fund the placements that the hardest to place children need. Let’s hope that states recognize that failing to provide therapeutic placements for these most fragile children now will only result in much greater costs later.