The child placement crisis: It’s time to lose the slogans and find real solutions

By Judith Schagrin

A note from Child Welfare Monitor: It is a privilege to publish this important essay by Judith Schagrin. Judith earned an undergraduate degree from the University of Pennsylvania and a master’s degree in social work (MSW) from the University of Maryland School of Social Work.  She unexpectedly found her passion in public child welfare, and more specifically, foster care after helping start an independent living preparation program for young people in care. After a decade as a foster care social worker specializing in adolescence in a large Maryland county department of social services, she supervised two different units before becoming the county’s director of foster care and adoptions, serving in this position for twenty years.  She also worked part-time for the Agency’s after-hours crisis response for a decade.  For almost 10 years, she served as a respite foster parent for a private foster care agency, and since 2008, has mentored a young person who aged out of care in California and came east for college.  In  2001, with a little help from her friends, Judith founded Camp Connect, a weeklong sleepaway camp to reunify brothers and sisters living apart in foster care and provide memorable experiences siblings can share for a lifetime.  For the past 23 years – one year virtual – she has spent the week at Camp Connect immersed in the care of Maryland’s foster children and youth.

The closing of children’s mental hospitals in the 1980s, the subsequent closure of detention centers leaving foster care to take up the slack, the movement to shutter all group homes and residential treatment programs and the prohibition of out-of-state placements have created a slow-motion train wreck whose results could have been predicted easily at every new chain in the sequence. Those results include children and youth staying in psychiatric hospitals long after being ready for discharge, “boarding” in emergency rooms and “placed” in hotels at a cost of $30,000 to $60,000 per child per month. From my 35-year vantage point as a caseworker, supervisor, and then running foster care and adoptions in a large Maryland county, I’ve had a front row seat to the evolution of this crisis and the failure to come up with real solutions. 

Deinstitutionalization

The first in a series of events that created this crisis occurred in the 1980s, when the deinstitutionalization that began for adults in the 1960’s with the civil rights movement expanded to include children.  Until then, youth remained in state hospital facilities for as long as a year or even more.  The closure of those state facilities led to the expansion of Medicaid-funded residential treatment centers (RTC’s), that stepped in to provide the longer term care once provided in the state hospitals.  In turn, group homes proliferated to meet the needs of youth discharged from RTC’s.  The advent of Medicaid was instrumental in expanding prIvate psychiatric treatment options, including hospitals.  But over time, Medicaid stopped funding even 30 days of treatment, limiting payment to only  a few days of crisis intervention. 

Today, many youth, especially older youth, are entering foster care not because of what we traditionally think of as maltreatment, but due to parental incapacity or unwillingness to care for them due to acutely problematic behavior, and behavioral health and/or developmental needs.  Services to meet these needs are often missing or inadequate, and parents of children with high-intensity needs cannot find residential treatment except through the child welfare system.  Medicaid doesn’t pay for treatment and care in a group home of any kind; access in Maryland requires the child welfare system’s physical or legal custody.

New approach to juvenile justice

In the early 2000’s, a series of Supreme Court decisions brought welcome changes to juvenile justice and shifted the country from the ‘get tough’ approach of the ‘80’s and 90’s to the ‘kids are different’ era.  Moving from punishment to rehabilitation and minimizing detention in favor of community services makes sense on both humanitarian and neuroscience grounds.  But it meant that youth who once fell under the purview of Juvenile Services now required child welfare intervention when parents or other caregivers were unwilling or unable to continue to provide care. The mother evicted from four apartments because of her son’s property damage; the grandmother who stepped in years ago and is no longer able to cope with her granddaughter after the third vehicular misuse charge and chronic episodes of running away; or a parent with younger children afraid that an older sibling known to have rages and episodes of violence will harm his siblings, are examples of desperate caregivers I have come across.

In Maryland, the first alarm that child welfare was ill-equipped to care for these youth was sounded in 2002 by local department directors in a memo to the head of the Department of Human Services.   Closing detention centers was a good thing, but alternatives weren’t developed for those youth unable to live at home, and no resources were provided to help child welfare accommodate its new clients. As the closure of state psychiatric facilities and detention beds was widely celebrated, the belief that every youth had a family eager and able to provide a home was more than a touch naive, as would soon become clear. 

Group home closures

Another domino fell in the early 2000’s, when group homes, many poorly administered with little oversight, became a scandal in Maryland.  A series of articles in the Baltimore Sun exposed the flaws of many group care programs, and some were forced to close.  With the scandals around bad group homes, the timing was perfect for state leadership, encouraged by a national advocacy group with deep pockets and the laudable dream of a family for every child, to lead a movement to shutter congregate care placements.  Funding constraints, too, forced some providers out of business.  Reimbursement rates did not keep up with costs, and some programs closed their doors due to inadequate reimbursement.   The state lost roughly 450  beds in five or six years, including entire residential treatment center programs.  Rate-setting ‘reform’, which began in October of 2021, will not be completed until July of 2026 if it stays on schedule.

At the same time group homes were being closed in Maryland, state agency leadership began to frown on out-of-state placements for youth with highly specialized needs when no placement in Maryland to meet those needs was available.  Public officials with little understanding of placement resources pronounced these out-of-state placements to be evil incarnate, and an overwhelming number of bureaucratic obstacles made them nearly impossible.  

With the loss of group homes as an option, we were urged to ‘re-imagine’ care for children, yet discouraged from developing individualized plans of care because insufficient flexible funding was allowed to make that happen.  We’re fond of slogans in child welfare, as if words will change outcomes, but too many initiatives are about clever slogans and not about substance.  If only we would review every child in group care, we were told, we would realize how many had other options.  With consultation from the national advocacy group, we spent hours seriously poring over the needs of our children in congregate care and attempting to find matches with kin or foster families.  Not at all surprising to our staff, “low hanging fruit” didn’t exist.   

We also initiated a rigorous “Family Finding” practice, in hopes of finding kin willing to become providers with services and supports.  What we learned is that youth in congregate care had  already exhausted family and “kin of the heart” resources.  Today it’s not clear that public officials and child welfare leaders grasp that children and youth wouldn’t be in hotels if there were any kin – fictive or otherwise – willing and able to provide care, or if parents could and would be a safe resource.

Youth with intensive, complex needs

As other doors closed, the child welfare system became increasingly tasked with providing residential behavioral health care for children and youth with high-intensity and complex needs for supervision and treatment.  The differences between those involved with the juvenile justice system (and may have gone to detention centers in the past) and those who are not are often hard to discern.  Both groups tend to engage in behaviors that pose a serious safety hazard  to themselves or others.  These  behaviors may include physical violence; property damage; compulsive self-harm such as cutting or swallowing objects; chronic truancy; frequent runaway episodes; sexual victimization of siblings; aberrant sexual behaviors such as public masturbation; molesting younger siblings; participating in petty crimes; harming family pets; and generally oppositional and dysregulated behavior.  

Contrary to the popular notion that the public child welfare system is tearing families apart, these are children whose families are typically frustrated, exhausted, and often eager to place their child.  Some even view foster care as a much-needed punishment, imagining that when the youth is ready to “behave,” they can return home.  Of course these young people have many strengths to be nurtured, but they need intensive supervision and therapeutic intervention by professionals trained to evaluate and address their special needs and work with families.

The gist of the matter is that we are serving two different out-of-home placement populations with very different needs.  One is a younger population in foster care primarily due to maltreatment stemming largely from parental substance abuse and/or untreated mental illness. The other is older youth with complicated behaviors, and behavioral health needs and/or developmental disabilities.  The parents and kin of the older group are asking for placement, not objecting to it, and are typically worn out and adamantly opposed to more in-home services.  In spite of the stark differences in these two populations, our policymakers and those upon whom they rely have failed to recognize their needs are not the same.

In Maryland and other states, treatment, or ‘therapeutic,’ foster care stepped in to accommodate this new population of older, harder to serve foster youth. To some extent this approach has been effective as an alternative to congregate care, but it’s not the panacea some would like to believe.  The desperate need for foster families willing to care for these youth means there’s a certain amount of pressure to lower expectations and even turn a blind eye to foster parents that do a less than stellar job.  Tales of locked refrigerators and youth left sitting on the stoop at the end of the school day until the caregiver came home soon proliferated.  However, we were told by representatives of a national advocacy group that, “Youth are better off moving from shabby foster home to shabby foster home than in the very best congregate care.”   In my own experience, instability begets instability and there’s little more soul-sucking than being rejected from family after family.

Setting aside the question of quality, foster care, whether treatment or not, has great challenges recruiting homes for youth with weapons charges, those with a history of drug dealing, or whose parents have refused to pick them up from the police after another runaway episode. “Cutters” and “swallowers” need 24/7 supervision to keep them safe and in general, kin have already tried to provide care long before the child’s entry into state custody.  With the closure of group homes and residential treatment centers in Maryland and the prohibition on out-of-state placements, finding placements willing to accept youth with high-intensity needs became literally impossible.  As a result, for years now children have been left in psychiatric hospitals (sometimes for months) after “ready” for discharge, and others are ‘boarding’ in emergency rooms for weeks or months.  

A failure to recognize reality

Instead of recognizing the lack of capacity to serve those youth with nowhere to go after being hospitalized, hospital representatives, public officials, and legislators blamed caseworkers for not ‘picking children up’, as though they were simply lazy and incompetent.   “Advocates” proposed legislation imposing more caseworker accountability as the solution, as though if caseworkers worked harder and filled out more forms, placements that didn’t exist would magically appear.  Fortunately, none of the legislation passed, but being a lonely voice trying to explain the source of the problem wasn’t lazy caseworkers or enough forms was painful.  Public officials, leaders and advocates also clamored for more “prevention” services, not recognizing the acute needs of older youth developed over many years and that new services authorized today are not going to keep them safely at home.

During my 20 years as the director for my county’s foster care and adoptions program, I can’t count the nail-biting times we came close to not finding a placement for a child – but we were always able to pull something together.  The state made funding available for a 1:1 staff person (or sometimes 2:1) we could offer existing providers, allowing us to use that as a bargaining chip. Of course, increasing reimbursement rates and staff salaries would have been far less expensive than millions for extra staff to support ill-equipped placements, but that change in fiscal allocation has yet to happen. 

Five years have now passed since I retired, and hotel placements have become not a rarity but a regular necessity.  At the rate of $30,000 to $60,000 per child each month (not including damages to hotels) to warehouse children in hotel rooms supervised by an untrained aide – one can only imagine what that kind of money could be doing productively for children.  Caseworkers are overseeing the most precarious and risky “placements,” and being ‘hotel reservation clerks’ isn’t the reason competent social workers choose to do the work.  We’ve all heard the tales of youth stealing their 1:1’s car; or youth locking themselves in their rooms doing what we don’t know; a youth who overdosed on his medication; parties taking place with the acquiescence of the 1:1; youth harassing guests; and the youth who leaped over the reservation desk to try to steal cash.

Over the years there have been many, many meetings among high ranking state officials and others; ironically, these meetings didn’t include the experienced and knowledgeable child welfare staff responsible for the children.  Lots of strategies, goals, and plans too – a personal favorite was the goal of instructing local department staff on hospital discharge planning, as if they weren’t already experts.  Despite all the meetings and all the hand-wringing, progress meeting the needs of the children in our care, or soon to be in our care when parents abandon them at the hospital or elsewhere, has been negligible. Years that could have been spent on developing and promoting new model programs have been wasted. In the meantime, Congress saw fit based on testimony from well-heeled advocacy groups to pass the Family First Prevention Services Act,  which limited congregate care even more by restricting funding to approvable options based on criteria seemingly pulled out of a hat.   

Today, the deepening and pervasive placement crisis is affecting nearly every state and attracting media attention around the country.  Given the financial resources dedicated to keeping children in hotels, finances clearly aren’t the issue.  And it certainly isn’t about quality of care, since hotel rooms, overstays in hospitals, and boarding in emergency rooms rank far below a quality congregate care program as a suitable home for a child.  

What is to be done?

In the short run, Maryland and other states need respite programs for young people awaiting placements in hospitals, emergency rooms, and hotels.  In the long run, we must acknowledge child welfare’s responsibility not only for maltreated children, but also those with high-intensity needs for supervision and treatment once served by other child-serving organizations.  We need to bring the finest minds together to reimagine how residential care is provided, and its role in the continuum of child welfare resources to meet the needs of older youth entering foster care because of needs related to behavioral health and/or developmental disabilities. That process should include some of the scholars who have been studying the use of congregate care in other countries where it is more highly valued as a treatment and a professional field.  Exploring the development of real alternatives to congregate care is also a worthy investment.  Finally,  the unintended consequences of the Family First Prevention Services Act that disincentivized needed placements without a credible replacement must be remedied.

How many more years until we wake up?  And how many children will have to be harmed?  A colleague had a quote in her office that stays with me always, “when we are doing something with somebody else’s child we wouldn’t do with our own, we need to stop and ask ourselves why.”  Who among us would consent to our own children boarding in emergency rooms, on overstay at hospitals, or ‘placed’ in hotel rooms?  If that’s not okay for our own children, it shouldn’t be okay for the children in our state’s custody either.