First “Family First” Plan to be approved shows limits of new law

PuttingfamiliesfirstDCOn October 29, 2019, the Administration on Children and Families (ACF) announced its first approval of a Title IV-E Prevention Plan to be submitted under the Family First Prevention Services Act (“Family First”). This plan, called Putting Families First in DC, was submitted by the District of Columbia’s Child and Family Services Agency (CFSA). While it is encouraging that the District was successful in gaining federal support for its plan, it is disheartening that there will be very little expansion of services under this new legislation, and that Family First will have no impact on the shortage of critically needed mental health services for parents.

Family First widened the population of children and families that can be served under Title IV-E of the Social Security Act from children in foster care to children who are “candidates for foster care” and their families.  A “candidate for foster care” is defined as a child who is identified in the jurisdiction’s prevention plan is being at “imminent risk of entering foster care” but who can remain safely at home or in a kinship placement if services are provided.  Each state sets its own definition of a candidate for foster care in its Title IV-E plan. CFSA has chosen a fairly broad definition, which includes many types of families that have been investigated by CFSA after an allegation of child abuse or neglect

Most interestingly, CFSA has chosen to include as “candidates for foster care” children of pregnant or parenting youth who are in foster care or have left foster care within five years. The inclusion of these families is particularly significant because it allows services to families in which abuse or neglect has not taken place. Rather than preventing the recurrence of abuse or neglect (known as “tertiary prevention”) this extends  the use of Title IV-E funds to preventing the first occurrence to a high-risk population (known as “secondary prevention”).  This  represents a more “upstream” approach, which many experts and child welfare leaders have long been arguing deserves more support.

However, the effects of this expansion of the eligible population are drastically constrained by the severe limitation on what services can be provided under Family First. The Family First Act extends the use of Title IV-E funds to services designed to prevent placement of children in foster care. Three categories of services are allowed: “in-home parent skill-based services,” mental health services, and drug treatment. (“Navigation” services to kin who are caring for children are also covered). So far, so good. But when specific services are considered, things become complicated.

As I described in earlier posts, the decision of Congress to make Medicaid the payer of last resort rules out using Title IV-E to fund many mental health and drug treatment programs that are crucial to keeping families together safely. And Congress’ decision to limit reimbursement to programs that are included in a Title IV-E Prevention Services Clearinghouse rule out support for many promising and supported programs that jurisdictions are already using or might want to use to support their struggling families.

Through a Program Instruction, ACF recently gave states an option to claim “transitional payments” for services that have not yet been approved by the clearinghouse, by conducting an “independent systematic review” of such services. But the funding will be cut off if the Clearinghouse decides not to approve the service, and it is not clear if any states will use this option. The District of Columbia has elected not to do so. As a result, after all the hoopla, the District is claiming only one evidence-based prevention service for funding under Family First! That is the Parents as Teachers (PAT) home visiting program, which is already being provided by the DC Department of Health using federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) funds. CFSA will be using local dollars, matched by federal Title IV-E funds, to add slots to this program to meet the needs of its foster care candidates and their parents.

It is worth noting that the evidence on PAT’s potential to prevent child maltreatment or its recurrence not very compelling.  The California Clearinghouse for Evidence Based Practices in Child Welfare (CEBC the leading organization of its kind) rates it as only “promising” (not “supported” or “well supported”) on primary prevention and does not even rate it on prevention of maltreatment reduction. Since the CEBC rated the program, a new study was released testing the potential of PAT to reduce maltreatment among parents who already have been found neglectful or abusive. The study found no overall effect, though they did find that there was a reduction in maltreatment reports for parents who were not depressed and did not have a significant history with Child Protective Services–in other words, the easiest-to -treat minority of the population of parents involved with CPS.

It is likely that CFSA will eventually receive Title IV-E support for a second service. Motivational Interviewing (MI) was approved by the Title IVE Prevention Services Clearinghouse after CFSA had already submitted its plan. MI is a method of counseling to facilitate behavior change, especially regarding substance abuse. It is typically delivered over one to three sessions.  However, CFSA has included Motivational Interviewing in its plan as a “cross-cutting” program rather than a program addressing substance abuse. The agency states that it intends to use MI as a “core component” of its case management model, rather than a two-or-three-session freestanding program. Brenda Donald, CFSA’s director, told the Chronicle of Social Change that she expected to be able to claim IV-E reimbursement for case management once it was added to the clearinghouse. Other jurisdictions are moving in the same direction, according to the Chronicle.

CFSA included in its Family First Plan other programs eligible for Title IV-E funding but is not planning to claim federal funds for these programs because they are already supported by federal funds. Also included are several services that have not yet been approved for Family First funding and are supported by Medicaid or local dollars. It’s a large array of programs, none of which will be supported by Title IV-E funds except PAT and perhaps MI.

So under Family First, Title IV-E dollars are being used to expand one home visiting program in the District and perhaps can be used to match funds spent on case management if CFSA succeeds in making the case that the use of the MI approach makes case management reimbursable. In the meantime, District parents with children at risk of foster care placement are desperately seeking needed services, especially mental health services to treat their mental disorders, such as depression and Post Traumatic Stress Syndrome (PTSD) that contribute to child abuse and neglect.  As recently reported by the District of Columbia’s Citizen Review Panel (CRP), there is such a shortage of basic  mental health services for parents that social workers are doing therapy themselves and also trying to substitute alternative services that may not be as effective, such as telemedicine or yoga. Lack of appropriate mental health services and long waiting lists were major themes of CFSA’s 2019 Quality Service Review, as reported by the CRP.  Poor quality of Medicaid-funded services and rapid turnover of providers are also problems that plague CFSA-involved parents and their social workers.

What a difference Family First could have made if its funds could be used to augment the supply of Medicaid-funded basic mental health services such as medication management, individual and group therapy! How many families could be strengthened if the Clearinghouse had included, or was considering, newer and exciting evidence-based mental health services like EMDR and Mindfulness Based Stress Reduction that may not be covered by Medicaid! Without federal help through Family First, parents involved with CFSA continue to wait for services they need to parent their children safely.

Another problem for CFSA lurks down the road. As CFSA describes in its plan, the law requires that 50% of IV-E spending be for practices that are “well-supported” as defined by the Act. But most of the “well-supported” practices that CFSA is using are funded by Medicaid in the District. If the Medicaid-funded programs cannot be counted as part of CFSA’s total Family First expenditures (which ACF has suggested will be the case), CFSA will not be able to show that it is spending 50% on “well-supported” practices. Congress has already passed the Family First Transition Act, which delays implementation of this requirement to 2024, with a requirement that by 2022 states have to show 50% of practices as “supported” or “well supported.” But what will happen then? The Chronicle voices the hope that more practices would have made it to the well-supported list by that time. We shall see.

With all the fanfare around Family First and CFSA’s large investment of time in developing this plan, it seems clear that the agency is gaining few resources in return for the large  burden of showing compliance with Family First.  It’s ironic that CFSA must provide extensive documentation to ACF regarding services that are getting no funds under the act. CFSA and other jurisdictions should press for amendments that make Family First more likely to achieve its objective of supporting parents to improve their parenting and keep their children safely at home.

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

Red Rock Canyon
Image: Salt Lake Tribune

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.

 

 

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

Family First ActPassage 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.

 

 

Title IV-E as Payer of Last Resort: The Achilles Heel of the Family First Act?

Family First ActThe Family First Prevention Services Act Act was widely hailed as allowing for the first time the use of federal Title IV-E child welfare funds for services to prevent a child’s placement in foster care. Unfortunately, the law has been interpreted in a way that has almost negated this central purpose of Family First. Thanks to a technical-sounding determination about Title IV-E’s place in the hierarchy of programs as payers for services, Title IV-E funds are now unavailable to beef up services that are eligible for funding from other programs.

Before implementation of Family First on October 1, 2019, federal matching funds under Title IV-E of the Social Security Act could be used only to match state spending on foster care. Advocates of Family First and its predecessors argued that providing Title IV-E funds for foster care and not services to prevent it encouraged  jurisdictions to place children in foster care rather than helping their parents address their problems and keep their children at home. As I argued in an earlier post, this was a false narrative that disregarded the fact states were already working with families in their homes using other funds, such as Medicaid, maternal and child health programs, and others.

But the advocates won and Family First was passed. It allowed federal Title IV-E matching funds to be used for evidence-based practices (EBP’s) in the categories of “in home parent skill-based programs,” mental health, and drug treatment programs that meet criteria for being “evidence-based” as defined by the Act. These are all considered to be “prevention services” because they are aimed at preventing placement of children in foster care. (Funds can also be spent on kinship navigator programs to help kin who agree to take custody of children temporarily while their parents pursue services.) The Act also created a clearinghouse  of programs from which states can choose.  The clearinghouse has so far approved nine programs for inclusion and is in the process of considering 21 more.

But the contents of the clearinghouse have much less impact in light of decisions made by Congress and the Children’s Bureau, as explained in a useful webinar from the Chronicle of Social Change. As a result of these decisions, Title IV-E became in effect the “payer of last resort” for the foster care prevention services authorized under the Act .

It would be difficult to overestimate the magnitude of this decision to make Title IV-E the payer of last resort for foster care prevention services. Many of the services that are already included in the clearinghouse or being reviewed now are covered by Medicaid or paid for by other programs in many states.  This means that states with more generous Medicaid plans (those covering more people and/or more services) and more participation in other federal programs have less opportunity to use Title IV-E funds for foster care prevention services.

Consider the District of Columbia, which has a generous Medicaid program in terms of whom and what it covers. In my five years as a child welfare social worker in the District, I don’t remember a parent who was not eligible for Medicaid. The District was the first jurisdiction to submit a Family First plan and the first to have its plan approved, but it’s hard to understand the District’s eagerness to make the transition. In its plan, the District’s Child and Family Services Agency (CFSA) indicates that of the seven services in its plan that are currently deemed allowable by Title IV-E, six are funded through other federal sources–Medicaid and the Maternal, Infant, and Early Childhood Home Visiting Program. Therefore, CFSA will be claiming Title IV-E funds for only one allowable evidence-based program–Parents as Teachers (PAT).

So here is the irony. Family First was supposed to revolutionize child welfare by allowing federal foster care funds to be used for family preservation or foster care prevention, whatever one chooses to call it. Never mind that states have been using Medicaid and other funds for this purpose for many years. And now it turns out that with Title IV-E as a payer of last resort, many states will continue to provide these services with other funds. Family First will make little difference except adding a new layer of bureaucracy: states will now have to include these services in their prevention plans even if they are not funded by Title IV-E!

Things are actually worse under Family First for the 27 states that had waivers under Title IV-E. Under the waivers, states were able to use Title IV-E funds in combination with other funds to expand and improve services–an option not available to them now.

It gets even worse. Under Family First, states must spend at least 50% of their Title IV-E prevention funds on practices defined as “well supported” as defined by the Act. It looks like payments made by Medicaid won’t count toward the 50%, so states will need to find enough “well-supported” practices that are not covered by Medicaid in order to meet this requirement, which may cause great difficulty.

Title IV-E’s status as payer of last resort also appears to prevent Title IV-E from paying a provider who does not accept Medicaid for an EBP that is allowed under Medicaid. It is widely known that low Medicaid reimbursement rates restrict the quality and quantity of mental health services available to Medicaid participants. Both jurisdictions where I have served as a foster care social worker, Maryland and the District of Columbia, use their own funds to pay for top-notch providers who don’t accept Medicaid. In both jurisdictions and I suspect many others, children with the most complex mental health needs are enrolled with one of these high-quality providers rather than left to the mercy of the Medicaid-funded agencies, with their long waits for service and high turnover. We rarely or never paid for mental health services to parents but isn’t that just what Family First should allow jurisdictions to do? Where, otherwise, is the revolution in child welfare that Family First was supposed to bring about?

Title IV-E as payer of last resort means that very little will change, except perhaps in some states with very narrow Medicaid programs and little categorical federal funding.  To have any hope of fulfilling its promise to keep families together, Family First should be amended to allow Title IV-E to supplement Medicaid and other funding to provide critically needed services to parents.

System-induced School Absenteeism: The hidden scourge of foster care

EveryDayCounts“Faith,” an 18-year-old high school senior that I know, has already missed four days of school without ever being sick. You see, Faith is in foster care and lives in a group home. She missed one day for a morning court hearing and one day for a morning clinic appointment. Both days, Faith was brought back to her group home because nobody had time to take to her school in Maryland, which she was attending before being returned to foster care from a failed guardianship. Another missed day was for a 12:30 clinic appointment. The logical solution would be to schedule her appointments after school, but that is impossible because the group home staff are busy picking up six girls from six different schools in different parts of the city or Maryland suburbs. Faith is a senior and has to pass every one of her classes in order to graduate this June. She failed a class last year due to excessive absences, but none of many adults involved in her case seems to be making the connection between going to school and graduating.

When it comes to missing school, Faith would probably not be any better off in a foster home. As a foster care social worker for five years I learned that the paraprofessional family support workers who took our clients to all of their appointments (because their foster parents refused to take time off from work) always scheduled these appointments during school hours. That’s because these workers were busy after school transporting children to visits with their parents. 

I remember hearing about another social worker’s client, who was failing in school.  This young lady had recently come into foster care after years of neglect and had more than a dozen cavities. In a school meeting to find out why she was failing, school staff informed the social worker that the missed class time was making it difficult for this young woman to complete her assignments. Apparently, scheduling visits out of school time had never been considered.

So I was not surprised that Faith’s appointments were scheduled during school hours and that nobody was available to take her back to school in Maryland, resulting in her missing a full day of school for each. Never mind that the Mayor of the District of Columbia has a campaign against school absenteeism entitled Every Day Counts, citing facts like “Missing just two days a month can put students at risk of academic failure.” I wish Faith’s social worker and group home staff knew that. And I wish the Mayor knew that another part of her government was sabotaging this campaign among the very students most at risk of failure.

In addition to staff constraints due to resource limits, one reason for this widespread disregard of the value of school attendance is an attitude shared by many social workers, foster parents, group home staff, and foster youth themselves, that absence from school is fine as long as it is excused. After all, schools must call Child Protective Services when a student has a certain number of unexcused absences.  Excused absences don’t seem to matter, regardless of the reason for the excuse. Nobody at school asks if the child had to miss a whole day due to a 30-minute medical appointment. And I have seen at least one case when a parent who was at risk of having her child removed due to neglect was encouraged to go to school and retroactively excuse all her child’s absences.

I know this problem is not unique to the District of Columbia. In Kentucky, the Lexington Herald-Leader published an excellent article about foster children’s educational disadvantages. Education officials told the reporter that “foster children are too often pulled out of the classroom for various meetings, appointments, and discussions linked to their status as a foster child, sometimes including visits from social workers or guardians ad litem.”

The problem of system-induced absenteeism among foster youth likely exists around the country, and I hope to hear from readers with examples. So it is not surprising that studies suggest that children in foster care are about twice as likely to be absent from school as other students. This higher absenteeism rate is probably just one among many reasons why educational outcomes for foster youth are so much worse than for the general population. Nationally, only 65% of foster youth complete high school by the age of 21, compared with 86% among all youth aged 18-24. Estimates of the number of foster care alumni who attain a bachelor’s degree range from 3% to 11% compared with 32.5% for the general population.

Of course absenteeism that is not caused by the foster care system itself is also a large problem, especially among older foster youth. That is another, more complex issue that is related to the long history of trauma and school failure as well as inadequate placements. But  the system itself should not be contributing the absenteeism for students who want to attend and do well in school. There should not be a trade-off between health care and education. 

So what can be done to ensure that foster youth are not kept out of school by the foster care system? Child welfare agency leaders must establish from the top that being in school every day is a priority. Agency policy should be that all court hearings, appointments, and meetings take place outside school hours unless there is a documented reason this cannot happen.

Observance of this policy can be monitored only through data sharing between the child welfare agency and the school system. A very helpful fact sheet from the Legal Center for Foster Care and Education provides information about what some jurisdictions are doing to address school absenteeism among foster youth, including data sharing. Jurisdictions should follow the example of Allegheny County PA, where child welfare social workers are able to easily access education data, including attendance. (See Roadmap for Foster Care and Education Data Linkages for more information about how to address the barriers to such linkages.)

Every child welfare agency should have one or more education liaisons for each school or group of schools who have access to all school data including attendance data and reasons for absence if possible. These liaisons should monitor these data  and contact social workers as soon as there is evidence of excessive absenteeism. Kids in School Rule! is a collaborative program between Cincinnati Public Schools and the Hamilton County Department of Job and Family Services. It includes child welfare-based education specialists who have access to real-time data to alert them when a child is absent so that they can intervene quickly.

Clearly, many students in foster care are attending school more regularly than before they were removed from their homes. But when the system removes children, it must not to continue the neglectful parenting that may have brought them into the system in the first place. Foster care should be a time for youth to make up for past disadvantages, rather than fall further behind.

 

 

 

Family court crisis: courts placing children with abusive parents with tragic results

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Autumn Coleman’s crib is now a shrine: New York Times

On May 5, New York City firefighters were called to a horrible scene. A three-year-old girl had been locked in a car and the doors had been chained shut. Then the car was set on fire. As reported by the New York Times, the perpetrator had weekend visitation rights with his three-year-old daughter Autumn. Less than two weeks before, Autumn’s mother wrote to the family court in charge of her custody case, that Pereira was “losing a grip on reality and I honestly feel my child is in danger while in his care.” The court did not intervene.

This terrible case is not an aberration. The Center for Judicial Excellence (CJE) has compiled data on 707 children who have been murdered by a divorcing or separating parent since 2008. CJE has documented 98 cases during that time period in which a child was killed by a parent or parental figure after the family court allowed them unsupervised contact with the child despite being warned that the perpetrator posed a risk to the child.  But this is likely only the tip of the iceberg as there is no agency that records these cases.

A four-month investigation by Gillian Friedman in the Deseret News found that in many cases family courts are failing to protect children, allowing unsupervised visits or even custody to abusive parents. These decisions are resulting in physical and sexual child abuse and sometimes homicide.

Why would family courts put a child in danger by allowing unsupervised contact with a dangerous parent? One reason, experts told Friedman, is that judges and custody evaluators hired by courts often do not believe the claims of danger from the other parent who is trying to protect the child. As the director of CJE told Friedman, “In custody proceedings, family courts often see a parent’s allegation of child abuse as no more than a tactic to undermine the other parent’s custodial rights to the child — and therefore not a credible accusation.” Several of the mothers interviewed by Friedman reported that their attorneys told them not to allege abuse for fear that these allegations would lead to an adverse custody ruling.

Disbelief of the protective parent is not the only possible factor that causes courts to make decisions that put children in danger. Experts told Friedman that evidence of child abuse is often not conclusive and courts are reluctant to bar a parent from access to a child unless the evidence of past abuse is airtight. Moreover, many judges are overwhelmed. They may see as many as 20 cases a day and may have to make a decision after spending no more than 20 minutes on a case.

Finally, judges may be prioritizing parental rights over child safety and well-being. Even if a judge believes that a parent has been abusive, family court professionals told Friedman that it is very hard to get a judge to deny visitation to a parent. Instead, they will require the abuser to engage in treatment or counseling, while maintaining visitation.

Judges may also think a child is safe with a parent who has abused the other parent but not the child. But placing a child with a parent who has a record of domestic abuse may be dangerous even if that parent had not hurt a child. That’s because the parent may harm the child in order to punish the other parent.

Both mothers and fathers can abuse and kill their children. But  domestic violence victim advocates like Joan Meier cite evidence that women are in a disadvantage when alleging abuse in the context of a custody dispute, in part due to the influence of inaccurate beliefs about “parental alienation,” which I described in an earlier post. The “alienation” concept can be used by either parent to connote that the other parent is poisoning the child’s mind against them and has often resulted in the placement of children against their will with a parent that they allege abused them–more often than not, the father. 

But fathers’ advocates claim that that family courts are prejudiced against fathers. It seems clear that judicial attitudes have changed over time. As described in a useful article published in 2011 by San Francisco Weekly,  family courts were traditionally biased against fathers, believing that children belonged with their mothers. However, as divorce became more common, advocacy by fathers’ rights group has led to the acceptance that children’s time should be split as evenly as possible between parents. While it seems clear that child safety should trump any considerations of equity between mom and dad, it seems that some judges do not agree. 

The problem of placing parents’ rights over safety should be familiar to readers of Child Welfare Monitor from our many columns about child welfare agencies and family court judges accepting risks to child safety and well-being in order to keep families together or reunite them. In our experience with such cases. the court and the child welfare agency usually agree about the primacy of parents and the need for children to remain or be reunified with their parents. There are occasional disagreements. Child Welfare Monitor will never forget tearfully trying to convince a judge that my six-year old client would do better with a foster parent who had loved her for two year than with a mother who could not think of one good thing to say about her–to no avail. But in these custody cases it is the protective parent whose pleas to keep the child safe are being disregarded.

Thankfully, there is a growing recognition that family courts are failing to protect children in custody cases, with sometimes tragic results. Last year, Congress passed a resolution stating that “child safety is the first priority of custody and visitation adjudications, “and that courts should resolve safety risk and family violence claims first, before assessing other factors that may affect a child’s best interests. The resolution makes several recommendations to states for improving their court processes, including setting standards for evidence presented in custody proceedings and for the professionals who are accepted as experts.

In 2019, the Governor of Maryland signed a bill requiring the formation of a new workgroup, the first of its kind, to study child custody court proceedings involving child abuse or domestic violence allegations and make recommendations about “incorporating the latest science regarding the safety and well-being of children and other victims of domestic violence.”

It is important for child advocates  to become involved with this issue, which has generally been the province of mainly domestic violence advocates. Child advocates around the country should push for legislation like that passed in Maryland to establish commissions to study this issue and make recommendations about how the family courts can be improved to ensure the safety of children involved in custody litigation.

 

 

 

 

Family First Act: a False Narrative, a Lack of Review, a Bad Law

Family First ActThe passage of the Family First Prevention Services Act (FFPSA) was greeted with joy and celebration when it passed as part of the Bipartisan Budget Act of 2018. “The Family First Prevention Services Act will change the lives of children in foster care,” crowed the Annie E. Casey Foundation.  The new law “will change foster care as we know it,” raved the Pew Charitable Trusts. But the Act took effect on October 1 to little fanfare. Based on contacts with all the states, the Chronicle of Social Change expects only 14 states and the District of Columbia to implement the Act and 36 to delay implementation for up to two years as allowed by the law. But as of two weeks before implementation, only four states had submitted the plan required in order to implement the Act.

An Act with Many Flaws

FFPSA has been revealed (as some knew all along) as a messy and poorly written piece of legislation. It starts with a misnomer. What the Act calls “prevention services” (“in-home parent skill-based,” mental health, and drug treatment programs for parents who have already been found to have abused or neglected their children) are aimed at prevention of foster care, not of child abuse and neglect before they occur. To most experts, these would be considered to be “intervention” and not “prevention” services. But beyond this misnomer, the legislation has multiple flaws which means it may create more problems than it solves.  Among these issues, covered in detail in a recent webinar from California’s Alliance for Children’s Rights and an article in Governing, are the following:

  1. Lack of new funding: FFPSA was designed to be budget neutral, redirecting funds toward foster care prevention services from congregate care and a delay of an expansion in adoption assistance. The Congressional Budget Office has estimated that FFPSA will actually result in a $66 million reduction in federal spending over a ten-year-period. This comes on the heels of 20 years of federal disinvestment in foster care, leaving jurisdictions struggling to maintain reasonable caseloads and services.  Some states are anticipating crippling losses of of funds due to the loss of their Title IV-E waiver programs, which expire at the end of the year and were far more generous and less restrictive than FFPSA. For example, California anticipates the loss of $320 million in federal funding when the waiver ends, forcing service reductions in some of its largest counties. New York will lose support for a program that hired more social workers and supervisors and has been credited with allowing youth to leave foster care earlier.
  2. Requirement that 50% of funding be spent on “well-supported” programs. FFPSA requires that 50% of funding be spent on programs that meet a rigorous set of criteria to be defined as “well-supported.” But so far, the clearinghouse created for the purpose of this provision has designated only six programs as “well-supported”: three mental health programs, three home visiting programs, and no drug treatment programs. Some states may prefer to adopt or expand in other similar programs that are not on the list. Therefore there has been a chorus of proposals that this provision be eliminated or delayed.
  3. Interaction with Medicaid: Each state’s Medicaid program covers a different set of services, but many of the services meeting FFPSA criteria, especially mental health and substance abuse treatment, are already funded by Medicaid in most cases. Allowing Title IV-E to supplement Medicaid funds might have helped improve the quantity and quality of services available. But in its guidance on implementing the legislation, the Children’s Bureau specified Title IV-E as the payer of last resort for these services. That means that Medicaid must pay first before Title IV-E can be billed. Thus, in states with more generous Medicaid programs, the law will greatly expand the services available to families. Moreover, it appears, based on the federal government’s answer to one state’s question, that programs paid for by Medicaid may not count toward the 50% of programs that must be “well-supported,” leaving states that use Medicaid to fund these programs in a difficult situation. 
  4. Restrictions on congregate care: One of the two main purposes of FFPSA was to restrict congregate care, which is basically any placement that is not a foster home. To do so, FFPSA cuts off funding after two weeks for any placement that is not a foster home, with four exceptions. Three of these are programs for special populations and the fourth is a new category called a Quality Residential Treatment Programs (QRTP)–a new category created by FFPSA. QRTP’s must meet numerous requirements, such as accreditation, 24-hour nurse coverage, and a “trauma-informed” approach. Moreover, a child must be assessed by a “qualified individual” as needing placement in a QRTP and that decision must be approved by the family court. Furthermore, a youth may not remain in a QRTP for more than 12 consecutive months without written approval from the head of the agency. As Child Welfare Monitor has discussed elsewhere, there is concern that some group homes will have trouble meeting the FFPSA criteria. Group homes are closing around the country due to insufficient funding and state-level policy changes. Many states have desperate shortages of foster homes, and closing group homes at the same time will worsen their placement crises. Furthermore many young people, especially those with more issues, may need more than 12 months in a group home and may lose all their gains if transferred prematurely to a foster home.  There is also a problem with Medicaid and QRTP’s, as it appears they will fall into a category of “Institutions for Mental Diseases” that are not payable by Medicaid.
  5. Kinship Diversion: FFPSA creates an avenue for prevention of foster care by placing a child with relatives (often called kinship diversion) while the parents receive prevention services for up to 12 months. If reunification with the parents never happens, there is no requirement that the children be placed formally with the relatives, or that the relatives receive any assistance either financially or with services. They would be forced to rely on Temporary Assistance for Needy Families (TANF), which is much less generous than foster care payments, and to make do with any services they can find in the community. There is concern that FFPSA may encourage states and counties to use kinship diversion rather than licensing relatives as foster parents, thus entitling them to more services and assistance and ensuring that the agency does not lose track of the children.

How a bad bill was born

The passage of FFPSA was the outcome of many years of advocacy, under the mantra of “child welfare finance reform.” So how did such a flawed bill pass after so many years of proposals and discussions? The answer includes a truncated legislative process, an insistence on budget neutrality,  and a false narrative promoted by a wealthy group of organizations.

False Narrative

This call for finance reform was based on the idea that, as expressed by one of its primary proponents, Casey Family Programs, in a white paper published in 2010:

 …the major federal funding source for foster care, Title IV-E, primarily pays for maintaining eligible children in licensed foster care, rather than providing services for families before and after contact with the child welfare system. The fact that no IV-E funding can be used for prevention or post-reunification services has created a significant challenge to achieving better safety and permanency outcomes for children.

This statement was literally true. Before implementation of FFPSA, Title IV-E funds were not available for services provided to families to help them avoid placement of their children in foster care. But plenty of other funds were available to cover these services. We’ve already mentioned that Medicaid currently pays for many or most of the services that will be provided under FFPSA, with the specifics depending on the state. Other funding sources  included Title IV-B, TANF, Social Services Block Grant, and CAPTA funds.

Moreover, Title IV-E does not cover all foster care costs. The federal government reimburses states for 50 to 75% of the cost of foster care payments, depending on the state. But only 38% of foster children were eligible for federal reimbursement under Title IV-E in 2016, down from an estimated 54% in 1999. The reason for this decline is an antiquated provision (often called the “Title IV-E lookback”) that links Title IV-E eligibility to eligibility for Aid to Families with Dependent Children, a welfare program that ended in 1996. Anything calling itself finance reform should have addressed this senseless linkage, but the framers did not.

So, between the availability of other funds and the fact that states had to pay a large share of foster care costs themselves,  it is hard to accept the narrative that states had an incentive to place children in care rather than provide services to their families to keep them at home. And indeed states have for years been providing in-home services to help families avoid foster care. According to federal data, 1,332,254 children received in-home or family preservation services in FY 2017 compared to only 201,680 children who received foster care services. So the argument for “finance reform” is simply a red herring.

The idea that a foster home is almost always better than a group home or residential placement is behind the other major part of FFPSA, the strict restrictions on funding for congregate care. But this narrative ignores the fact that there are not enough foster parents, especially those who are willing, loving and gifted enough to care for older and more troubled young people. Perhaps some supporters think that these foster parents will suddenly appear once group homes disappear. But this kind of wishful thinking failed when the mental hospitals closed in the 1960’s and the promised community mental health services did not appear, and there is no reason to think it will be more accurate this time around.

So how did a false narrative gain such a large following and become accepted as the truth? This idea has been supported by a powerful coalition of organizations led by Casey Family Programs, author of the white paper quoted above. Casey’s assets totaled $2.2 billion at the end of 2018 and it spent $111 million that year in pursuit of its goals, which include “safely reducing the need for foster care by 50 percent by the year 2020.” Casey has relentlessly promoted this narrative through publications, testimony, and assistance to jurisdictions that agree to implement its agenda.

Budget Neutrality

As mentioned above, FFPSA does not add resources to the system but instead redirects them from congregate care and adoption assistance to services designed to keep families together. Much of the savings will come from states taking on the full cost of group home placements that they cannot avoid. The Congressional Budget Office estimates that about 70% of the children residing in group home placements (other than residential treatment programs) would become ineligible for Title IV-E funding in 2020. So the cost of funding this placements will be shifted to states and counties that are often already struggling to fund these necessary placements. Moreover, the continuation of the TItle IV-E “lookback” means that the federal share of foster care funding will continue to decrease.

Much of the blame for the Act’s budget neutrality goes to Casey and its fellow advocates, who have been uninterested in increasing resources for foster care. As longtime Hill staffer Sean Hughes points out, “…Congressional staffers will tell you that child welfare advocates are perhaps the only group of federal advocates that consistently decline to even ask for new resources.” According to Hughes, these advocates have been unwilling to increase resources for foster care because of their bias toward family preservation. (Remember Casey’s goal of reducing foster care by 50% by 2020). They apparently hope that “starving the foster care beast” might result in fewer foster care placements, whether or not children might be left in unsafe situations. The framers wanted a budget neutral bill, and the advocates were happy to accept it in order to reallocate resources away from foster care (through the continuation of the “lookback” and the restrictions on group homes) toward family preservation.

Lack of review

Aside from a pair of hearings that were orchestrated by the bill’s sponsors to support their vision for the legislation, there were no hearings or floor debate on the Family First Act after it was introduced in 2016. In 2017, it passed the House by voice vote, and its Senate sponsors failed to get it passed. In 2018, after failing twice to attach it to larger bills without hearings of debate, the sponsors succeeded at the eleventh hour in getting it attached to the budget act. Young people whose lives were saved by group homes were never able to tell their stories. The technical problems with Medicaid eligibility were never discussed and may not have even been noticed until long after passage.

A bill called the Family First Transition Act has been introduced to ease the transition to the new legislation. It would delay for two years the implementation of the 50% “well-supported” requirement for services reimbursement,  provide a small amount of transition funding to help states implement the Act, and provide temporary grants to jurisdictions with expiring waivers to make up for a portion of their loss under FFFPSA. However, none of these temporary fixes would cure this fundamentally flawed bill, the inevitable result of a false narrative, inadequate funding, and a truncated legislative process.

This post was updated on November 7, 2019, to specify that the Children’s Bureau made the determination that Title IV-E would be the payer of last resort for prevention services to foster care candidates. This designation of Title IV-E as payer of last resort was not made in the Act itself.