The placement crisis for high-needs kids: it is residential facilities, not foster homes, that are lacking

Several housing units leased by DFPS for housing foster youth were adjacent to blighted abandoned housing development. From Court Monitor’s Report, published by Texas Public Radio, https://www.tpr.org/government-politics/2022-01-12/texas-foster-care-in-crisis-after-a-decade-in-litigation-and-5-years-under-federal-oversight

Around the country, child welfare systems are struggling with a placement crisis, especially for their most troubled youths. In North Carolina, an assistant secretary of the health and human services department told county directors that the state’s child welfare system is in crisis and could be hit with a massive class action suit due to children with emotional and behavioral health needs being boarded in offices or left in emergency rooms. In Illinois, the Director of the Department of Children and Family Services has been found in contempt of court a dozen times for not find a appropriate placement for specific children who were left in psychiatric hospitals after they were ready for discharge, left in juvenile detention centers after their sentences expired, or slept on office floors for want of a better placement. A recent case involved a girl who remained in a psychiatric hospital 170 days after being cleared for discharge.

In Colorado, Florida, Kentucky, Maryland, Massachusetts, Michigan, New Mexico, New York, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Virginia, and Washington, the stories are similar. State and local agencies are unable to find appropriate placements for foster children and youth with the most severe behavioral health needs. As a result, they are being warehoused in inappropriate settings, such as temporary shelters, hotels, offices, or state-leased houses staffed by social workers; sent far away for residential care, or being left in psychiatric hospitals and detention centers after being cleared for release. Depending on the nature of the setting, these young people are deprived of normal schooling, activities, contact with their families, heathy food, exercise and opportunities to develop the life skills that they need. And equally important, they receive the message that nobody cares about them. As Cook County’s Public Guardian told a reporter about the children left for months in hospitals after a stay that should last no longer than a week or two :

“Imagine what it says to a child to see other kids come in, be treated, leave after a week. And they’re (wards of the state) stuck there for months, and months, and months because there’s nowhere for you,” Golbert said. “imagine the message that that sends to these children. It very powerfully tells these children that you don’t matter. And these are kids that often have attachment issues to begin with, by definition — they’ve been removed from abusive parents to be in DCFS care.”

Not surprisingly, the children languishing in inappropriate placements tend to be those who are hardest to place in foster homes. They tend to be older and with mental and physical disabilities, behavioral health problems, or both. Many of them have been bouncing from foster home to foster home for years until no foster home would take them. Many of these children have displayed violent or self-destructive behavior and are at risk of harming themselves or others. With fewer abused and neglected children being removed from their homes, foster care professionals all over the country are reporting that the children who are being placed today have more serious needs and often need of intensive services from professionals.

Few potential foster parents are willing to open their homes to youth who might be a threat to themselves or others in the home. Furthermore, many of these youth require a placement with intensive therapeutic services before being able to function in a normal foster home. Such a placement might be called a therapeutic group home, residential treatment center, or psychiatric residential treatment facility. Definitions of these terms vary, but the federal government’s foster care data system (AFCARS) classifies all these settings as “congregate care,” a term that has come to mean any setting that is not a foster home. Perhaps a specially trained, paid and supported therapeutic foster home could help some of these youths, but the numbers of such homes are tiny compared to the need.

So how did we get to this place where so many children with acute needs, far from having their needs met, are being housed in inappropriate and harmful settings? The foster care placement crisis is part of a larger crisis in residential care for youth (not just those in foster care) that stem from a push by advocates and governments to reduce the number of children in institutional care. Egregious cases of abuse in residential facilities have led to extensive press coverage, lawsuits, investigations, and the closure of many residential treatment centers. But they have also been used by opponents of residential care to argue that all such facilities are abusive or unnecessary, instead of recognizing that there are high-quality residential placements that can help the most wounded children who cannot be helped in another setting.

In addition to the growing opposition to residential care, other factors have also affected the supply of these facilities. Reimbursement rates have stagnated around the country, resulting in closure of some facilities. And those that are still open cannot pay their employees more than they would make in jobs in fast food or retail, with much less stress and risk. This has resulted in a staffing crisis that has caused facilities to close.

In a disturbing echo of the deinstitutionalization movement of the 1960’s, disappearing residential treatment facilities have not been replaced by other options for providing the necessary care. The Colorado Sun reported on the catastropic state of residential care in that state. More than 44 youth treatment centers, with more than 1,000 beds, have closed since 2007. Only “a handful” of the 40 remaining centers will take the youth with the most severe mental health problems. And the director of human services for Weld County, Colorado, told the Sun that when the county does find a residential bed for a child, the child is often kicked out for displaying behaviors to severe for them to handle.

At the same time as residential facilities for youth in general have been closing down, a series of laws and court settlements has resulted in massive reductions in residential beds available to foster youths specifically. As is often the case, California took the lead by passing its Continuum of Care law, and Congress followed by adopting the Family First Prevention Services Act (FFPSA), of which one of its two main purposes was the reduction of children’s placements in congregate care. FFPSA accomplished its purpose by limiting to two weeks the time a child could spend in congregate care, except for certain specialized facilities for youth who had been sex-trafficked, pregnant and parenting teens, and independent living facilities. The only other exception is a new facility type called a Quality Residential Treatment Program (QRTP), which must meet stringent requirements, like a trauma-informed model, accreditation, and full-time nurses on site, that would require major modifications for many existing facilities. FFPSA also required that any placement beyond two weeks be approved by a court and that a stay longer than 12 months be approved in writing by the head of the agency. FFPSA contains another poison pill for residential care, of which its framers may have been unaware. QRTP’s of over 16 beds will likely be classified by Medicaid as “Institutions of Medical Diseases,” and therefore youth who are placed in these facilities will be ineligible for Medicaid funding of any of their care.

New Mexico is a “window into challenges facing other states, as documented by Searchlight New Mexico and Pro Publica. in the aftermath of a court settlement in which it agreed to reduce its reliance on residential treatment centers for foster youth, the number of group facilities has dropped by about 60 percent over the four years ending last August. But the state has yet to build the the community-based behavioral health system that it had promised. Therefore, the highest-needs youths are spending months in crisis shelters designed for brief stays and not equipped to deal with severe mental illness. Practically every day, reports Searchlight New Mexico, someone at a shelter that accepts foster teens calls 911 with a report of young people harming themselves, attacking or threatening staff or other residents, or running away. According to Pro Publica, the state plans to train four therapeutic foster parents and open two small group homes, with six beds each, for troubled youth. The state has not yet licensed a single QRTP.

The states with the largest numbers of foster youths are facing crises as well. In California, according to a letter from four state associations in April 2022, 1,193 residential therapeutic beds available to foster youth had been lost since January 1, 2020. The writers report that they are “aware of a number of other providers who are either greatly reducing their capacity, shifting program models to serve youth with less intensive needs, or closing.” In Texas, at any time there are as many as 75 children sleeping in unlicensed facilities like hotels or state-leased houses staffed by CPS workers for lack of an appropriate placement. In New York, more than half of residential treatment facility beds for children have shut down in the past ten years, dropping from 554 to 274, according to Pro Publica. In New York City, the Imprint recently reported that at least 40 children currently in the City’s emergency Children’s Center have been there for more than a month. The center, designed for temporary stays, currently houses 72 children. Housing children with a variety of complex diagnoses and speaking multiple languages, the center is responsible frequent calls to 911 and has been the subject of public scrutiny as a result of some of these episodes.

Some commentators and media outlets persist in blaming the placement crisis on a shortage of foster homes. Confounding the foster home shortage with the shortage of placements for high-needs kids is deceptive. As mentioned above, there are not many potential foster homes that would agree to take these children or that could help them. The option of using therapeutic foster care, while politically popular, has so far resulted in only very small programs due to the difficulty in recruiting suitable parents. This is not to say there is no foster home shortage for children who could be accommodated in a foster home; such shortages probably exist in many or most states, especially when we talk about the supply of quality foster homes.

What can be done? As many advocates argue, we should help children earlier so that they don’t become so damaged that they have to be placed in residential care. Many child welfare leaders and and advocates say the answer is to reach out to families before they become involved with child welfare. But they rarely talk about intervening earlier and more intensively with families already known to child welfare agencies. As a member of the District of Columbia’s Child Fatality Review Team for years, I have observed a striking pattern among youths who are victims of gun violence. More often than not, their families have extensive child protective services case histories, often involving multiple children with repeated referrals for excessive absences from school, lack of supervision and physical or sexual abuse. The records show referral after referral being screened out, in-home cases being opened and quickly closed, and children being placed in and returned from foster care without any evidence of improvement in family functioning. Over time, the children’s behavior worsens, they acquire mental health diagnoses, become involved with juvenile justice, and those young people whose sad cases I reviewed eventually were killed by other youth and adults with similar backgrounds. We need to understand the deep intergenerational problems of chronically maltreating families and intervene with more intensity earlier–through intensive in-home services (with participation enforced by a court if necessary) and, when all else fails, removal of the child to a safer environment.

No matter what we do to help children earlier, it is obvious that at least in the short-run we must replace some of the lost residential facilities. These new facilities should be QRTP’s or other high-quality residential placements. But they must be established, and funded adequately enough to hire and adequately reward staff who are dedicated and passionate about their work. Some states have already taken action to boost their residential capacity for high-needs youth. The Legislature in Texas, for example, appropriated $70 million to the Department of Family and Protective Services (DFPS) for supplemental payments to retain providers and increase provider capacity, and another $20 million for new facilities for the young people with the most intense needs. Congress can help by exempting QRTP’s from the IMD exclusion. The federal government could also incentivize creation of QRTP’s through a pilot or grant program.

Around the country, and in states encompassing the vast majority of foster youth, there is a placement crisis that is affecting mostly those youth who require more intensive care and services. This is part of a larger crisis in residential care for youth, which is exacerbated among foster youth because of new laws and policies discouraging their placement in what is called “congregate care.” Those who explain this as a shortage of foster homes fail to understand the nature of the youth affected. Perhaps earlier intervention with children who are chronically abused or neglected can reduce the number of children who are in need of residential care. But at least in the short run, we must increase the supply of quality residential facilities in order to prevent further damage to these youths. It will be costly, but the costs of inaction would be far greater.

 

“Five Myths about the Child Welfare System” misleads more than it corrects

Source: UAlberta.ca

by Marie Cohen and Marla Spindel

The following was submitted as an Op-Ed to the Washington Post in an effort to ensure the. public has the benefit of various viewpoints on this topic but, unfortunately, the Post chose not to publish it.

We were troubled to read Dorothy Roberts’ “Five myths about the child welfare system” in the April 17th Outlook section of the Washington Post. Roberts’ version of reality does not agree with what we see every day as child advocates in the District of Columbia, nor with the research on child welfare.

“Myth” No. 1: Child welfare workers mainly rescue children from abuse. Roberts is correct that at most 17 percent of the children placed in foster care in FY 2020 were found to be victims of physical or sexual abuse. But she is wrong when she implies that most neglect findings reflect parents who are too poor to provide adequate housing, clothing and food to their children. Many of the neglectful parents we have seen have serious, chronic mental illness or substance use disorders that impact their parenting, and they are unwilling or unable to comply with a treatment plan. Meanwhile, the children in their care are often left to fend for themselves because their parents cannot feed and dress them, change their diapers, or get them to school. Many children neglected in this way develop cognitive and social deficits, attachment disorders, and emotional regulation problems. Most poor parents do not neglect their children. Even with scarce resources, they find a way to provide safe and consistent care.

“Myth” No. 2: Homes are investigated only if children are at risk of harm. The purpose of an investigation is to determine whether children are at risk of harm. Professionals who work with children are trained to report concerns about possible maltreatment, not to investigate on their own. The system is not perfect. Some reports are too minor to meet the definition of maltreatment, or even maliciously motivated. A surprisingly large number of children are reported every year and only a minority of these reports are substantiated—but that does not mean they are not true. But to propose that investigations should take place only if it is first determined that children are at risk puts the cart before the horse and disregards the safety of children.

“Myth” No. 3: Foster children are usually placed with loving families. Roberts’ statement that large numbers of children are placed in some form of congregate care — group homes, residential treatment centers and psychiatric hospitals—is misleading. Only eight percent of children in foster care were in a group home or institution at the end of September, 2020, though the percentage is higher for older youth. The problem is the lack of quality therapeutic placements for children who have been so damaged by long histories of abuse and neglect that they cannot function in a family home. It is true that many children bounce from one foster home to another, but these are often youths with acute behavior problems that make it difficult for them to function in a home. Roberts also fails to mention that 34 percent of foster children were residing in the homes of relatives as of September 2020, and that they have more placement stability than children placed in non-kinship homes.

“Myth” No. 3: Foster children are usually placed with loving families. Roberts’ statement that large numbers of children are placed in some form of congregate care — group homes, residential treatment centers and psychiatric hospitals—is misleading. Only eight percent of children in foster care were in a group home or institution at the end of September, 2020, though the percentage is higher for older youth. The problem is the lack of quality therapeutic placements for children who have been so damaged by long histories of abuse and neglect that they cannot function in a family home. It is true that many children bounce from one foster home to another, but these are often youths with acute behavior problems that make it difficult for them to function in a home. Roberts also fails to mention that 34 percent of foster children were residing in the homes of relatives as of September 2020, and that they have more placement stability than children placed in non-kinship homes.

Myth No. 4: Placing children in foster care improves their well-being.” Arguing that foster care is harmful is like arguing that treatment in a cancer ward increases the risk of dying of cancer. Foster youths are likely to have poor outcomes given their history of maltreatment, which foster care cannot erase. It is difficult to assess how foster care placement affects children, since we cannot do a controlled experiment in which some children are placed and a similar set of children are not. Roberts quotes only one study, from 2007, that shows harm from foster care—and that study included borderline cases only, leaving out children suffering severe and obvious maltreatment. She does not quote the same author’s brand-new paper, which finds both positive and negative effects for different contexts, subgroups, and study designs.

“Myth” No. 5: This system was founded after the case of Mary Ellen Wilson. This is an esoteric myth, as few people have heard of Wilson. Roberts is right that many histories trace the roots of today’s child welfare system to the case of that little girl. We appreciate Roberts’ clarifications but are not convinced of their significance. We believe other myths are much more relevant, such as that neglect is synonymous with poverty, or that all children are betteroff with their parents no matter how badly abused or neglected they are.

It is disappointing that the Post allowed Roberts to use this series to propagate new myths, rather than dispel old ones.

Marie Cohen is a former foster care social worker, current member of the District of Columbia Child Fatality Review Committee, and author of the blog, Child Welfare Monitor. You can findher review of Dorothy Roberts’ new book here. Marla Spindel is the Executive Director of DCKincare Alliance and a recipient of the 2020 Child Welfare League of America’s Champion for Children Award.

Torn apart: A skewed portrait of child welfare in America

In her 2009 book, Shattered Bonds: The Color of Child Welfare, Dorothy Roberts drew attention to the disproportional representation of Black children in foster care and child welfare in general and helped make “racial disproportionality” a buzzword in the child welfare world. In her new book, Torn Apart: How the Child Welfare System Destroys Black Families–And How Abolition Can Build a Safer World, Roberts revisits the issues addressed in Shattered Bonds and creates a new buzzword, renaming child welfare as the “family policing system.” Those who liked Shattered Bonds will likely love Torn Apart. But those who value accuracy in history or in data will find it to be sadly misguided, although it does make some valid points about flaws in the U.S. child welfare system.

Roberts starts with a horrific anecdote about a mother, Vanessa Peoples, who was doing everything right–she was married, going to nursing school, about to rent a townhouse and was even a cancer patient. But Peoples attracted the attention of both the police and child welfare and ended up hogtied and carted off to jail by police, placed on the child abuse registry, and subjected to months of monitoring by CPS after she lost sight of her toddler at a family picnic when a cousin was supposed to be watching him. But citing these extreme anecdotes as typical is very misleading. This particular story has been covered in numerous media outlets since it occurred in 2017 and continues to be cited regularly. One can counter every one of these horrific anecdotes with a story of a Black child who would have been saved if social workers had not believed and deferred to the parents. (See my commentary on the abuse homicides of Rashid Bryant and Julissia Batties, for example).

Roberts’ book restates many of the old myths that have been plaguing child welfare discussions as of late and that seem to have a life of their own, impervious to the facts. Perhaps the most common and pernicious is the myth that poverty is synonymous with neglect. Roberts embraces this misconception, suggesting that most neglect findings reflect parents who are too poor to provide adequate housing, clothing and food to their children. But parents who are found to have neglected their children typically have serious, chronic mental illness or substance use disorders that severely affect their parenting, and have refused or are unable to comply with a treatment plan. Many are chronically neglectful, resulting in children with cognitive and social deficits, attachment disorders, and emotional regulation problems. Commentator Dee Wilson argues based on his decades of experience in child welfare that “a large percentage of neglect cases which receive post-investigation services, or which result in foster placement, involve a combination of economic deprivation and psychological affliction…., which often lead to substance abuse as a method of self-medication.” Perhaps the strongest argument against the myth that poverty and neglect are one and the same is that most poor parents do not neglect their children.  They find a way to provide safe and consistent care, even without the resources they desperately need and deserve.

Roberts endorses another common myth–that children are worse off in foster care than they would be if they remained in their original homes. She argues that foster care is a “toxic state intervention that inflicts immediate and long-lasting damage on children, producing adverse outcomes for their health, education, income, housing, and relationships.” It is certainly true that foster youth tend to have bad outcomes in multiple domains, including education, health, mental health, education, housing and incarceration. But we also know that child abuse and neglect are associated with similar poor outcomes. Unfortunately, the research is not very helpful for resolving the question of whether these outcomes are caused by the original child maltreatment or by placement in foster care. We cannot, of course, ethically perform a controlled study in which we remove some children and leave a similar set of children at home. We must rely on studies that use various methodologies to disentangle these influences, but all of them have flaws. Roberts cites the study published in 2007 by Joseph Doyle, which compared children who were placed in foster care with children in similar situations who were not. Doyle found that children placed in foster care fared worse on every outcome than children who remained at home. But Doyle focused on marginal cases* and left out the children suffering the most severe and obvious maltreatment. In a brand-new paper, Doyle, along with Anthony Bald and other co-authors, states that both positive and negative effects have been found for different contexts, subgroups, and study designs.

There is one myth that Roberts does not endorse: the myth that disproportional representation of Black children in child welfare is due to racial bias in the child welfare system, rather than different levels of maltreatment in the two populations. After an extensive review of the debate on this issue, Roberts concludes that it focused on the wrong question. In her current opinion, it doesn’t matter if Black children are more likely to be taken into foster care because they are more often maltreated. “It isn’t enough,” she states, “to argue that Black children are in greater need of help. We should be asking why the government addresses their needs in such a violent way, (referring to the child removal). Roberts was clever to abandon the side that believes in bias rather than different need as the source of disparities. The evidence has become quite clear that Black-White disparities in maltreatment are sufficient to explain the disparity of their involvement in child welfare; for example Black children are three times as likely to die from abuse or neglect as White children. As Roberts suggests and as commentators widely agree, these disparities in abuse and neglect can be explained by the disparities in the rates of poverty and other maltreatment risk factors stemming from our country’s history of slavery and racism. Unfortunately, Roberts’ continued focus on these disparities in child welfare involvement will continue to be used by the many professionals who are working inside and outside child welfare systems all over the country to implement various bias reduction strategies, from implicit bias training to “blind removals.”

In Part III, entitled “Design,” Roberts attempts to trace the current child welfare system to the sale of enslaved children and a system of forced “apprenticeship” of formerly enslaved Black children under Jim Crow, whereby white planters seized custody of Black children from their parents as a source of forced labor.** As she puts it, “[t]hroughout its history US family policy has revolved around the racist belief that Black parents are unfit to raise their children. Beginning with chattel slavery and continuing through the Jim Crow, civil rights, and neoliberal eras, the white power structure has wielded this lie as a rationale to control Black communities, exploit Black labor, and quell Black rebellion by assaulting Black families.” In other passages she adds other groups to the list of victims, adding “Indigenous, immigrant and poor people to the list of communities that are being controlled by the “family policing system.” But most of her statements refer to Black victims only.

Roberts’ attempt to connect slavery and Jim Crow practices with child welfare systems highlights a major flaw of the book. She herself explains that due to racism the child welfare system served only White children when it emerged in the nineteenth century with the creation of child protection charities and the passage of state laws allowing maltreated children to be removed from their homes and placed in orphanages. Foster care was established in the middle of the century and also excluded Black children. The system did not begin serving Black children until after World War II, so it is difficult to understand how it could stem from slavery and Jim Crow practices. It seems much more plausible that the child welfare system arose from basically benevolent concerns about children being maltreated, and that with the rise of the civil rights movement, these concerns were eventually extended to Black children as well.

While Black children’s representation as a share of foster care and child welfare caseloads rose rapidly starting in the 1960’s, and Black children are much more likely to be touched by the system than White children, the system still involves more White than Black children. According to the latest figures, there were 175,870 White non-Hispanic children in foster care (or 44 percent of children in foster care) and 92,237 Black (non-Hispanic) children in foster care, or 23 percent of children in foster care. Moreover, the disparity between Black and White participation in child welfare and foster care as a percentage of the population seems to be decreasing.*** So the idea that this whole system exists to oppress the Black community and maintain white supremacy seems farfetched.

Roberts’ attempt to make Black children the focus of the book results in some awkward juxtapositions, like when she admits that though the Senate investigation of abuses by a for-profit foster care agency called MENTOR “highlighted cases involving white children, we should remember that Black children are more likely to experience these horrors in foster care—not only because Black children are thrown in foster care at higher rates, but also because government officials have historically cared less about their well-being.” A page later she states that the “child welfare system’s treatment of children in its custody is appalling but should come as no surprise. It is the predictable consequence of a system aimed at oppressing Black communities, not protecting Black children.” It is hard to understand how White children being maltreated in bad placements supports this narrative.

Fundamental to Roberts’ critique is her system is “not broken.” “Those in power have no interest in fundamentally changing a system that is benefiting them financially and politically, one that continues to serve their interests in disempowering Black communities, reinforcing a white supremacist power structure, and stifling calls for radical social change.” Even if one believes there is a white supremacist power structure, it is hard to see the direct connection between the abuses Roberts is highlighting and the disempowerment of Black communities; it seems more likely that the more abusive the system, the more protests it would generate. And at a time when the federal government and some of the wealthiest foundations and nongovernmental organizations are echoing much of Robert’s rhetoric, her reasoning seems particularly off-target.

Roberts makes some valid criticisms of the child welfare system. Her outrage at the terrible inadequacies of our foster care system is well-deserved. She is right that “The government should be able to show that foster care puts Black children [I’d say “all children”] on a different trajectory away from poverty, homelessness, juvenile detention, and prison and toward a brighter future.” Any society that removes children from their parents needs to be responsible for providing a nurturing environment that is much, much better than what they are removed from. And we are not doing that. As Roberts states, “The state forces children suffering from painful separations from their families into the hands of substitute caretakers…..who often have unstable connections, lack oversight and may be motivated strictly by the monetary rewards reaped from the arrangement.” As a foster care social worker in the District of Columbia, I was driven to despair at my inability to get my superiors to revoke the licenses of such foster parents; the need for “beds” was too great to exclude anyone was not actually guilty of abuse or severe neglect. Roberts is also right to be concerned the outsourcing of foster care to private for-profit organizations that may be more concerned with making money than protecting children, sometimes resulting in scandals like the one involving MENTOR Inc., which was found to hire unqualified foster parents and fail to remove them even after egregious violations like sexual assault.

Roberts also raises valid concerns about children being sent to residential facilities, often out of state, that resemble prisons rather than therapeutic facilities. But she ignores the need for more high-quality congregate care options for those children who have been so damaged by years of maltreatment that they cannot function in a foster home, no matter how nurturing. Instead, she repeats the usual litany of scandals involving deaths, injuries, fights and restraints, without noting the undersupply of truly therapeutic residential settings, resulting in children sleeping in office, cars, and hotels or remaining in hospital wards after they are ready for discharge. Ironically, she supports defunding the system, even if that would mean even worse situations for these children.

Roberts decries the fact that parents sometimes relinquish custody of their children in order to get needed residential care, arguing that “rather than providing mental health care directly to families, child welfare authorities require families to relinquish custody of children so they can be locked in residential treatment centers run by state and business partnerships.” That statement is completely backwards. The child welfare system does not provide mental health services but, like parents, it often struggles to secure them for its clients. Some parents are forced to turn to the child welfare system because their insurance will not pay for residential care for their children. That is not the fault of child welfare systems, which clearly do not want to take custody of these children. The underlying problem is the lack of adequate mental health care (including both outpatient and residential programs), which has destructive consequences for the foster care system. This is exacerbated by the lack of parity for mental health in health insurance programs. It’s hard to believe Robert is unaware of these well-known facts.

Roberts is correct that parents as well as children are shortchanged by inadequacies in our child welfare program, such as the “cookie cutter” service plans which often contain conflicting obligations that are difficult for struggling parents to meet. But she is wrong when she says that parents need only material support, not therapeutic services. But this error flows logically from her concept of neglect as simply a reflection of poverty. In fact, many of these parents need high-quality behavioral health services and drug treatment, which are often not available because of our nation’s mental health crisis, as well as the unwillingness of taxpayers and governments at all levels to adequately fund these services.

In her final chapter, Roberts concludes that, like the prison system, the child welfare system cannot be repaired because it exists to oppress Black people. “The only way to end the destruction caused by the child welfare system is to dismantle it while at the same time building a safer and more caring society that has no need to tear families apart.” In place of family policing, Roberts favors policies that improve children’s well-being, such as “a living wage and income support for parents, high-quality housing, nutrition, education, child care, health care; freedom from state and private violence; and a clean environment.” I agree with Roberts that aid to children must be expanded. The US is benighted when compared to many other Western countries that invest much more heavily in their children through income support, early childhood and K-12 education, healthcare, and housing. But family dysfunction occurs even if a family’s material needs are met. That is why every other developed nation has a child welfare system with the authority to investigate maltreatment allegations and assume custody of children when there are no other options. Moreover, some of the countries with the strongest safety nets for children also have higher percentages of children living in foster care than the United States.****

Torn Apart is a skewed portrait of the child welfare system. In it Roberts restates the common but easily discredited myths that poverty is synonymous with neglect and that foster care makes children worse off than they would have been if left at home. The underlying flaw in her account is the idea that this system exists to repress the Black community, even though it was established solely for the protection of White children. Roberts makes some valid criticisms of child welfare systems and how they shortchange the children and families they are supposed to help. But when she talks of dismantling child protection, she is proposing the abandonment of abused and neglected Black children in homes that are toxic to them, an abandonment that will perpetuate an intergenerational cycle of abuse and neglect. These children are our future; abandoning their well-being to prioritize that of their parents is a bad bargain with history.

*Doyle’s study included only those cases that would have resulted in foster placement by some investigators and not by others, leaving out the cases in which children were in such danger that all investigative social workers would agree that they should be placed.

**In various places, she also attributes it to different combinations of slavery and apprenticeship of Black children with the transfer of Native American children to boarding schools, the exclusion of Black children from charitable aid and the servitude of impoverished White children.

***A recent paper reports that disparities between Black and White children began to decrease in the twenty-first century in nearly every state, closing entirely in several Southern states.

****Unicef’s report, Children in Alternative Care, shows that Denmark has 982 children in “alternative care” per 100,000 and Sweden has 872 per 100,000, compared to 500 per 100,000 for the United States.

Congress must take steps to ensure availability of therapeutic residential care

Around the country, there is a lack of appropriate placements for the most traumatized and hard-to-place foster youth–a shortage that has reached crisis proportions in many states, including Texas, Washington, and Illinois. These children are spending days, weeks or even months in offices and hotels or languishing in inpatient psychiatric units where there is no semblance of normal life. These young people have been damaged by our negligence and now deteriorate daily without the treatment they need and deserve.  Unfortunately, recent federal legislation is likely to worsen the crisis by withdrawing federal funding for children placed in some of the best therapeutic residential settings.

An unforeseen consequence of the much-heralded Family First Prevention Services Act (FFPSA) of 2018 may exacerbate the shortage of therapeutic placements in many states. FFPSA had twin goals: to shift resources from foster care to family preservation, and within foster care, to shift resources from congregate care settings (anything other than a foster home) to foster homes.  However, the framers of the act did recognize that some children need more intensive care than a foster home can provide, and for them FFPSA defined a new category of placement called a Quality Residential Treatment Program (QRTP). QRTP’s must have a trauma-informed treatment model, involve families, be accredited by an approved organization, and provide at least six months of aftercare. A child can be placed in a QRTP only if a qualified professional determines that the child’s needs cannot be met in a foster home, and the placement must be approved by a judge. Other than specialized settings for teen parents, children who have been sex-trafficked, and supervised independent living settings for foster youths aged 18 and older, QRTP’s are the only non-family placements that can be funded under FFPSA.

Unfortunately, in creating QRTP’s, Congress unintentionally created a conflict with a provision of the Medicaid law that may sharply limit the number of children who can benefit from this new category of therapeutic placement. The problem is that federal Title IV-E foster care funding pays for room and board, but not the costs of medical, dental, behavioral and mental health care for children in foster care. States generally extend Medicaid to all foster youths, allowing the program to cover those costs. But the “IMD exclusion,” a provision included in the original 1965 legislation creating the Medicaid program, prohibits federal Medicaid dollars to be used to pay for any care or services to anyone under 65 who is a patient in an “institution for mental diseases” except for in-patient psychiatric services provided to children under 21. An Institution for Mental Diseases (IMD), as defined by Section 1905(i) of the Social Security Act, is a “hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases including medical attention, nursing care, and related services.” (For more on the IMD exclusion, see Fact Sheets by the Legal Action Center and the Training and Advocacy Support Center.)

This “IMD exclusion” reflects the sentiment at the time of Medicaid’s creation in 1965 against the large public institutions where the mentally ill were warehoused at the time. The provision was a driving force behind the transformation of public mental health care from an inpatient to an outpatient model, often known as “deinstitutionalization.” But now, many high-quality therapeutic residential programs have more than 16 beds distributed between separate units or cottages on one campus, and in many states these are exactly the facilities that qualify to be licensed as QRTP’s. Without a legislative fix, QRTP’s of over 16 beds may be considered IMD’s and children placed there will not be eligible for federal Medicaid funding for any of their care, including medical, dental, behavioral and mental health services, whether delivered inside or outside the residential program.  States will then have to pay the entire costs of all care for foster children placed in these settings.

Decisions as to whether a facility is an IMD are made on a facility by facility basis based on federal law, regulations and guidance. But the definitions of IMD’s and QRTP’s, as well as the guidance provided by the Center for Medicare and Medicaid Services (CMS) in the State Medicaid Manual section 4390 on how to determine if a facility is an IMD, suggests that QRTP’s are likely to be considered IMD’s. When California wrote to CMS arguing that its “short-term residential treatment programs” (which they were hoping to designate as QRTP’s) should not be considered IMD’s, CMS responded that it was  “unable to provide California the blanket assurance requested that STRTPs are not IMDs.” While a state Medicaid agency can elect not to consider a facility to be an IMD, CMS can essentially overrule these decisions by requiring a state to review the status of these facilities based on its guidance.

Even before the current crisis over QRTP’s, the IMD exclusion had resulted in the loss of Medicaid coverage for foster children living in therapeutic residential facilities in at least two states. For years, Minnesota was using residential programs that would have met the definition of QRTP’s as an alternative to, or a step down from psychiatric hospitalization. But, as reported by the Star-Tribune, after a review ordered by federal officials, 11 treatment centers with a total of 580 beds lost about $4.5 million in federal Medicaid funding–a cost that had to be picked up by counties. Utah went through an “IMD sweep” in 2010, which resulted in its replacing most of its residential treatment centers serving children in foster care with facilities having less than 16 beds.

The Association of Children’s Residential and Community Services (ACRC) has been contacting states to find out how they are dealing with the IMD/QRTP issue. They found that states fall into several groups:

  • Some states are not concerned about the IMD problem because they are not planning to implement QRTP’s. Some already rely on facilities that are exempt from the IMD exclusion (Psychiatric Residential Treatment Facilities or facilities with fewer than 16 beds) or will use state funds to pay for children placed in residential care.
  • Some states are proceeding on the hope that their QRTP’s will not be declared to be IMD’s even if they have more than 16 beds. This includes six states where all of the programs that have been approved as QRTP’s have more than 16 beds.
  • Some states are discussing whether to limit the size of their QRTP’s but have not yet decided whether to do so. In many of these states, the majority of the potential QRTP’s have more than 16 beds–or the majority of the QRTP beds are in facilities with more than 16 beds.
  • Some states are trying workarounds to avoid the IMD designation. Two states have decided to separately license cottages that are on the same campus, which enables them to use the bed count for the individual cottage rather than the entire facility, thus potentially avoiding an IMD designation. Another state has classified all residential facilities as serving youth at risk of sex trafficking, one of the allowable uses of congregate care. Whether these workarounds will be accepted by CMS or the Administration for Children and Families (in the case of the latter state) remains to be seen.

Colorado has decided to limit its QRTP’s to 16 beds or less, and a FAQ document from the Colorado Department of Human Services provides an interesting case study in how one state has tried to address the QRTP issue. Hoping to find a way to license its existing residential facilities as QRTP’s, Colorado’s Medicaid and child welfare agencies worked together to analyze the federal IMD criteria and its application to QRTP’s. These agencies “explored every possible argument that would allow Colorado to confidently move forward with QRTPs without risking an IMD designation.” But ultimately they agreed that the only way to avoid the designation was to reimburse only QRTP’s with 16 beds or less. Currently almost all of Colorado’s residential facilities that could have been designated as QRTP’s have more than 16 beds. Instead of creating smaller programs, the state is planning to serve fewer children in residential facilities. The question is whether they will have appropriate options for those children who have been determined to need therapeutic residential care. There is considerable concern that they will not.

Without legislation exempting QRTP’s from the IMD exclusion, states will be faced with the choice of paying the full costs of care for children in therapeutic residential care or scrapping their current facilities and starting from scratch. Vulnerable children may end up in greater numbers in hotels, offices, and hospital beds or bouncing between foster homes that are not equipped to care for them.

According to ACRC, there is no evidence that residential programs with 16 beds or less produce better outcomes than programs with a higher capacity. As a matter of fact, there are reasons to think that a larger campus would be able to offer more services (like therapeutic riding or other specialized therapeutic modalities) that would not be possible to offer on a smaller campus. It is also possible that the IMD/QRTP conflict might result in more foster youth receiving a higher level of care through Psychiatric Residential Treatment Facilities (PRTF’s). These are facilities that deliver an inpatient level of care outside a hospital and they are not considered IMD’s. They are exempted from the IMD exclusion and Medicaid can pay all costs for these facilities, including room and board. So FFPSA might have the perverse result of having more children in a more restrictive, less homelike setting.

On July 23, ACRC sent a letter to the House and Senate leadership asking them to pass legislation by October 1, 2021, exempting Qualified Residential Treatment Programs (QRTPs) from the Institution for Mental Diseases (IMD) exclusion. In the letter, ACRC argues that that “without the exemption for QRTPs, thousands of children in foster care who are vulnerable will be pushed into more restrictive placements, non-therapeutic shelters, unlicensed or unstable settings, or they will bounce from placement to placement without addressing their true needs – which is opposite the intent of the FFPSA.” So far, about 540 organizations have signed onto the letter, and more signatures are coming in daily.

Many groups concerned with the mentally ill have long been advocating for an end to the IMD exclusion altogether, arguing that it is behind the nationwide shortage of psychiatric beds. Rep. Grace Napolitano, Democrat from California, has introduced a bill (H.R. 2611) to eliminate it. CMS and ACF during the Trump Administration also proposed eliminating the exclusion specifically for QRTP’s in its budget for 2021. There are strong arguments for eliminating this exclusion, but the urgency of the QRTP problem requires immediate action, rather than waiting to change a policy that has lasted 50 years.

Unfortunately, there is opposition to lifting the IMD restriction among powerful and wealthy advocates whose ideology appears to blind them to the reality facing our most vulnerable children. William Bell of Casey Family Programs, the nation’s most influential child welfare funder and a leading force behind the Family First Act, urged Congress in testimony to “stand firm” in resisting modifications to the IMD rule. In the real world, where staff work face-to-face with wounded children, the picture looks very different.

The IMD exclusion for QRTP’s threatens to eliminate one of the most promising avenues to address the desperate shortage of therapeutic residential placements for foster youth that already exists in many states. On the state level, legislators must open their hearts and their minds to the pleas of those who are on the front lines caring for our most troubled children. They must increase funding for the therapeutic residential programs the most vulnerable foster youth so desperately need. Congress must help by exempting QRTP’s from the IMD exclusion, enabling the federal government to ensure access to therapeutic residential care–and ensure that the legislation they authored and passed can actually be implemented by states. 

When Ideology Outweighs what’s Best for Kids: the case of San Pasqual Academy

Image: Jeffery Heil, Twitter.com

In 1998, something extraordinary happened in San Diego County. Galvanized by the heartbreaking stories of local foster youth who were disgorged at the age of 18 from a system that never gave them the tools to thrive, the community came together to create a place where foster youth could prepare for happy and productive futures. In 2001, the San Pasqual Academy (SPA) opened as a result of this unique moment of community solidarity and altruism. Twenty years and over 400 graduates later, SPA is on the chopping block because of federal and state legislation that eliminates any funding for placements that are not standard foster homes, unless they are providing temporary intensive treatment for severe mental health conditions.

The story of SPA began in 1998 when James R. Millikan, the presiding judge of the San Diego Juvenile Court, arranged for a group of foster youths to speak to the County Board of Supervisors, as described in a moving video. It was a transformational moment for many of the listeners, who were essentially unaware of the plight of older foster youth. Supervisors were riveted by young foster care alumni, who described surviving as many 30 placements and being discharged to the streets at the age of 18, with no supports or tools for success. This magic moment resulted in the creation of SPA.

In a rare moment of collaboration by multiple agencies and community leaders, SPA was developed with the support of Judge Milliken, the County Board of Supervisors, the Child Welfare Director, the Office of Education, as well as attorneys, social workers, healthcare providers, educators, law enforcement, foster youth, and other community members. They found a disused boarding school for sale on 238 acres, refurbished it, and opened it in September 2001. The goal was to “provide a safe, stable and caring environment” where youth [could] work toward their high school diplomas, prepare for college and/or a vocation, and develop independent living skills.” The Academy was “designed to be a place its students can call home, providing stable relationships needed for development of social skills and future relationships during their student experience at the Academy and beyond.”

SPA services can be classified into four categories: residential, education, work readiness and child welfare.

  • Residential: The residential component is run by New Alternatives, Inc., a private nonprofit. Youths live in family-style homes with house parents for up to eight children per cottage. “Foster grandparents,” who live on campus for reduced rent, mentor, tutor and engage students in hobbies and activities. An on-campus health and wellness center provides comprehensive health care, including mental health. Housing and supportive services are also available to Academy alumni for up to 24 months. (Twelve alumni are living on campus right now, taking advantage of this crucial safety net in the midst of a pandemic.)
  • Education: The onsite high school program is operated by the County Office of Education. After-school activities include student government, athletics, yearbook, and dances.
  • Work Readiness: Provided by the San Diego Workforce Partnership, services include tutoring, career counseling, job training, internships, employment, vocational electives, and assistance in creating resumes and portfolios.
  • Child Welfare: Social workers from the County Department of Health and Human Services (DHHS) onsite provide case management, services and advocacy.

The resources provided to SPA students are enhanced by the support of Friends of San Pasqual Academy, a dedicated group of community members who provide additional financial support and volunteer work. Friends’ support pays for special events, school supplies, and personal items, all designed to give students a “normal high school experience.” The Friends raise money for maintenance and upgrades to the cottages, the pool and other parts of the facility. They have leveraged outside resources to help SPA. The San Diego Chargers helped build the football field and the Padres built the softball field for SPA.

SPA truly embodies the definition of wraparound services, and the research shows that it works. To assess the effectiveness of the SPA model, New Directions commissioned a ten-year research study that followed 478 SPA alumni, including all youth who attended the academy between February 2001 and June 2011 and left the program between July 2002 and July 2012. The results were summarized in an article titled “Comprehensive residential education: a promising model for emerging adults in foster care,” which was published in Children and Youth Services Review. The findings were impressive. As the authors put it, “Foster youth who participated in the Academy until they were 18 years old or older attained high school diplomas or GEDs at rates far above state and national standards for foster youth. Of the youth who were at least 18 years old when discharged from the Academy, 92% of them graduated with a high school diploma or GED, which greatly exceeds Californias high school graduation/GED rates for foster youth of 45% and for the general population of California youth of 79%….In fact, we are not aware of any other program serving foster youth in the United States…with such high rates of high school diploma/GED completion.”

The evaluators concluded that “the Academy provided its alumni with safety, significant relationships with adults, and well-being that exceed state and national standards for foster youth. Those youth who attended the Academy for longer periods of time through their 18th birthday and participated in extracurricular activities had the most positive outcomes, including safe housing, employment, access to healthcare, attainment of a high school diploma or GED, and attendance at institutions of higher education. The Academy appears to provide a stable, comprehensive residential education program that helps foster youth successfully emerge into adulthood.” A preliminary draft of a follow-up study focusing on current students and alumni is equally glowing.

In addition to the spectacular evaluation mentioned above, SPA has been the subject of several other flattering reports. Five San Diego County “grand juries” (groups appointed by Superior Court judges to investigate, evaluate, and report on the actions of local government) and four county Juvenile Justice Commissions have issued glowing reports on SPA. The most recent report, by the group meeting from 2016-2017, lamented the fact that SPA was operating at only 50 percent of its capacity of 184 students. The Grand Jury recommended that SPA be fully utilized to make full use of its life-saving potential. San Diego’s Juvenile Justice Commission has also issued multiple flattering reports on SPA. In its most recent report, issued in 2018, the commission stated that “SPA continues to be a model facility delivering essentially full service, wrap around services in a residential setting to foster youth.”

Despite the overwhelming evidence of SPA’s life-changing impact, the number of children at SPA declined from 139 in April 2011 to 69 as of February 1, 2021. The most important reason for declining referrals appears to have been the decline in support by child welfare leaders for what is often called “congregate care,” usually meaning any type of setting other than a foster home. This change in mindset was created in large part through influence of two wealthy organizations started by the same family, Casey Family Programs and the Annie E. Casey Foundation, that have used their financial resources to produce reports like Every Kid Needs a Family, lobby legislators, and provide free consultation with states. With the help of the “Casey Alliance,” a new narrative has been created that that all “congregate care” settings are prison-like institutions and any family home is better than a group setting for almost every child.

The change in mindset eventually resulted in legislative changes. California’s Continuum of Care Act, passed in 2015. ended the placement of foster youth in group settings except to provide short term therapeutic care. Thanks to SPA’s known track record and strong support, pilot program was authorized to allow SPA to operate through December 2021. But passage by the U.S. Congress of the the Family First Prevention Services Act (FFPSA) sealed SPA’s fate. Like Continuum of Care, FFPSA essentially eliminated federal funding for placement in settings other than foster homes except for short-term placements for youth who assessed to have a diagnosis that requires a level of care that a family cannot provide. With the implementation of FFPSA scheduled for October, the California Department of Social Services (CDSS) decided to advance the date of SPA’s closure to avoid having to use state funds to maintain it until December. In an undated letter, CDAA informed San Diego County DHHS that SPA must close by October.

Both Continuum of Care and FFPSA were based on the belief that children almost always do better in families than in other, more institutional settings. But as we have written, supporters often misuse data and research to support this belief. Research generally shows children in group care having poorer outcomes than those in foster care. But these studies do not account for the fact that children placed in group care generally have much more severe issues, which is why they were placed in group care in the first place. Moreover, supporters of “a family for every child” fail to define the concept of a family. The cottages at SPA and many other residential facilities offer a family setting, with house parents who play the parental role, as one house parent eloquently described in the video cited above. SPA homes are much more like families than many foster homes, where the foster parent has little interaction with the youth and provides little besides room and board. In fact, the residential component of SPA could be called “enhanced foster care” more accurately than congregate care.

And that raises the related concept of quality, which the reformers ignored. Quality matters much more than the type of setting. It is likely that most parents whose child had to leave home, would prefer a high-quality group setting (even if not family-style) for their children than a low-quality family setting. Anyone who has worked in foster care will know the difficulty of obtaining high-quality settings for older foster youth. Due to the scarcity of foster families, especially those willing to accept older youth, few jurisdictions can afford to be choosy enough about whom they accept and retain. What they do get more often than not are foster homes that provide little beyond room and board (and often those are barely adequate), foster parents who never set foot in the child’s school, refuse to take them to the doctor and the therapist, and quickly return difficult youths to the agency–resulting in multiple placements for each foster youth. Moreover, in my experience as a foster care social worker in the District of Columbia, few of my high school age clients participated in extracurricular activities because foster parents were unwilling to pick them up late from school or take them to weekend games, performances or other activities. Yet, engagement in after-school activities is linked with higher academic performance and college attendance, better health, and fewer problem behaviors.

Opponents of group care also ignore the problem of sibling separation. Many children placed in traditional foster homes are separated from one or more siblings because foster families do not have room for sibling groups. As I argued in Sibling Separation: An Unintended Consequence of the Family First Act, family-style group homes like those provided by SPA have been an important vehicle for keeping siblings together. In addition to providing a home for sibling groups of high school age, SPA accepts siblings of current students who are of middle-school age, allowing them to live at SPA and attend school in the community. The importance of siblings to foster children is such that even some congregate care opponents admit that it is better to place siblings together in congregate care than to separate them into different foster homes.

It is important to note that the restrictions on group care in FFPSA had another purpose aside from the alleged benefits to foster care. Restricting group care, which is more expensive than foster care, was necessary to free up federal funds to pay for the expansion of funding for services to prevent the placement of children in foster care. In other words, to find the money to preserve families, Congress took it away from services to the children who will have to be removed when family preservation fails. As long-time Congressional staffer and child welfare consultant Sean Hughes wrote in the Imprint, the focus among child welfare advocates seems to have shifted almost exclusively toward preventing entry into foster care, with little advocacy being devoted to actually improving the continuum of care for children in out-of-home care.

Current students, alumni and supporters of SPA were stunned by the CDSS letter. A petition on Change.org has obtained almost 11,000 signatures so far. Supporters of SPA have created a Facebook page and deluged public officials with letters and telephone calls. Reverend Shane Harris, the President and founder of the People’s Association of Justice Advocates, says SPA changed his life and gave him a safe place to grow up and is fighting to keep it open. One alumna is quoted on the Save San Pasqual Facebook page as follows: “I really loved living at SPA. I got to create relationships, a family and a strong support system. I also became stable by living here. I was able to attend school and catch up from how behind I was. I succeeded in sports and found outlets to deal with emotions. I couldn’t live in foster homes because the families wouldn’t treat me like their own.” Simone Hibbs-Monroe, valedictorian of the class of 2009 told KUSI News that “SPA has been a community safe haven and the only solution for many foster youth and a dedicated home for many alumni of foster care… “It’s an opportunity for children to feel normal. We are able to play sports, get jobs, have pep rallies, have our first proms, get our drivers’ licenses …..these are all the things that the caring community of San Pasqual offers its youth and its alumni….Often people [say] it takes a village to raise a child. That is San Pasqual Academy.”

Current and former staff have joined the call to save SPA. SPA’s Clinical Director, Rex Sheridan, wrote as follows in an eloquent letter to the County Supervisors and San Diego’s DHHS leadership team. “During my career in mental health and youth services, two decades of which has been in San Diego County, I have had contact with and worked in many different settings dedicated to meet the needs of our most vulnerable youth populations; yet none could even remotely be compared to what is offered at SPA. That is why I have now spent a third of my life committed to and working to develop this program because of first-hand experience witnessing lives transformed, hearts opened back up after years of disconnection, wounds healed after lifetimes of abuse and trauma, siblings reunited after separation, goals reimagined out of hopelessness, skills and knowledge crafted and nurtured out of feelings of incompetence, and new identities and possibilities replacing desperation and fragmentation. And if you think that those experiences sound overstated or dramatic, then you haven’t had the privilege of attending games where youth are cheered for the first time in their lives, one of our talent shows where they perform an original song, or a college road trip where they get to visit universities all over the state and envision a new possibility that was never previously imagined.”

What can be done to save SPA? The state and the county must adopt a stop-gap solution to keep SPA running as they work to permanently amend state law to create a category of residential schools that is eligible for reimbursement. On the federal level, advocates are already working on legislation to amend FFPSA to add residential campuses with family style homes as a placement option. We will share more information as it becomes available.

The proposed closure of SPA is a victory of ideology and greed over humanity and common sense. We need more, not fewer San Pasqual Academies. Rather than shutting it down, the state and county should be ensuring that it is at capacity and boasting that within their borders lies the most effective foster care program in the country.

Washington Post on foster care: old tropes and false narratives

The Donald R. Kuhn Juvenile Center in Julian, W.Va., where Geard Mitchell, now 17, spent part of his childhood. A lawsuit says 10 states’ agencies tasked with caring for children failed, “jeopardizing their most basic needs.” (Sarah L. Voisin/The Washington Post)
Image: Washington Post

Foster care has finally made it to the front page of the Washington Post, and a sad story it is. The story highlights the growing crisis in many states due to the increase in drug addiction bringing in its wake a cascade of child removals into foster care, outstripping the supply of  foster homes and other placement. The problems outlined in the article are real and urgent, but the analysis and prescriptions offered in the article and subsequent editorial reveal the authors’ lack of understanding of the issues, which results in the repetition of false narratives and common misleading tropes.

The Post‘s front-page article focused on a growing crisis caused by increased drug addiction among parents, especially the opioid crisis. The author, Emily Wax Thibodeaux, zeroed in on West Virginia, one of the epicenters of the crisis. She introduced us to Arther Yoho, a young man who spent more than two years in a detention center because there was no foster parent available to take him in. Locked up with 27 juveniles with criminal convictions, Arther was failed by the system that was supposed to protect him.

Thibodeaux reports that other desperate states are using emergency shelters, hotels and out-of-state institutions to house youth for whom there is no foster family home available. This is tragic and true, and I wrote about it in a recent post, although the placement of foster youth in detention centers along with criminally charged youth may be unique to West Virginia with its cataclysmic foster care crisis. Thibodeaux reports Oregon’s use of refurbished detention centers to house foster youth, which is certainly not ideal but is quite different from housing them with juvenile offenders. In any case, Thibodeaux is right to point out that many young people in foster care are being placed in inappropriate (and often harmful) placements because appropriate ones are not available.

However, Thibodeaux takes an unwarranted conceptual leap by linking the placement of children in inappropriate facilities to states’ use of congregate care, a term used to connote placements that are not families. These include what are generally known as group homes, as well as residential treatment centers, which are part of the accepted continuum of care for foster youth. While detention centers are never appropriate for foster youth who have not been charged with a crime, group homes and residential treatment centers may be the appropriate placement, often for a limited time, for some youths in foster care. These are the young people who cannot be maintained in a regular foster home because of their defiant, violent, or self-destructive behavior. Many of these children might be able to “step down” to foster care after spending time at a therapeutic residential facility.  It is possible that some of these young people could be helped in a professional therapeutic foster home staffed by salaried and trained foster parents, an approach that is gaining increasing interest, but programs so far are few and small and not likely to meet the need for therapeutic placements.

Thibodeaux cites the common trope that “Compared with foster children living with families, those housed in congregate care settings are more likely to drop out of high school, commit crimes and develop mental health problems.” That is very true. But it is a matter of correlation, not causation. It is the younger and less damaged children who end up in foster homes in the first place. Not surprisingly, they are likely to have better outcomes. Concluding that congregate care causes the negative outcomes may well be akin to concluding that fire trucks cause fire damage since buildings that have been visited by fire trucks are far more likely than typical buildings to have sustained fire damage. We don’t have a body of research on what happens to children with similar risk factors who spend time in foster homes compared to those who spend the same amount of time in group homes.

Thibodeaux appears to be unaware that some of the states with the lowest proportions of children in congregate care are those that are struggling the most with inappropriate placements. Washington and Oregon are among the states with the highest proportions of foster children placed in families as opposed to congregate care facilities, according to federal data cited in a recent report from the Annie E. Casey Foundation. Both states have been the subject of disturbing media reports that foster youth are staying in hotels, offices and substandard and abusive out-of-state facilities. That’s not surprising, since appropriate options are not available.  In Washington, ten years of group home closures led to the current crisis. The director of Washington’s child welfare agency has requested funding to expand the capacity of therapeutic group home beds to accommodate the children who are now staying in hotels and offices. The director of Oregon’s agency has cited a reduced number of treatment beds as a cause of children being sent to substandard and abusive out-of-state facilities.

By implying that all congregate care placements are inappropriate, Thibodeaux lays the groundwork for false conclusions about policy. Rather than saying that states need to beef up their therapeutic options, whether they are professionally-trained therapeutic foster parents or therapeutic group homes or residential treatment centers, Thibodeaux suggests that the new Family First Prevention Services Act, which makes it more difficult to obtain federal reimbursement for congregate care stays, may solve the problem.

Actually, the Family First Act may well make things worse. By making it harder to license therapeutic group homes, there is reason to fear that Family First will exacerbate the placement crisis. This has already happened when group homes closed in in jurisdictions like Oregon, Washington, New York City, and Baltimore. In California, the closure of group homes due to their Continuum of Care “reform” (a predecessor of the Family First Act) has resulted in, according to one veteran service provider, “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.”

The Washington Post followed Thibodeaux’ article with an editorial, “The Crisis in Foster Care,” which repeated and further distorted some of Thibodeaux’s questionable statements. Where Thibodeaux reported that 71% of foster children aged 12 to 17 are in congregate care placements in West Virginia (a high number to be sure), the editorial page erroneously stated that seven in ten of all foster children are in such foster care placements. That is a huge difference as older children are much more likely to be in such placements.

The opinion writers go on to repeat Thibodeaux’ misleading statement from the Casey Foundation about children in group homes doing worse than those in foster homes. However, they also cite discouraging outcome data about children growing up with foster parents. Because both options seem bad, the opinion writers suggest that “the least-bad option for many children” may be staying or reuniting with their parents, “unless there is abuse in the home. “They go on to cite one of the most persistent tropes of all that child protective services workers “often remove minors from neglectful parents who, while a far cry from being good caregivers, may still be better than group homes.”

The trope that child neglect is “less than ideal parenting” is belied by some of the stories that have come out of West Virginia and other states in the throes of the opioid crisis. We’ve all heard the stories: infants born addicted to drugs to mothers unable to care for them,  children who lost their parents and even their extended families due to opioid overdoses, children abandoned at home without food while parents seek drugs, children strapped in cars while their parents get high, babies and toddlers who ingest heroin, alcohol or meth; children whose parents are incarcerated due to substance abuse or dealing; and more. This is not “imperfect parenting” but something much worse. Living with an addicted parent is has a host of negative consequences that may be lifelong and is in itself considered an Adverse Childhood Experience (ACE).

One article from the Seattle Times documents the impact of the drastic increase in infants born addicted to drugs when they reach school age. “[The lives of children who grow up with drug-abusing parents are marked frequently by the presence of police, the constant fear of a mother or father’s incarceration and the likelihood of sudden death by overdose — all traumas shown to impede brain development and learning.”

To add insult to injury, the Post did not even seek to find out what is happening in its own back yard. Only two weeks before Thibodeaux’s article, a hearing was held in the 30-year-old LaShawn class action case to discuss the current placement crisis in the District of Columbia. The Judge referred to a letter from the court monitor 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  a new group home and “a couple of” professional foster parents. The District is a small jurisdiction and its crisis is dwarfed by that of West Virginia, but its 60 office stays deserved a mention in our hometown paper.

The Washington Post‘s treatment of foster care illustrates the consequences of letting reporting and editorial staff without subject matter expertise tackle a complex subject like foster care. Repeating false narratives and tropes from alleged authorities is easy and saves time. But it does not help readers to understand what is wrong and what is needed and on the contrary leads them to look for “solutions” that may make things worse.

 

 

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.

 

 

 

 

 

 

The foster care crisis in Massachusetts: common sense solutions, not ideology, are needed

FosterCareMass
Image: Boston Globe

An investigation by the Boston Globe’s Kay Lazar has drawn public attention to the foster care placement crisis in Massachusetts. The opioid epidemic has led to a spike in the demand for foster homes, but the Department of Children and Family Services (DCF) has been unable to recruit and retain enough foster parents. Therefore, children newly removed from their homes often have no place to spend the night, sometimes spending it in a car with a social worker awaiting a call to say a bed is available up to 100 miles away.

And the trouble doesn’t end with the first overnight placement. One third of foster children in Massachusetts were moved at least three times during their first year in the system. According to one social worker quoted, relatively healthy children come out of care with behavioral problems and attachment issues due to their devastating experiences in foster care.

Lazar and her paper are to be commended for making the public aware of these unacceptable flaws in the Commonwealth’s treatment of its most vulnerable citizens. But by interviewing only a small group of child welfare experts with similar perspectives, Lazar missed some of the obvious common sense solutions to these problems.

Take the lack of emergency foster homes, which results in many children spending their first night in foster care in a car waiting for a bed. There is an obvious solution, and that is to establish temporary regional shelters so that every child can find a warm bed and a welcoming hug on what may be the most traumatic night of their lives.

So why was this solution not mentioned? Many states have seen their emergency shelters become warehouses for children for whom a placement cannot be found. As a result, some states have closed these facilities–instead of improving them. But these closures don’t solve the problem that homes are not available.

Smarter jurisdictions, often working with nonprofits, use emergency shelters for children newly removed from their homes. A nonprofit called Amara operates temporary shelters for children who have just been removed from their homes in Seattle and Tacoma, Washington. The shelters are a haven for traumatized children where they receive loving care from staff and volunteers. And they offer social workers a much needed three to five days to find a foster home that is the best match available–not just the first to answer the phone.

There is a no obvious solution to the overall shortage of foster home beyond the first few nights of a placement. Lazar rightly draws attention to the bad treatment that foster parents receive from an agency that fails to provide information about the children who are placed with them, does not provide the therapy and services the children need, pays them too little to support the kids, doesn’t train them in caring for traumatized children, and requires them to adhere to conflicting and outdated regulations. By all means these problems must be fixed–for the sake of the children as well as the foster parents. But it is unlikely that they will rectify the shortfall of foster homes. More creative and courageous solutions are necessary. 

Providing free housing and/or salaries for foster parents might help increase the supply of foster homes. An Oklahoma nonprofit is building larger homes where foster families can live rent-free in exchange for taking in larger sibling groups.  SOS Children’s Villages Illinois operates several foster care communities in which full-time professional foster parents care for large sibling groups of up to six children. Child welfare agencies should work in partnership with local nonprofits to develop such programs. 

But Massachusetts needs to face the facts. There will never be enough high-quality foster homes for all the children who need them. As Stan Rosenberg, former President of the Massachusetts Senate and a former foster youth, wrote in the Globe,  many foster parents are loving and caring but others are in it for the stipend and the children placed with them will suffer the consequences. A high-quality group home or residential facility can be much more nurturing and family-like than a low-quality foster home.  More such facilities (often known as “congregate care”) are needed in order to prevent our abused and neglected children and youth being re-traumatized by repeated moves between foster homes.

Children who have trouble finding permanent placements tend to be older and/or have more severe behavioral, neurological and cognitive problems which stem from many years of trauma, deprivation, and often in utero substance abuse. Some of these children cannot thrive in traditional foster homes, which are not trained to deal with their difficult behaviors. There are many high-quality group homes around the country where dedicated staff devote their lives to changing the trajectories of these wounded children.

But the political climate has been opposed to such facilities for a long time, as Child Welfare Monitor has often discussed. Congregate care facilities  have been closing for years as states have deprived them of funding and stopped sending children there–even if they have to be left in dangerous homes, placed in barely-adequate foster homes, or bounced from home to home. The percentage of children in Massachusetts placed in congregate care facilities decreased from 22% in 2007 to 17% in 2017

The bias against congregate care has been enshrined in the Family First and Prevention Services Act, (FFPSA) passed as Title VII of the Bipartisan Budget Act of 2018. Under FFPSA, states will no longer be able to draw upon federal funds for congregate care except for children who have been judged too disturbed to thrive in a foster home by a “qualified professional.” These facilities must meet new criteria for licensure, and congregate care placement will be reviewed at every court hearing. Moreover, a child cannot remain in one of these placements for more than 12 consecutive months (or 6 months for a child under 13) without written approval from the head of the child welfare agency.

Sadly, ideology is reinforced by the reluctance of public officials to ask their taxpayers to find room in their hearts to fund high-quality facilities to these neediest of all children. Such facilities are much more expensive than foster homes and many have been starved out of existence around the country.

Instead of discussing the need for more congregate placements, Lazar quotes advocates who state that more children could be maintained in their own homes if adequate services could be provided to their parents. Yet, as she herself states, about 80% of the children in DCF’s caseload are living at home while the agency attempts to help their families avoid foster care. A spate of deaths of children in DCF-supervised homes since 2014 has distracted the agency from any attempt to reform foster care. Do we really want to put more children at risk to avoid spending money to nurture and house our most vulnerable children?

Reducing Congregate Care Placements: not so easy, not always good for kids

Plumfield
Image: plumfieldacademy.net

Most child welfare experts and policymakers at all levels seem to agree that our nation needs to reduce the use of group homes and other non-family placements (often called “congregate care”) for foster youth. Yet signs from around the country suggest that the drive to move foster youth quickly out of congregate care is facing some obstacles–and may be resulting in more damage to foster youth.

The child welfare establishment–including the federal Administration for Children and Families, agency leaders at the state and local level, prominent think-tanks, scholars, and foundations–is in agreement that “every kid needs a family.” These leaders acknowledge that some foster youth need a group placement to address behavioral issues that may prevent success in foster care, but such youth should be moved out of the group setting as soon as these issues are addressed.

In 2015, the California Legislature took the lead in implementing this new focus by enacting the Continuum Care Reform (CCR), which required all foster youth to be placed in families except those requiring intensive supervision and treatment for a temporary period. Such youth must be placed in Short-Term Residential Treatment Programs (SRTP’s), which must be accredited and meet rigorous standards.

Congress followed in 2018 by adopting the Family First Prevention Services Act (FFPSA, (Title VII of the Bipartisan Budget Act of 2018), which imposed similar changes on the federal level, with a temporary congregate therapeutic option called Quality Residential Treatment Programs (QRTP’s) instead of SRTP’s. To receive reimbursement for a QRTP placement, a “qualified professional” must determines within 30 days of the placement  that the child needs to be placed in such a setting rather than a relative or foster family home. The decision must be approved by a court within 60 days and reviewed at subsequent hearings (usually every three to six months). Moreover, a child cannot remain in a QRTP for more than 12 consecutive months (or 6 months for a child under 13) without written approval from the head of the agency.

California, where CCR took effect in 2017, has been widely viewed as a harbinger of what might happen after FFPSA takes effect next October. But Golden State policymakers have been “shocked shocked” to learn that children have not been moving out of congregate care settings as fast as anticipated. The reform was expected to pay for itself due to savings from moving children from pricier congregate care settings to cheaper family homes.  However, this has not happened. The Office of the Legislative Analyst has found higher than projected state spending for one main reason: instead of moving from group homes into family foster homes, children are moving into “STRTPS,” the new congregate option offered by CCR.

Although the Legislative Analyst did not speculate about reasons for the slow transition, one does not have to look far for clues. A report from San Joaquin County indicates that the county is unable to find homes for the teens with the greatest needs, who remain in group homes. Efforts to recruit foster parents willing to take on these challenging youths have so far failed.

Another jurisdiction that started eliminating group homes long before the Family First Act was New York City. The city’s Administration for Children and Families (ACF) is reeling from an alarming report about the intake center where children are taken after being removed from their families. Workers 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.” This intake center was was meant as a place for children to wait for a few  hours until a placement could be arranged. But staff report young people with behavioral problems or medical needs living in the shelter for months because foster families cannot be found for them. One disabled teenager lived there for a year. The president of the union representing ACF workers blamed these long stays on management decisions made years ago to close group homes, based on the belief that family homes were better for children. Unfortunately, the agency has not been able to find families to take in many children with behavioral problems, mental disabilities, and histories of trauma and abuse.

In Georgia, there are more children in foster care than ever before and not enough homes for them. Wanting to address this problem, long-time foster and adoptive parents John and Kelly DeGarmo started the Never Too Late (NTL) foster home for boys. But when they applied for a license to accept youth from the foster care system, they found it was too late. Due to the Family First Act, Georgia was not going to license any new residential group homes. State administrators instead asked NTL to serve as a Transitional Living Program, (TLP), for youth ages 16-21 as the boys transition from foster care to independent living. These programs are also needed, but one can’t help but wonder about Georgia’s plan for meeting the needs of the many children who cannot find foster homes and could have thrived in atmosphere of loving care at Never Too Late. 

In my own jurisdiction, the District of Columbia, the Child and Family Services Agency is proud of the low percentage of foster youth that are in group homes, attributing it to “the agency’s success in supporting children and youth with higher needs in traditional foster homes.”  Yet, advocates are declaring a foster care placement crisis. There is a lack of appropriate foster homes for many children, particularly older teens and those with behavioral problems. As a result, according to the Children’s Law Center, foster youth experience multiple placement disruptions, with devastating consequences to their mental health. CLC also blames the placement crisis for delayed removals of children from unsafe homes, youths remaining in poorly matched placement, and youths leaving their official placements for unofficial community settings. Yet, there is no voice advocating for more therapeutic group homes, the most appropriate setting for many such youths.

The state of Washington has about 100 youths in out-of-state facilities due to a lack of in-state beds. A scathing report recently described abusive restraint practices and other problems at an Iowa facility where Washington was sending some of its foster youth. In a letter to the legislature, Ross Hunter, director of the Department of Children Youth and Families, acknowledged that the agency has an insufficient array of therapeutic group homes and residential facilities for children with severe behavioral problems that make it impossible to maintain them in foster homes. Among the consequences of this shortage, Hunter cites the following: (1) children being repeatedly placed in homes that can’t handle them, resulting in damage to the children and loss of foster parents to the system; (2) over 2000 office and hotel stays for children last year; and (3) use of expensive one-night placements “at extraordinary cost and detriment to the child,” in addition to the out-of-state placements. Hunter proposes to bring all of Washington’s children home and eliminate office and hotel stays by expanding the number of therapeutic group home beds, as well as increasing the quality of existing congregate placements.

Oregon is also reeling from reports of abusive out-of-state placements. After being sued for housing foster kids in hotels, it stopped that practice but sent more high-needs children out of state. Reports of a nine-year-old being injected with Benadryl to control her behavior have led to a public outcry that over 80 Oregon foster kids are in out-of-state facilities, many of them troubled for-profits, because the state lacks residential programs to provide the treatment they need.

Washington and Oregon are among the states with the highest proportions of foster children placed in families, according to federal data cited in a recent report from the Annie E. Casey Foundation that drew extensive press coverage.  The report provided state-by-state numbers, generating media coverage (but not in Washington and Oregon) that praised those jurisdictions with lower group home percentages and chastising those with higher rates. But nowhere did the authors mention the fact that eliminating too many congregate placements may lead to foster youth staying in offices, hotels, emergency placements, and abusive out-of-state facilities.

We are not taking this opportunity to argue that many group homes (especially those using the house parent model) are more family-like than many foster homes–which we have argued elsewhere. Even if we accept the premise that no young person should be in a group home one minute longer than necessary once ready to function well in a foster home, there are several problems with implementing this premise in the real world.

  • We don’t have a diagnostic instrument capable of determining in advance who “needs” a congregate placement and who does not. As of now, it is a subjective determination, making it difficult to project a specific decline in congregate care placement. There is concern that the FFA may make it too difficult for children to gain access to the therapeutic placements they need.
  • Whether a child is “ready” for family life depends upon the families available. Some very gifted, well trained and dedicated foster parents can nurture high-needs youth who would not thrive in the average foster home. But when such a parent is not available, a child might be better off in a high-quality therapeutic group placement.
  • Often a family simply cannot be found that is willing to accept a teen with troubling behaviors or a history of residential treatment or delinquency. The most ridiculous sentence in FFPSA is this one: “A shortage or lack of foster family homes shall not be an acceptable reason for determining that the needs of the child cannot be met in a foster family home. ” What should be done then with a child that has no place to go?
  • A year (or six months for a preteen) may not be enough time for a troubled child to become “family-ready.”. Many children and teens in foster care have suffered years of trauma in their homes, and perhaps multiple placements in foster care. The time required is more likely measured in years than in months.
  • It may be difficult for smaller, high quality group homes to meet the criteria for QRTP’s.

There is no doubt that many congregate care facilities are of poor quality–witness the horrors suffered by Washington and Oregon youths who were shipped out of state. The framers of FFPSA were right in wanting to ensure that these facilities entrusted with our most fragile youth are up to the task, although they  adopted a blunt instrument for doing this. Let’s hope that other states follow Washington’s plan and respond to FFPSA by ensuring that therapeutic group homes are adequate in quality and quantity rather than eliminating them.

 

Therapeutic Group Homes: Needed Programs in Danger from Family First Act

Greenacres
Image: Greenacrehomes.org

It is a fact universally acknowledged that some children cannot thrive in foster care. This includes children whose behaviors are so challenging that most foster parents will be unable to cope. These children often go through many foster homes before they are finally placed in a more appropriate placement, usually a therapeutic group home or residential treatment program.

One of the goals of the Family First and Prevention Services Act (FFPSA), passed last year as part of the Bipartisan Budget Act of 2018), was to reduce the use of placements other than relative homes and traditional foster care. However, FFPSA recognized that some children and youth cannot thrive in foster care and allowed for placements to meet their needs. Unfortunately, the many restrictions imposed by the Act mean that many of these young people may not able to access these facilities or will be prematurely removed from them.

Many youth who are placed 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. As a result of these problems, many of these hard-to-place young people have been placed in ten or more foster homes.

High-quality therapeutic group homes are more able than foster families to work with challenging youth for a number of reasons described in an excellent video from the Sonoma County Juvenile Justice Commission. Their staff are trained in working with behaviorally challenging youth and often operate from a trauma-informed perspective. These facilities often have therapists and psychiatrists and other mental health personnel on staff. Good therapeutic group homes create a homelike environment, with young people living in cottages with a total of six or eight youths. Staff are dedicated and passionate about what they do. Unlike foster parents, these staff usually work shifts and thereby avoid burnout. Residents also draw strength from peers with similar issues, especially older peers who have improved and can serve as role models.

Some hard-to-place youth could thrive in the right kind of foster homes, those with training, time, and willingness to work with young people whose behavior is challenging. But many foster parents refuse to take teens or any or children with behavioral or mental health problems. Some states are trying to increase the availability of therapeutic foster homes, but funding and supply constraints mean that such efforts will be far too small to replace therapeutic group homes.

Unfortunately, the restrictions imposed by FFPSA may make it difficult to for many needed therapeutic group homes to continue operating. FFPSA allows the federal government to share the costs of treatment-based congregate care only at facilities that qualify as Qualified Residential Treatment Programs (QRTP). These programs must meet several criteria, including accreditation, a trauma-informed model, medical staff on call, and an aftercare program, among others. Accreditation especially is a long and arduous process that generally takes 12 to 18 months and some homes may not be able to accomplish it by the time the Act takes effect on October 1, 2019 (unless the state chooses to delay implementation for two years). Accreditation is a difficult and costly requirement for a smaller facility. It is important to ensure that only high-quality group homes retain state contracts, but accreditation may not be the best way to ensure quality for smaller programs.

Even more concerning are the limits on which children can be placed at these facilities and for how long. A child’s initial placement in a QRTP will not be reimbursed unless a “qualified professional” determines within 30 days of placement that the child needs to be placed in such a setting rather than a relative or foster family home.  This assessment must use an approved tool and be conducted by “a trained professional or licensed clinician who is not an employee of the State agency and who is not connected to, or affiliated with, any placement setting in which children are placed by the State.” The decision must be approved by a court within 60 days and must be reviewed at subsequent status hearings. Moreover, a child cannot remain in a QRTP for more than 12 consecutive months (or 6 months for a child under 13) without written approval from the head of the agency.

There are several problems with these restrictions. It is not clear that agencies can find enough qualified professionals who are not employed by the agency or connected to any placement setting used by the state. More concerning are the time limits. Many therapeutic group home professionals believe that most children with emotional and behavioral problems cannot be in and out of therapeutic residential settings in six months. Many will need to stay a year or even longer.

Without needed therapeutic group homes, many children will experience a string of failed foster home placements, with each one leading to further damage to the child, who may end up on the streets or in jail. As a director of a facility that closed in North Dakota put it, new policies mean that “You are only going to refer kids to (residential child care facility) levels of care after you have exhausted all the other less restrictive options of care. That means putting them with their families, in foster care and repeating failed foster care placements several times before a referral to this level of care would be entertained.”

Group homes have already been closing around the country as states have adopted policies against congregate care (and also due to failure to provide adequate funding) and some states are already seen bad consequences from these closures. In Baltimore, the number of children sleeping in offices shot up from less than five per six month period in 2015 to 130 in the first half of 2018 due to a shortage of foster homes and a dramatic reduction in group home capacity. In Hillsborough County, Florida, hard-to-place foster youths have been spending the night in cars for lack of appropriate placements. In the state of Washington, group homes have been shutting down for years due the state’s failure to keep up with the increasing costs of care. This has contributed to a crisis in care for older, harder-to-serve youth, who are being put up in hotels, offices and $600-per night emergency foster homes and being sent out of state for care. In Illinois, hundreds of foster youths were being kept unnecessarily in psychiatric hospitals as of last August because of a decline in licensed residential facilities.

The attempt to close congregate care facilities without providing an alternative is eerily reminiscent of the closure of institutions for the mentally ill in the 1960s. These hospitals were supposed to be replaced with community health services that were never funded. We are still reaping the consequences with the abundance of mentally ill people sleeping on the streets of America’s cities.

As I mentioned in last week’s post, FFPSA’s group home restrictions were not based on ideology alone. The cost savings from reducing federal reimbursement for group homes were necessary to offset the increased cost of funding services to prevent children’s placement in foster care. But penny-wise is often pound-foolish and the future costs of eliminating therapeutic residential options for foster youth may be much greater than the present savings.

It is not too late for Congress to amend the Family First Act to reduce restrictions on therapeutic group care. Until we have an abundance of qualified therapeutic foster parents willing and able to take the hardest to place youth, cutting down on therapeutic group homes is irresponsible, short-sighted, and a recipe for possible disaster.

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