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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New book debunks prevailing child welfare myths

After the Cradle FallsA new book by two leading child welfare researchers aims to elucidate the complex world of child welfare for the general public and policymakers.  In After the Cradle Falls, Melissa Jonson-Reid and Brett Drake of Washington University provide a useful primer for the child welfare field. While they may be overly optimistic in assuming that a lay audience will pick up this book, it will certainly be useful for policymakers, journalists, students and advocates who want a general overview of child abuse and neglect, child welfare systems, and proposals for change.

Jonson-Reid and Drake make a particularly valuable contribution by highlighting myths and common misconceptions that are rife in the child welfare field. Among the common myths they debunk are the following:

  • “Neglect” is just another word for poverty, and parents become embroiled with Child Protective Services just because they are poor. Johnson-Reid and Blake explain that while poverty increases the risk of neglect, most parents who are poor do not neglect their children. Neglect is much more serious than a missed dental appointment or a messy house. Some neglect cases are extremely severe, even fatal. But even less severe cases can result in devastating lifetime consequences on brain development and the ability to form relationships.
  • Racial disproportionality in child welfare involvement is caused by racist decision-making by Child Protective Services (CPS). There is no dispute that African-American children are overrepresented in child welfare services and foster care compared to their share of the population. But Jonson-Reid and Drake conclude that “it is hard to find current empirical data that suggest that widespread bias within today’s CPS system is a significant driver of current disproportionality.” It would have helped if they had included the key research finding that actually debunked the myth about racism and disproportionality. As I have explained elsewhere, research has conclusively shown that higher Black representation in the child welfare system reflects higher rates of maltreatment in African-American families. This Black/White maltreatment gap may in turn reflect the relationship between race and poverty, as Jonson-Reid and Drake suggest.
  • State and local agencies have an incentive to take more kids into foster care. This trope was mentioned over and over again by supporters of the Family First and Prevention Services Act (FFPSA), which was signed into law on February 9, 2018. Jonson-Reid and Drake rightly give it short shrift. They explain that states are required to make “reasonable efforts” to keep children with their families and can be sanctioned by the federal government if they fail to document that they have made such efforts.  The authors could have cited some other key evidence against this myth.  For example, only about half of children in foster care are eligible for federal foster care support under Title IV-E of the Social Security Act and the federal government pays only part (50 to 83% depending on the state) of the cost. States and localities spent about $8 billion on foster care in FY 2014, 47% of their total child welfare spending, so it is hard to understand how they could have an incentive to place children in foster care. Moreover, states have access to other federal funds for services to intact families, such as TANF, Title IV-B, and the Social Services Block Grant.
  • Child welfare systems should prevent abuse and neglect. As the authors point out, child welfare systems (which they refer to as CPS, a term that I prefer to reserve for the investigation function only) have no truly preventative role. They are charged with responding to abuse and neglect after they have already occurred. This common misconception is particularly important in relation to the recent debate on FFPSA. Despite its name, the Act does not fund prevention; rather it funds treatment, or services to parents who have already maltreated their children. Obscuring the distinction between prevention and treatment prevents an honest and clear-headed debate about the appropriate allocation of resources between these purposes.
  • Child welfare is a broken system: Jonson-Reid and Drake argue that rather than being broken, the child welfare system has never been completed. They compare it to a fire department that will will send out a fire truck only 60% of the time, and often after the house has been consumed by flames. When a truck does respond, the firefighters may have minimal training in firefighting. A firefighter might show up without a truck and will have to wait until a truck with water is found. An injured person, instead of being taken into a hospital, may be placed in the home of someone who has no idea what treatment they need.
  • Child welfare can be fixed in a cost-neutral manner. Jonson-Reid and Drake point out that reform efforts (such as privatization or differential response) have often aimed to do more with less or the same amount of resources and have thus either done harm or failed to make a difference. They argue that any real improvement would raise costs but but could result in big long-run savings. They point out that we spend only $30 billion a year on child welfare when the long-term costs of child maltreatment have been estimated at $250 to $500 billion for each year’s cohort of victims.

The last myth is particularly poignant in view of the recent passage of FFPSA. It expands the use of federal Title IV-E funds to  services to parents at risk of losing their children  to foster care. But it  finances some of this new spending by taking money from other key functions of child welfare. like congregate care placements (necessary both for therapeutic reasons and to make up for the foster parent shortage), and foster care payments to kin, who will now not be allowed these payments if the parent is receiving federally-funded services.

Jonson-Reid and Drake end with an extensive list of suggestions for changing programming, policy and law. These include primary (or universal) prevention such as poverty reduction and educating parents about positive parenting, systemic improvements to child welfare (such as completing the system), and improving and expanding treatment for children and families. The list is somewhat overwhelming, but gives policymakers and advocates many options for where to start addressing this massive and complex problem.

After the Cradle Falls is a realistic and informed discussion of child welfare. It will be a useful resource to those who are open minded enough to accept the conclusions of science and common sense even when they conflict with the facile platitudes of ideologues, which have all too often had a disproportionate influence on policy and practice.

 

Family First: A “Reform” that Isn’t

Family FirstBy now most readers will know that Congress passed the Family First Prevention Services Act (FFPSA) as part of the continuing resolution to fund the government until March 23. The passage of this major legislation as part of a continuing resolution marks the final victory of an ideological agenda that has taken over the child welfare advocacy community.

FFPSA was drafted in secret without feedback from stakeholders such as state and county child welfare administrators, many of whom expressed opposition to the bill or at least concern about its consequences.  After several failed attempts to pass the bill over a two-year period, it was finally passed as part of a continuing resolution that was urgently needed to fund the entire government and avert a shutdown.

If we had a more pluralistic intellectual landscape in child welfare, FFPSA might have looked very different. Any bill calling itself “child welfare finance reform” should have started by addressing the most egregious flaw in child welfare financing–the linkage between Title IV-E eligibility and eligibility for the long-defunct AFDC program, which was terminated in 1996.

As a result of this linkage, fewer children are eligible for Title IV-E assistance every year, and states spend millions of dollars on the useless exercise of verifying eligibility for every child entering the system, as described by Sean Hughes in the Chronicle of Social Change. Yet, the advocacy community, in its single-minded quest to reduce the foster care rolls, gave up the fight to de-link foster care from AFDC.

Instead, the goal of “finance reform” became expanding the use of Title IV-E funds to included what the Act calls “prevention services.” These are not services to prevent abuse and neglect, but rather to prevent a child’s entry into foster care once that abuse or neglect has already occurred. FFPSA allows the use of these funds to fund parenting education, drug treatment and mental health services for parents.

Most of these “prevention” services logically belong to other systems, such as drug treatment and mental health, and are also funded by Medicaid. But prevailing ideology favors diverting foster care funds to other purposes, ostensibly to encourage prevention. In the most recent display of this ideology, the President and CEO of Casey Family Programs testified last week that “for every $7 the Federal government spends on foster care, only $1 is spent on prevention.”

No footnote was provided, but it appears that Bell was restating a common refrain that compares Title IV-E foster care expenditures with spending under Title IV-B, that is used mostly for in-home services. This comparison fails to take into account all the services provided by other programs, such as Temporary Assistance for Needy Families, Social Services Block Grant, the Child Abuse Prevention and Treatment Act, Medicaid, the Maternal Infant and Early Childhood Home Visiting Program and the Comprehensive Addiction and Recovery Act. Most of these programs are insufficiently funded, but it makes sense to increase their funding rather than divert funds that were designed to help good Samaritans meet the needs of the children they have volunteered to care for temporarily.

This view that a foster home is always better than a congregate (non-family) placement is another part of the prevailing ideology in child welfare. Congregate placements also happen to be more expensive, making restrictions on congregate care a perfect offset to FFPSA’s increased costs. It’s very convenient when ideological correctness coincides with saving money! Unfortunately, restrictions on congregate care may be harmful to children when there is a foster home shortage and so many of today’s foster homes are inadequate, as I described in my last column.

The lack of robust conversation and debate in the child welfare advocacy community has resulted in a “reform” that will create more problems than it solves. Our most vulnerable children deserved a better outcome.