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.

 

Therapeutic residential care: A necessary option for foster youth with greater needs

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The tide of opinion in the U.S. child welfare arena has been turning against institutional settings for foster youth for some time. A spate of reports of child abuse and improper disciplinary techniques in residential facilities for young people has intensified calls for the elimination of residential care as an option for foster youth. But as all who are intimately involved in the child welfare world know, therapeutic residential care is a critical part of the continuum of services that must be available for foster youth.

Media investigations have targeted abusive behavior by staff at poor-quality residential facilities around the country, with a spotlight on a for-profit company called Sequel. Concern and outrage reached a fever pitch when a 16-year-old boy died at a Sequel home in Michigan after being restrained for 12 minutes. The Imprint and the Texas Observer co-published a harrowing account of Residential Treatment Centers (RTC’s) in Texas, documenting horrific instances of abuse at multiple centers around the state.

Unfortunately, some commentators, like the author of the report on Texas RTC’s, are using reports of abuse and violence to support ending all residential care rather than getting rid of bad providers. These critics of residential care miss two basic points. First, there are children who, for a variety of reasons, are not having their needs met in a family setting. These are the children who bounce from foster home to foster home, spend nights in agency offices or hotels, or even end up sleeping in cars with their caseworkers. 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. These children need treatment delivered in a residential setting before they can function safely and thrive in a family setting.

Perhaps some of these youths could heal and thrive in a home with professional therapeutic foster parents, an option which is gaining increasing popularity. These foster parents are highly-trained and paid to take care of children with complex needs full-time. This is an option that deserves more attention but its growth is probably limited by both the lack of willing and qualified candidates and the expense.

Residential care abolitionists also miss the importance of quality. Residential programs can range from outright abusive to very high quality and highly successful in achieving positive outcomes for their clients. In an op-ed in The Imprint, Dana Dorn and Kari Sisson of the Association of Children’s Residential Centers explain that “High-quality residential interventions have the ability to change lives for the better and are a critical part of the continuum of behavioral health services. They have well-trained and supported staff who provide individualized, trauma-informed, youth-guided, family-driven care in environments that are safe, welcoming and encourage healthy relationships.” The authors stress that providers who are incompetent or “prioritize profits” over people should not be allowed to stay in business.

Opponents of residential care often use faulty reasoning to make their point. They often state that children who attend residential care have worse outcomes than those in family care without explaining that it is the most traumatized, troubled kids with complex histories who are placed in residential facilities. Those children would be expected to have worse outcomes than their peers because they have often had the worst past experiences by the time they finally have access to treatment.

The State of Washington provides a cautionary tale of what can happen when residential care in a state almost disappears. Budget pressures stemming from the 2008 recession dovetailed with the growing sentiment against residential options, as described in an excellent article in The Imprint by Elizabeth Amon. Between 2009 and 2019, over 200 residential beds in 13 locations disappeared. Unfortunately, the state lacks enough appropriate placements for youth with psychiatric, behavioral and developmental needs. These young people end up staying overnight in offices, emergency one-night foster homes, hotels, and cars–or sent to out-of-state facilities including some operated by Sequel. Not only are these arrangements anti-therapeutic, but they are extremely expensive, as Amon points out.

In Texas, where the Imprint focused on the poor quality of many RTC’s, child welfare administrators are worried about the declining number of residential centers. Every year, at least one RTC stops contracting with the state due to inadequate reimbursement, which means they cannot pay workers enough to retain them. As a result, the number of Texas foster children sleeping in offices and hotels spiked last year, according to an article in the Austin American-Statesman. These were mainly teenagers with trauma histories and/or significant behavioral and mental health issues, according to a state official.

In New Mexico, the Department of Children, Youth and Families (CYFD) contracts with ten residential treatment centers in the state, but that is not enough to care for all the foster youth who need therapeutic residential care, as the Secretary told the Santa Fe New Mexican. As a result New Mexico still sends children to out-of-state facilities. The Secretary has requested more funding for additional therapeutic residential care resources.

In Maryland, the Baltimore Sun and WYPR reported last February that dozens of children were spending weeks or even months in psychiatric units of hospitals without a medical reason because social workers had nowhere else to place them. Often these children were placed in psychiatric units after experiencing a crisis in a foster home. Most of these children are not ready to move to a foster home upon discharge and need a higher level of supervision and therapeutic care. But there are waitlists for the roughly 350 spots at Maryland residential treatment facilities, and for out-of-state facilities as well. These long hospital stays are destructive and traumatic to the children as well as extremely expensive.

Last January, I wrote about similar problems in Oregon, New York, California, and Illinois. Residential critics miss the point. If states don’t have quality residential facilities, or any residential facilities at all, they will send their kids to facilities run by operators like Sequel, put them up in offices, hotels, temporary placements or cars, or leave them in hospitals. That’s why only three out of 40 states and territories sending children to Sequel facilities have severed ties with the company, despite its awful track record.

Those who oppose all residential care for foster youths are blind to the challenging problems of some foster youth, the life-changing potential of quality therapeutic residential care and the vast differences between high and low-quality residential facilities. We need to make sure quality residential services are well funded and regulated to keep children out of offices, hotel rooms, abusive or out-of-state facilities, and hospitals. Legislators at all levels of government must recognize the need for adequate funding of this crucial service necessary to heal the wounds of our most fragile foster youth.