Adoptalk & Publications
What Nebraska's Experience Reveals about Child Welfare and Mental Health
from Winter 2009 Adoptalk
by Diane Riggs, NACAC Staff
“I love my son, and I thought I was doing the best thing [for him].” A mother from Michigan offered this explanation when asked why she traveled 700 miles last October to give up custody of her son under Nebraska’s safe haven law. Between July 1, 2008 when LB 157 took effect, and November 22, when a new law came into force, a total of 27 caregivers brought 36 children to safe haven sites in Nebraska. Well over half (22) were 13 or older, and 34 youth had received some mental health services in the past.
In February 2008, when they passed LB 157—a law that allowed caregivers to leave a “child” in imminent danger of harm at a safe haven location without threat of prosecution—state legislators could not have predicted the lessons it would teach the nation. One obvious lesson is that families whose children have mental health problems need far more support than they now get.
Where Child Welfare and Mental Health Connect
A recent research brief from the U.S. Department of Health and Human Services’ Office of Human Services Policy examined adopted children and their special health conditions. Research consistently found that children adopted from foster care have “particularly elevated risks of mental health problems,” and that the same children and their families were very likely to have unmet needs.
Similarly, a November 2008 report from the National Center for Children in Poverty (NCCP) suggests that while mental health issues arise for 5 to 13 percent of American children and youth in general, the incidence of mental health conditions among children with child welfare involvement may well top 70 percent. Prenatal drug or alcohol exposure, genetic disorders, early abuse and neglect, multiple placements, and ongoing losses create significant challenges for children—challenges that accompany them back home and to other placements.
The tie between child welfare and mental health problems was definitely reflected in Nebraska’s safe haven experience last summer. Twenty of the 36 youth brought to safe haven sites were or had been state wards, and 14 cases involved children who lived with adoptive or relative parents, or a legal guardian.
Mental Health Service Issues
As child welfare researcher Richard Barth wrote last November in a Chicago Tribune safe haven editorial, “Only when there is abject failure does a state take significant responsibility by placing children in foster care. Responsible but unsuccessful parents have little recourse.” According to the NCCP study, states attribute mental health service problems to limited federal health care coverage, little funding for other services, and inadequate capacity to help everyone in need.
The single biggest issue for families whose children need mental health services is accessibility. Listed below are some of the factors that play into families’ ability to obtain services:
- Eligibility rules. Kathy Moore, Voices for Children in Nebraska’s executive director, reports that state-funded children’s health insurance—coverage many families need to secure mental health services—is open only to families at or below 185 percent of poverty. Criminality or extreme dysfunction may also trigger help. As one Nebraska mother said of her troubled daughter, “Only when she became suicidal and homicidal did we get [mental health services].”
- Limits on services. An adoptive family in Colorado recently lost custody of their volatile six-year-old because they could not pay for his residential treatment after state funding ended. Faced with the impossible choice of bringing the boy home and endangering their other children or keeping him in treatment and being charged with neglect, the parents opted to sever legal ties to their son. Sadly, problems like this keep many foster parents from adopting children in their care, and cause some adoptive parents to cede custody of their children to foster care so the children can access intensive treatment that the parents cannot afford.
- Inadequate health insurance. Title IV-E eligible children who are in or adopted from foster care receive Medicaid or equivalent state health insurance. The basic health insurance is helpful, but coverage of mental health services is spotty. Some states, reports the NCCP study, restrict reimbursement for mental health services provided in childcare, school, or recreational settings (those most convenient and comfortable for families). Just 16 states, the study found, will reimburse the cost of certain services for young children who lack a formal diagnosis.
Medicaid covers residential treatment only if states opt to provide inpatient psychiatric services, and many states elect to not cover such services. Others impose limits on mental health coverage by restricting the length and cost of services or providing services only if a judge deems them necessary. Some caregivers who operate outside the child welfare system may not be able to afford children’s health insurance.
- Scarcity of qualified providers. There is a nationwide shortage of licensed child and adolescent mental health clinicians and, of those, relatively few are well-versed in foster care and adoption issues. Even fewer are culturally and linguistically competent to serve families who do not speak English. Worse still, many providers limit the number of Medicaid clients or simply do not accept Medicaid or its state equivalents.
- Lack of awareness about services. Adoptive parents, guardians, and kinship caregivers may have no experience locating the special services their young charges need, and may hesitate to appear overly needy or inept by asking for assistance. Relative caregivers may be especially leery of seeking help for fear that child welfare workers will think they cannot adequately care for the children and may decide to take the children away.
- Shrinking state budgets. The current recession has plunged more families further into poverty. And poverty, as the Children’s Defense Fund points out in its 2005 State of America’s Children report, “is the single best predictor of child abuse and neglect.” The unyielding stress of perpetual hardship and the ways in which people express stress or try to forget their troubles rarely benefits children.
As the recession persists, more children are likely to endure abuse and neglect and states—facing their own budget crises—will dramatically curb spending. Georgia’s proposed budget would eliminate 702 caseworker positions and substantially reduce services and residential programs for children with serious mental health problems. Private residential treatment centers in Kentucky are cutting services and staff to accommodate a drop in state reimbursement rates. All across the U.S., hard-fought efforts to reduce the number of children in foster care and improve services for children adopted from care are in jeopardy.
More subtle service barriers also exist. In Nebraska last fall, as the safe haven cases were mounting, Todd Landry, director of the Division of Children and Family Services (until April 1, 2009), repeatedly chastised parents for deserting their children. “They were tired of their parenting role,” he claimed in a September 2008 USA Today article. A month later, in the Wall Street Journal, Landry asserted that all of the children left at safe haven sites “have come into our system, in our opinion, unnecessarily.”
Those who parent children with impaired abilities to behave, communicate, and reason like other children experience a very different reality from other parents. Normal parenting techniques may not work, and ongoing problems can make caregivers vulnerable to feelings of failure. Insensitive comments from teachers, restaurant patrons, other parents, and public officials can reinforce parents’ deepest insecurities and make them less likely to seek the help that they and their children truly need.
Suggestions for the Future
Targeted and ongoing mental health care services are crucial for children in care and those who exit care to guardians, kinship caregivers, birth families, and adoptive families. An absence of appropriate services will result in far worse outcomes for children and their families, and cost society much more over time. As states finalize budgets, policy makers should consider the following children’s mental health service provision suggestions.
- Appropriate funding for prevention and early intervention services. The Florida Network of Youth and Family Services is a statewide not-for-profit that works to keep families (including adoptive families) together and divert troubled teens from crime. The program offers services such as youth advocacy, referral, respite, and training and technical assistance. Teens can also have a two-week cooling off period at a special shelter while going to their regular schools, doing homework and chores, receiving group counseling and individual therapy, and gaining perspective on the importance of their family. Within six months of accessing program services, 90 percent of youth are still at home and out of trouble.
- Increase the availability of state-funded services and create a broad-based education campaign to raise awareness about services and why they are needed. In its list of legislative priorities, Voices for Children in Nebraska suggests that the state appropriate funding to create a system of services for children with behavioral and mental health needs so they need not enter or re-enter foster care. In addition, the state should establish a broad-based public education campaign to de-stigmatize mental illness and raise awareness about the challenges of parenting children with special needs.
- Develop services that flow from a single point of entry. Based in New York City, the New York Jewish Board of Family and Children’s Services provides standard foster care services and—at the same office—mental health therapy for youth and families, mentorship programs, educational support for youth, and continuing education opportunities for mental health and child welfare professionals. Staff will even give children rides to and from therapy sessions when parents are unavailable or therapists need more time to develop a positive relationship with youth.
- Ensure that services are comprehensive, strength-based, community-based and appropriately welcoming to all races, ethnicities, and languages. Illinois’ Adoption and Guardianship Preservation program, funded by the state Department of Children and Family Services, offers free services to families who adopt or assume guardianship of children in state custody through eight contracted agencies. Bilingual staff at the Adoption Information Center of Illinois offer advice and referrals to services such as crisis intervention, intensive family or individual therapy, respite, and case management. When needed, home-based services are also available.
- Customize services to each child’s developmental age and life circumstance. The Post-Adoption Special Services Subsidy (PASSS) allows qualified Ohio families to access special services that can help address their children’s ongoing physical, developmental, mental, or emotional needs. The child does not have to meet the federal or state definition of a child with special needs; parents need only show that they have not been able to locate or cannot afford needed medical or psychological services (including respite care and residential treatment).
- Employ proven models of intervention and treatment. To ensure that mental health services are effective, states must educate service providers about proven treatment models. In Oregon, through the Continuing Education branch of Portland State University’s Graduate School of Education, mental health and child welfare professionals can earn post-graduate training certificates in “Therapy with Adoptive and Foster Families.” The program offers a series of evidence-based workshops that focus on treating children in or adopted from care, strengthening family systems, and enhancing parents’ and children’s resiliency.
- Take advantage of varied funding options. Missouri uses Title IV-E funding to operate a program specifically designed to make certain parents do not have to relinquish custody of their child solely to access mental health services. Other funds may also be available through the Promoting Safe and Stable Families program, adoption incentive program, Medicaid, private insurance, grants, and the newly reauthorized and expanded State Children’s Health Insurance Program (SCHIP). The new program expands coverage to millions of additional children and features guaranteed dental benefits as well as mental health parity.
As Nebraska discovered, states should make a concerted effort to assist families whose children desperately need accessible and comprehensive behavioral and mental health services. State officials had claimed that caregivers needlessly relinquished children, but a February 2009 Omaha World-Herald article reports that “some of the 29 Nebraska children didn’t appear to get the diagnoses, medication, and other help they needed until after safe haven.”
Times are tough for individuals, families, and state governments. We must all make hard choices. Fortunately, we know that an investment in quality mental health services for children whose lives have been scarred by abuse, neglect, and loss will pay dividends—both to state coffers and to families whose children need extra support to recover from early physical and psychological trauma.