One Size Does Not Fit All in Child Welfare Reform

There is no sadder day in America than when a single child experiences abuse or neglect in his or her family. The experience of abuse and neglect and the events that follow often needlessly tear families apart and negatively influence the trajectory of that child’s life.

Unfortunately, for too many children, the response of our current child protection system is often too little, too late and the current deep-end federal financing of the system exacerbates this problem. Yet with increasing knowledge, we know that we can successfully intervene earlier and more effectively to keep children with their families or place them with relatives or unrelated foster parents so they can continue to live in a family setting. Most abuse and neglect in America is neglect, and if we intervene earlier and more successfully, we can correct the trajectory of a child’s life.

Annie E. Casey KIDS COUNT

Today the Annie E. Casey Foundation released its KIDS COUNT policy report, Every Kid Needs a Family, which proposes solutions for addressing some of our nation’s most pressing child welfare challenges. The KIDS COUNT reports are always anticipated and generate exactly what they intend, a national dialogue on the realities facing many of Americas children. This year’s report makes the case for more effective and earlier intervention with families who come to the attention of child protective services so that children don’t have to be removed from their homes. Or in cases where safety concerns require removal, they are given every opportunity to live with fit and willing relatives or non kin foster parents who are given the support they need to be successful in their full care of the child while efforts are made to provide lifelong permanency—whether through reunification, guardianship, or adoption.

The Annie E. Casey report says what we all believe, every child deserves a family. The Alliance for Strong Families and Communities agrees with its premise and many of the recommendations though we do see the need for more dialogue around the report’s comparison of quality residential treatment to acute emergency room care which fails to recognize that this critical service is a key part of our national children’s behavioral health system and needs to be respected as such. For some children, this lifesaving treatment  may take longer, a few weeks or several months, and that use or length of treatment should not be determined by a one-size-fits-all policy, but by sound, individualized assessment; clinical judgement; and regular clinical and system review.

We heralded the achievement of mental health parity as a nation that says the services offered in primary care should be the same as is offered in mental health. So let’s consider primary care for a moment. If I was your foster parent and you were diagnosed with cancer, you would likely be in and out of the hospital over a period of time. Some of those stays could be months long depending on your diagnosis, treatment needs, and progress. No one says, “I am sorry but because you are a foster child, you only get a set amount of time to receive the lifesaving treatment you need.” Nor would your placement with me change when you go into the hospital (by the way, the last time I checked, hospitals too are congregate settings). Your belongings would still be in your bedroom at my home and, as your foster parent, I would be a critical support for you during your treatment and your return back home. Yet if you are a child in my foster home who has a significant emotional or behavioral health challenge that requires treatment in a residential setting, your placement with me is severed, and your home-based support system is gone. This report suggests that your need for intensive treatment should be time-limited, regardless of the severity of your needs and progress.

We all want children to have their behavioral health needs met in the community while they live in a family setting, whether that is with their birth family or foster family. And there are times a child only needs a brief stay in quality residential treatment to stabilize and return home. But just like a child with cancer needs hospitalization, without artificial time limits, there will always be children who need residential treatment. Their ability to access it should be based on comprehensive assessment, sound clinical judgement, and demonstrated progress. Without it, how can we expect them to get healthy and move on with their lives? Failing this, we will see these youth struggle, further decompensate in their communities, or end up in inpatient psychiatric hospitals. True parity does not treat mental and behavioral health differently than physical health. We don’t micromanage hospitalization for acute care needs of children in foster care, so why would we micromanage which children need quality treatment interventions, what they get, and for how long?

This whole discussion becomes clearer when we stop viewing quality residential treatment as a placement but rather as a service and treatment intervention. A placement should have the opportunity for lasting permanence which I define as a place to call home for the holidays and, by its very nature, residential settings can never be that for a child. But quality, evidence based residential treatments are essential and serve as a critical part of the community-based system of care. They should not be micromanaged by artificially controlled time or age limits or made bureaucratically difficult through artificial procedural barriers.

The Way Forward

The key is to understand that we must get better at making sure that only those children who need residential treatment, receive it, and that the quality and effectiveness of that treatment, includes the support of their birth family or foster family rather than severing it. To get there we need two things. First we need a validated capacity plan by state, much like hospitals now use, based on utilization, population trends, and projections, so we know how many residential beds the children’s behavioral health system needs, where they are needed, and by what type and quality. If not, I fear we will wake up one day, like we did in the adult mental health world, and realize we lost way too many of our community mental health beds by type, quality and location, creating a real crisis in many of our communities of not being able to keep adults living with mental illness living successfully in their communities.

Second, we need to understand to get from where we are today to where we want to get to go will require us to have more flexible federal financing that allows states to create more home and community-based behavioral health services and family supports, find more relatives for kids, recruit and support more foster families, and modernize child protection systems for the 21st century. These include working with today’s quality residential providers to right size their bed capacities and reposition their immense expertise for a home and community-based system of care.

We applaud Annie E. Casey for this report and bringing greater urgency to the larger goal we all share of promoting strong family connections for all children. I agree that the vast majority of children and youth who come to the attention of child protection can be provided the stability and treatment they require while remaining with in a quality and supported family setting. But, we must recognize that each child has unique needs, some children do require more intensive treatment, and child welfare cases are rarely simple. There can be no one-size-fits-all policy.

We need to do a better job of strengthening families before child protective services is ever called. When it is, we need to provide the services and supports that keep our children safe and cared for in their homes. We also need to confront the reality that too many children of color are being removed from their homes and placed in residential settings without convincing clinical reasons of why these decisions are deemed necessary. Addressing these considerations will allow us to use residential treatment for its intended purposes—as a critical, evidence-based behavioral health intervention for the children who most need it.

Working in child welfare for as long as I have, there’s no question in my mind that there is an urgent need to update our nation’s child protective services policies and practices and my thanks to the Annie E. Casey Foundation for its leadership and vision in helping elevate some of the critical issues that must be addressed if we are to move our nation forward. The Alliance is addressing child welfare issues head on through our strategic work with key stakeholders at the national and state levels to bring federal financing of child welfare into alignment with the practice and policy we know works. We will work hard to ensure we bring diverse perspectives and voices to these discussions. We don’t profess to have all the answers, but with a sound set of guiding principles we believe we can get there without blunt limitations to get this right.

As a nation we have long focused on treating the symptoms of our child welfare challenges rather than the root causes. We need a plan that focuses on comprehensive system reform and aligns the regulatory and fiscal realities to ensure that child welfare agencies have the tools, resources, and flexibility to act in the best interest of the children whose lives we are impacting. A plan that is not driven by a very limited scope of policy mandates but rather one that offers incentives for doing the right thing and provides flexibility with measurable accountability across the key partners necessary for success so that child-specific decisions can be made to preserve and strengthen families and achieve lasting safety, permanency, and improved well-being for all children who are served by the child welfare system. We have been talking about this long enough, let’s get it done!

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