unintended implications of child welfare reform for texas foster children’s mental health kelly j....
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Unintended Implications of Child Welfare Reform
for Texas Foster Children’s Mental Health
Kelly J. Gober, L.M.S.W.
Mental Health Services Research and Policy FellowHogg Foundation for Mental Health, University of Texas at Austin
Lynda E. Frost, J.D., Ph.D. Associate Director for Mental Health Policy and Law
Hogg Foundation for Mental Health, University of Texas at Austin
Presented at theUniversity of Oregon School of Law, Oregon Child Advocacy Project
ConferenceProtecting Children’s Need for Nurturance: Proven Strategies and New
IdeasMarch 24-25, 2006
Issues in Texas’ Spending on Child Welfare and Mental Health
46th spending in public mental health care: $37.53 versus $80.83 nationally
47th spending in child welfare
48th spending in child abuse and neglect: $109 versus $276 nationally
Child Fatalities in Texas
44th in maltreatment-related child fatalities
In 50% of Texas’ fatalities, CPS had previous involvement with the families
Cases per Out-of-Home Care Worker
12
23
40
25.9
05
101520253035404550
CWLAStandard
National Texas Texas' Goal
Foster Care and Mental Illness
Over 800,000 children served annually nationally
32,474 served annually in Texas Up to 80% diagnosed with one or more
mental or behavioral disorders Foster children use mental health services
up to 15 times more than other children in the Medicaid system
High rates of mental illness, criminal involvement, and homelessness as adults
Foster Care and Mental Illness:Alumni Study
21.5%
4.5%
15.3%
10.6%11.9%
8.9%11.4%
3.6%
9.4%
5.1%3.7%2.0%
3.6%
0.5%2.9%
0.4%0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
PTSD Depression SocialPhobia
Panic Anxiety Alcohol Drug Bulimia
Alumni General Population
Services for Texas’ Foster Children
Avg. Monthly Cost Per Child 2004N=25,000
$313
$86$111
$3 $21$13
$165
$27
$93
$3$0
$50
$100
$150
$200
$250
$300
$350
Medical BehavioralHealth
Dental All Drugs PsychotropicDrugs
Foster Children TANF Non-Foster Children
40 times higher 30 times higher
Mental Health-Related CPS Issues
High Caseworker Turnover
Placement Instability
Insufficient Mental Health Services
Inadequate Oversight of Mental Health Treatment
Turnover:Impact on Foster Child Mental Health and Well-Being Interruption of child's connections while in
foster care Lack of continuity in mental health services Increase child's feelings of neglect and sense
of abandonment Interference with therapy and goal attainment Longer time in care Longer to achieve permanency Less likely to reunify with family
Turnover and Reunification
75%
18%
5% 0.10%
0%
10%
20%
30%
40%
50%
60%
70%
80%
1 worker 2 workers 3-5 workers 6-7 workers
Flower, McDonald, & Sumski, 2005
Turnover 40% of children had more than one worker in 9 months
(Flower, McDonald, & Sumski, 2005)
Texas: 23.5% turnover for out-of-home care workers (APHSA, 2005)
Some report as high as 50% annually (CWLA, 2001; Alwon & Reitz, 2001; Graef & Hill, 2000; USGAO, 2003)
High percentage of workers on the job for <12 months (Flower, McDonald, & Sumski, 2005)
National average is three years (APHSA, 2004)
Turnover:Concerns in Texas
High turnover rate
Cost of training
Impact on caseload
Placement Instability: Impact on Foster Child Mental Health and Well-Being Short-Term Outcomes
– Insecure attachment– Unresolved grief or mourning– Anger and violence– Difficulty regulating behaviors, emotions, and
physiology
Long-Term Outcomes– Mental illness– Drug dependence – Homelessness
Pecora et al., 2005; Russell, 2002; Dozier, Albus, & Fisher, 2002; Lanyado, 2003
Placement Instability Average for permanency: 3.2 in 1-2 years
Average for emancipated: 8.7 in 5 years
14 states met CFSR standard of 86.7% of children having <3 placements within the first year of care (Median=50.9%; DHHS, 2004)
In Texas, only 71.2% of children had <3 placements during their first year of care (DHHS, 2004)
Placement Instability:Concerns in Texas Overuse of emergency shelters
Lack of available placements for children with mental health issues
Lack of services to foster families
Placements based on availability rather than appropriateness
DHHS, 2004
Insufficient Mental Health Services
Foster care population is grossly underserved
Nationally, approximately ¼ of foster children receive mental health services (Burns et al., 2004)
More than 500,000 children in the nation's child welfare system have unmet mental health needs (Burns et al., 2004)
Insufficient Mental Health Services:Concerns in Texas
Lack of available mental health services
Inconsistency in conducting mental health assessments
DHHS, 2004
Inadequate Oversight of Mental Health Treatment: Under-Prescription
50% of children with psychiatric diagnoses indicating a need for psychotropic medication received medication (Zima, 1990)
25%-35% of foster children are prescribed psychotropic medications, compared with 15% of the general child population (MN, FL)
Inadequate Oversight of Mental Health Treatment:Over-Prescription “The rampant ‘drugging’ of foster children
Multiple psychotropic medications in approximately 30%-50% of youth (Breland-Noble, Elbogen & Farmer, 2004)
Texas: one child had 14 prescriptions for 11 different medications (TDPRS, 2004)
Inadequate Oversight of Mental Health Treatment:Concerns in Texas Diagnoses and prescriptions at
assessment not reviewed, results in the continuation of unnecessary psychotropic medications
Lack of centralized information Not getting therapy as directed Medications not properly locked Missed doses of medication Poor medication documentation
TDPRS, 2004
Recent Legal Reform in Texas:Staff Recruitment and Retention
Funding for additional staff
Increased training for staff
Incentives for longevity
Questions about Recruitment/Retention
Availability of funding currently and over time
Need for specific training on mental health issues
Role of telemedicine
Recent Legal Reform in Texas:Medicaid Managed Care
Improved access
Value-based purchasing
Medical home
Questions about Medicaid Managed Care
Existing long-term relationships with service providers
Role of integrated health and mental health services
Recent Legal Reform in Texas:Information Management
Health passport
Management information system
Questions about Information Management
Confidentiality
Accessibility
Recent Legal Reform in Texas:Judicial Oversight
Requirement of child consent
Oversight of treatment
Questions about Judicial Oversight
Child competence to consent
Expertise in treatment management
Thank you for your interest!Please send questions or comments to:
Kelly Gober [email protected]
Lynda Frost [email protected]