Unintended Implications of Child Welfare Reform for Texas Foster Childrens Mental Health

1
Unintended Implications of Child Welfare Reform
for Texas Foster Childrens 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 LawHogg Foundation
  for Mental Health, University of Texas at Austin

Presented at the University of Oregon School of
Law, Oregon Child Advocacy Project
Conference Protecting Childrens Need for
Nurturance Proven Strategies and New
Ideas March 24-25, 2006
2
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

3
Child Fatalities in Texas

• 44th in maltreatment-related child fatalities
• In 50 of Texas fatalities, CPS had previous
  involvement with the families

4
Cases per Out-of-Home Care Worker
5
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

6
Foster Care and Mental IllnessAlumni Study
7
Services for Texas Foster Children Avg. Monthly
Cost Per Child 2004N25,000
40 times higher
30 times higher
8
Mental Health-Related CPS Issues

• High Caseworker Turnover
• Placement Instability
• Insufficient Mental Health Services
• Inadequate Oversight of Mental Health Treatment

9
TurnoverImpact 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

10
Turnover and Reunification
Flower, McDonald, Sumski, 2005
11
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 lt12
  months (Flower, McDonald, Sumski, 2005)
• National average is three years (APHSA, 2004)

12
TurnoverConcerns in Texas

• High turnover rate
• Cost of training
• Impact on caseload

13
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
14
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 lt3 placements within the first year of
  care (Median50.9 DHHS, 2004)
• In Texas, only 71.2 of children had lt3
  placements during their first year of care (DHHS,
  2004)

15
Placement InstabilityConcerns 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
16
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)

17
Insufficient Mental Health ServicesConcerns in
Texas

• Lack of available mental health services
• Inconsistency in conducting mental health
  assessments

DHHS, 2004
18
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)

19
Inadequate Oversight of Mental Health
TreatmentOver-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)

20
Inadequate Oversight of Mental Health
TreatmentConcerns 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
21
Recent Legal Reform in TexasStaff Recruitment
and Retention

• Funding for additional staff
• Increased training for staff
• Incentives for longevity

22
Questions about Recruitment/Retention

• Availability of funding currently and over time
• Need for specific training on mental health
  issues
• Role of telemedicine

23
Recent Legal Reform in TexasMedicaid Managed
Care

• Improved access
• Value-based purchasing
• Medical home

24
Questions about Medicaid Managed Care

• Existing long-term relationships with service
  providers
• Role of integrated health and mental health
  services

25
Recent Legal Reform in TexasInformation
Management

• Health passport
• Management information system

26
Questions about Information Management

• Confidentiality
• Accessibility

27
Recent Legal Reform in TexasJudicial Oversight

• Requirement of child consent
• Oversight of treatment

28
Questions about Judicial Oversight

• Child competence to consent
• Expertise in treatment management

29
Thank you for your interest!Please send
questions or comments to

• Kelly Gober kelly_gober_at_mail.utexas.edu
• Lynda Frost lynda.frost_at_mail.utexas.edu