Time to Press the Pause Button on Realigning Children’s Mental Health

By guest blogger Angie Schwartz, Alliance for Children’s Rights

California is in the midst of a grand experiment regarding the funding structure of programs designed to protect vulnerable children.  In July 2011, the California Legislature adopted “realignment,” a fiscal policy that shifts a portion of the state sales tax, along with seven functions from the state level to the county level, including the core programs of California’s child welfare system.  These core programs include Foster Care, Child Welfare Services, Adoptions and Adoptions Assistance, and Early Periodic Screening, Diagnosis and Treatment (EPSDT) mental health program. While realignment of programs aimed at providing support and protection to vulnerable children is problematic, the realignment of EPSDT is particularly troubling and will likely result in lasting harm to our state’s most fragile citizens.

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), is part of the federal Medicaid program, known as Medi-Cal in California. EPSDT provides comprehensive medical benefits, including mental health services, for low-income children from birth and up until age 21.  The mental health services that are required under EPSDT are especially critical for children in foster care. Research has shown that up to 80% of youth involved with the child welfare system experience emotional and behavioral problems that indicate a need for mental health treatment.

Prior to realignment, counties paid a small portion of the cost of EPSDT mental health services, just 5%. The rest was paid by the federal government (50%) and the state (45%).  Under realignment, the amount paid by counties will now increase from 5% to a full 50%; the federal government will continue to pay its 50%; the state will pay nothing.

Even before increasing the county share of cost tenfold, California was doing a bad job of providing medically necessary mental health services to children in foster care.  According to a report from the state’s own California Department of Health Care Services, just 60% of youth who required mental health services received them.  That’s right – only 60%!  Why?  Because that relatively small share of cost was still a cost to counties – and one they felt they could contain by controlling the services offered and access to those services.

Realignment will exacerbate the problem of access to critical mental health services by creating a greater fiscal incentive for counties to reduce or curtail access to medically necessary mental health services for children.  Under realignment, counties will be responsible for a full 50% of the cost of EPSDT services, with no guarantee that the level of realigned revenues will be adequate.

What is a predictable response for a county in this position? Manage costs by controlling caseload. This notion that caseloads can – or should – be controlled is completely contrary to the legislative intent and mandate of EPSDT.  EPSDT is not intended to be limited or capped based on arbitrary fiscal allocations.  Rather, it is supposed to provide each child the care he or she needs to thrive.

In addition, the capped allocation makes little sense given pending policy changes that will greatly expand the population of youth eligible for EPSDT.  Over the next couple of years, an additional 878,000 new children will enter the Medi-Cal program due to the elimination of the Healthy Families program. In addition, thousands more children will be newly covered by Medi-Cal due to implementation of the federal Affordable Care Act.  Finally, the recent settlement in Katie A. v. Bonta will require that specialized clusters of EPSDT mental health services be provided for youth at risk of group home placement.

However, the legislature is in the process of establishing the fiscal base line for EPSDT when we have no idea how much counties will require to serve these newly eligible children. The combination of these three policy changes create a perfect storm that, without careful deliberation and planning, will likely leave many needy children without critical care and supports.

The Governor’s approach to realignment of EPSDT should be reconsidered. The Legislature should slow down the process and ensure that adequate time and attention is paid to ensuring that our EPSDT mental health system will meet the needs of children and families. Rather then proceeding full steam ahead with all of these changes at once, I believe the Legislature should establish a statewide working group tasked with developing a plan to improve the service delivery system, ensure equity of access between counties, increase accountability, develop outcome measures, determine if EPSDT should be realigned ongoing, and if so, ensure adequate funding for the program in the realigned system.

This Thursday, April 12th, the Senate Budget Subcommittee will hold a hearing on EPSDT realignment starting at 9:30 a.m. in Room 4203. Please join me in encouraging the legislature to press the pause button on the realignment of EPSDT to provide more time for careful deliberation and planning. Yes, the state budget is in a crisis. That is no excuse for proceeding recklessly with the lives of abused and neglected children.

From Rise magazine comes a report of a twenty-year study of the number of childhood deaths resulting from abuse and neglect annually in Sacramento, California that demonstrates a direct correlation between decreases in preventive services and increases in death rates.

One of the goals of the child welfare system is to provide permanency for children. When children cannot be reunified with their biological parents, adoption offers foster children the chance to have a “forever family.” But adoption is a complex process for both parents and children.

Creating a family is not easy, under even the most ideal circumstances. Parents and infants must get to know each other—they must learn to send and receive cues and to respond sensitively. Parents must reconcile their conscious and unconscious expectations with the baby who is actually before them—whether they have a girl when they had hoped for a boy, or whether they have an active baby when the baby of their dreams had been easy-going and mellow.

Add to this the emotional complexities contributed by infants and children who have been separated from their parents and are very likely to be wary of new relationships because of the maltreatment they suffered. And, just like biological parents, adoptive parents must relinquish their fantasies about the child or children with whom they would create a “forever family” in order to fully embrace those who have actually been placed in their care.

New parents need a lot of support. They need help with the additional work that children bring. They need emotional support as they try to manage the inevitable anxieties and responsibilities of parenthood. Common sense would tell us that parents adopting from the foster care system would need even more support because of the inherent vulnerability of the child they are bringing into their lives.

While parents adopting from the foster care system can certainly benefit from the support of family and friends, professional help is often called for. They need to have the counsel of social workers and specialists who understand and can help them meet the emotional needs of children who have been traumatized and subjected to multiple losses. Yet, these are exactly the kinds of services that are cut when budgets decline.

When we think about preventive services we, understandably, think first of programs that will keep children with their biological parents and out of the foster care system. However, it is also important to attend to programs that will ensure that when children are adopted from the system that their parents have the support they need to keep their promise of creating a “forever family.”

Through A Home Within, children leaving the foster care system and their adoptive parents can have pro bono support from an experienced therapist who can help them with the challenges of building a family together. Watch this video to hear what Lorry, a parent who adopted a foster child, has to say about the help her daughter received from A Home Within – http://youtu.be/kxSNMN-cAbc.

In the care of a loving parent the infant “feels felt.” Her needs are understood and met — long before she can name them or even experience them as discreet desires. It is through being known by the caregiver that the infant comes to know herself. As her needs are felt by her caregiver, the infant experiences the security of being held — not just in loving arms, but in a loving mind.

The tragic loss that we inflict on too many foster children is the repeated loss of a loving mind. We long to be kept in the mind of another. Children who are raised by “good enough” parents take for granted, as well they should, that their parents keep them in mind. Indeed, when children discover that they sometimes slip out of a parent’s mind they are incensed. For example, if the parent returns from a shopping trip having forgotten to bring home something the child requested, the upset child is bemoaning not just the missing treat, but the awareness that he is not always in the forefront of the parent’s mind.

It is one thing to learn that parents are sometimes forgetful. It is quite another thing to learn that you may be entirely forgotten by the people who are supposed to care for you. And sometimes, foster children are entirely forgotten. When caregivers cannot keep children in mind, children do not learn their own minds; they are wary of and confused by others.

When children do not know how to know the mind of another, they do not know how to form loving relationships. Yet, as research is increasingly definitely demonstrating, it is loving relationships that protect our physical and emotional health. The foster care system was designed to provide for the physical needs of children suffering from abuse or neglect by their parents.

We have mounting evidence that we cannot separate physical needs from emotional needs. Food and shelter are insufficient to meet children’s basic needs. They simply must have a consistent, loving adult to care for them. Failure to provide that vital relationship compounds and exaggerates the hurts the system is supposed to heal.

* This blog entry was written in response to Diane Ackerman’s blog post in the Sunday, March 25th edition of the New York Times Opinionator blog, which can be found online at http://opinionator.blogs.nytimes.com/2012/03/24/the-brain-on-love/.

Wanda was placed with her great aunt following her mother’s suicide attempt. Although her aunt’s health has declined over the years, she and Wanda have recently been called upon to help care for an aging uncle. This has necessitated a move from a rural area into a small apartment in a town near Wanda’s biological mother. Wanda’s mother also suffers from serious health problems and does not adequately care for herself. Nevertheless, Wanda is determined to “give her a chance.”

Despite having to spend significant after-school time to care for her caretakers, Wanda maintains good grades with every intention of attending college. Maggie describes her as a talented musician who practices diligently and takes great pride in her performances.

Like most teenagers, Wanda values the time she spends with her friends. She explains to Maggie that having friends of different ethnic backgrounds is important, as she explores issues arising from having parents of different races. With Maggie, she thoughtfully considers where she fits in and tries to understand what makes her feel comfortable in some groups or with some people and not with others.

Maggie recalled that one day not long ago Wanda talked about being invited to participate in a discussion group at her school. She described the conversation and her contributions. After a while Maggie commented that Wanda had done such an amazing job of articulating her thoughts and feelings. Wanda responded: “What do you expect? I’ve been seeing you for seven years!”

What an amazing “thank you.”
* The child’s name has been changed and identifying information has been eliminated.

Only a few weeks earlier, Joey’s foster mother had insisted that his older brother be moved to a different home because the two boys fought too much. His new caseworker, the third in two years, was worried that the foster mother would have Joey removed, too, if his behavior didn’t improve. While Joey had begun to be more verbally expressive, he did still wet himself when he was anxious and acted out when stressed. The combined loss of his brother and the hope of returning to his mother in the space of a few weeks had certainly contributed to some regression.

Joey’s therapist was stunned when she received an excited call from his caseworker, announcing that a therapist at a clinic near the foster mother’s home, whose work she knew well, had an unexpected opening and was willing to see Joey. She had already scheduled an appointment for him for the following week. The therapist who had been seeing Joey through A Home Within expressed her concern that his stopping therapy with her would mean yet another loss at a critical time. She worried that he would regress even more and lose his newly developing verbal capacities. If his acting out escalated in response to an additional loss, which seemed more likely than not, his foster mother might actually ask to have him removed.

However, the caseworker was adamant, explaining that it would be so much more convenient for the foster mother to get Joey to his appointments at the clinic and that she and her supervisor had already informed the foster mother of the change. Joey’s attorney, who had referred him to A Home Within because he thought that Joey really needed a long-term relationship with a therapist, also tried unsuccessfully to intervene and have him continue with the person he had finally come to trust. The combined voices of the therapist and attorney about the importance of lasting relationships could not compete with the expectation that the new therapist could somehow turn things around quickly, especially since Joey could get many other services at the clinic.

Sadly, his therapist explained to me, “I did everything I could to protect my relationship with Joey. I really care about him but I couldn’t prevent his having yet another loss—this one completely unnecessary. I’m worried that the caseworker is expecting the new therapist to work miracles. They just keep adding services—as if more people and new people are more important than familiar people and relationships that last. What if this doesn’t work and Joey does get moved and the clinic isn’t convenient for the new foster mother and he has to start over again? Why not try to support the relationships that are already in place instead of creating yet another transition without the support that it needs to succeed?”

When faced with a relationship under stress—as was the case with Joey and his foster mother—it is often tempting to make a change in the hope that a fresh start will erase the problems at hand. And changing a therapist seems less disruptive than changing a foster home.

Under externally- and internally-imposed expectations that placement stability must be maintained above all, caseworkers and supervisors often feel as if they have little choice but to respond to the demands or desires of the foster parent, even when doing so places additional demands on the child. And, unfortunately, even when they want to offer services to support and sustain the placement, there may be few resources available.

Joey’s A Home Within therapist was unable to stop the transfer to the new therapist. However, she was able to slow the transition and support Joey through it. She made clear to all of the adults involved in Joey’s care that she would like to stay in touch with Joey, through occasional notes, phone calls, or visits. The new therapist promised to stay in touch and let her know whether and when maintaining contact with Joey would be helpful to him.

Even though Joey did get a new therapist, it is not clear that it was necessary for him to lose someone he had only slowly come to trust and count on. The fact that he will continue to have therapy does not mitigate the loss of a relationship with someone who had become important to him. We cannot prevent every unnecessary loss, but we will continue to carry the message that lasting relationships are essential for healthy development and every loss has lasting negative consequences.

* The child’s name has been changed and identifying information has been eliminated.

It seemed that nine-year-old Nora had finally found a family, and she had a formal family portrait to prove it. But then the parents who had planned to adopt her decided that she just wasn’t quite the child they had in mind. This was the fourth family Nora had lost. First she lost her mother to drugs and the streets. Then she lost the relatives she had been living with when they couldn’t adequately care for her. After a brief time in emergency foster care, Nora thought she had found a family that would be hers forever.

Sadly, Nora’s therapist was planning to leave the clinic where she had been seeing her at about the same time Nora would move to a new family. Then a colleague told her about A Home Within. “I was so relieved and pleased when I learned that I didn’t have to transfer her to a new therapist in the clinic, but could continue to work with her through A Home Within.”

Nora is now settled into a new adoptive home. Instead of losing her therapist and feeling rejected by yet another person, Nora has had her therapist’s help through this very difficult transition. Nora and her new adoptive parents are still getting to know each other, but the family dog has become her constant companion. She continues to work to make friends in her new school. Her teachers are working with her therapist to help Nora control her temper and learn better ways of approaching people.

Nora has been able to work with the same therapist for over three years. Without this continuing support, her feelings of rejection and anger might have put too much strain on the relationship with her new foster parents, leading to yet another loss.

Happily, this is not an unusual story. The clinicians who are part of the network of A Home Within give their all for the child they agree to see “for as long as it takes.”  Valentine’s Day is a fitting time to honor these clincians and the love that they infuse in their work. They are truly the heart of A Home Within.

If you would like to volunteer, please contact us at www.ahomewithin.org or call 888-898-2249.

* Identifying information has been changed.

Bryan Samuels, Commissioner of the US Department of Health and Human Services’ Administration of Children Youth and Families has that vision. The flight home from the Summit on Healthy Adolescent Development and Well-Being convened by the Center for the Study of Social Policy and the Jim Casey Youth Opportunities Initiative gives me time to try to absorb both the enormity of the changes Commissioner Samuels imagines for the child welfare system and to relish the thought that he just might make them happen.

The primary charge of the child welfare system has been to ensure the physical safety of the children in its care with more recent attention to the reduction of risk. Fortunately, Commissioner Samuels is not alone in his insistence that this is not good enough for foster children, or for any children, for that matter. There is a large and growing chorus of voices demanding that our policies and programs must integrate those approaches known to protect and promote the well-being of all children and youth, but most particularly, those who are the most vulnerable.

There are many risk factors that can impair or impede children’s healthy development – among them, poor nutrition, poverty, lack of medical care and inadequate education. But if we don’t ensure that all children have a good relationship with an adult who loves and cares for them we deprive them of the single most robust predictor of healthy development.

Most parents and substitute caregivers do their best to make sure that their children have access to medical care, educational opportunities, and community support. For many complex reasons, not all adults can provide this for the children in their care. But their love for the child and their continuing care through adversity offers the child protection from the overwhelming emotions that impede development. A relationship with a caring adult creates the psychological space children need for healthy development.

As Bryan Samuels attests: “resilience is not good fortune arising from chance encounters with a supportive friend, peer or partner.” Resilience grows from ongoing relationships – this is the gift children most need from the adults who care for them.

We hear this time and again from young people in the foster care system. These children and adolescents have a lot on their minds. For whatever reason, their parents were unable to care for them. That fact alone contributes to the unusually high levels of depression and anxiety in this population. Add to that the frequent changes among those charged with their care. Change and uncertainty are a way of life for foster children as caseworkers come and go and they move from one foster home to another — often without warning or explanation. They want to make connections — to have someone to hear about what is making them so unhappy that it is difficult for them to think and learn, to make friends, and to enjoy life. However, as the New York Times reports, when these children want someone to lend an ear, they are often given pills instead. And the drugs they are given, even at a very young age, are powerful psychotropic drugs, formulated to treat the most serious of mental illnesses.

Researchers from the University of Maryland, Johns Hopkins University, and the University of Pennsylvania analyzed the distribution of psychotropic medication among nearly 17,000 Medicaid-enrolled youth in one mid-Atlantic state. Among three groups — youth in foster care, disabled youth receiving Supplemental Security Income (SSI), and those receiving Temporary Assistance for Needy Families (TANF) — foster youth were more likely to be prescribed more than one psychiatric medication and to be maintained on those medications for longer than youth in the other two groups.

The findings of this study are extremely disturbing. First and foremost, as the authors note, “concomitant antipsychotic use is not empirically supported.” While the evidence does not suggest that youth will benefit from a regime that includes two or more of these powerful drugs, the evidence does demonstrate that even one of these “atypical antipsychotics” can produce dangerous and lasting side effects. For example, metabolic changes induced by these drugs can lead to obesity, high cholesterol levels, and diabetes and patients taking these medications should be carefully monitored.

The need for ongoing medical supervision points another concern arising from this study. Life in foster care is notoriously unstable. When children move from one foster family to another, there is no guarantee that they will remain in the same community or that there will be continuity in their medical care. Indeed, “Medical Passports” were created to address the need for foster children to carry their records with them because of the great likelihood that they would receive medical care in different places and from different people. In attempting to understand the results of their study, the authors posit a number of possible clinical explanations and suggest that some “might lack a reasonable clinical rationale.” These explanations might be directly related to larger systemic issues. For example, it may be that as a result of multiple changes and the lack of a consistent adult, foster youth remain on medications longer than other children because they simply didn’t have consistent follow-up appointments.

No doubt, there are many possible clinical, systemic, and other ways of explaining the outcomes of this study. One issue that must be kept in mind is role of the parent or caregiver throughout the medication process. Parents are called on to describe the child’s symptoms, participate in the decision making-process, administer medications, monitor effects and side effects, and maintain communication with physicians and other professionals involved in the child’s care. This is a complex and lengthy process that depends on the parent or parent substitute knowing a child well enough to detect behavioral and affective changes over time and in different context. Most parents can offer this to their children. When they can’t, we owe children long-lasting relationships with other adults who can.

And yet some of these young parents – overwhelmingly mothers – manage to raise physically and emotionally healthy children, while simultaneously finding their way through the developmental tasks of adolescence. The odds are not in their favor.

Parents who grew up in foster care are six times more likely than others to lose their children to the foster care system. Why do some succeed when so many fail? We explored that question this past week at two conferences focused on working with adolescent parents: ‘Caregiving Orientations’ in Dallas, Texas and ‘Nurturing Adolescents’ in Denver, Colorado.

Clearly, inherent individual differences contribute to success in parenting, as in other aspects of a teenager’s life. However, beyond that, the single most important factor may be the teen parent’s contact with caring, supportive adults who can help her navigate the complex and often conflicting developmental tasks of adolescence and parenting. Sometimes teens have the support of parents and extended family, particularly if they have grown up in a culture that readily accepts early parenting.

However, teen parents in foster care rarely have the support of their families. In fact, many of those who become pregnant while in care will lose their foster families as a result. These young people are ill-equipped for independence, either as individuals, still in the throes of development, or as parents, attempting to promote the healthy development of another.

Fortunately, some of them have access to programs like “How to Read Your Baby” or “Reaching HOPE,” that recognize that consistent relationships are the key to helping teenagers do the best they can for themselves and their children. Successful programs are built on the realization that the adults who work with these young parents must find ways of keepinghope alive for themselves and their clients.

The internal and external challenges facing any one of these young parents are daunting. Staff members must often hear one story after another with seemingly no way to get to a happy ending. Every day they are asked to hold the hope in the face of situations that appear hopeless. Sometimes even a glimmer of hope is hard to find, but sometimes that is enough.

Programs that maintain hopefulness in their staff also support hope for the young parents and children they serve. Sometimes a sense that things might be better tomorrow – even if just a little better – is enough to get through the day. And sometimes, just getting through the day creates a sense that things just might be better the next day.

I am always inclined to greet news like this with cautious optimism, ever hopeful that good intentions will result in more and better services for these vulnerable young people. Cautious because, however difficult it might be to arrive at far-reaching plans and programs, implementing them will be even tougher.

Children who are already in or in danger of entering the foster care system have led hard lives. Most have been neglected by parents who have been unable to care for them adequately because of mental illness or substance abuse. Some have been physically or sexually abused. Many have been in the care of a number of different friends or relatives before they enter care. Once in care, they may cycle through multiple foster homes, caseworkers, pediatricians, and therapists.

Extreme instability in a child’s life creates a psychological instability that presents daunting challenges for even the most experienced and well trained mental health professionals. If the state of California is going to deliver on the promises of this settlement, it will need the support and expertise of professionals from both the public and private sectors.

One of the simple reasons that foster children don’t get adequate mental health services is that there are not enough resources in the public sector to meet the very substantial need. Unfortunately, legal settlements and legislation don’t create more professionals with the education and experience required to meet the complex needs of these children and families.

We know from personal experience that clinicians in the private sector are willing and able to do their part to help address this issue. Through A Home Within, mental health professionals in twelve communities across California volunteer their time so that foster children can have weekly pro bono psychotherapy with a consistent therapist “for as long as it takes.”

Our organization is not alone in mobilizing private sector resources to meet a public need. For example, through Give An Hour, therapists provide free sessions of psychotherapy to returning veterans and their families. And in clinics and offices across the country doctors and nurses, attorneys and accountants donate professional time to help meet the needs of those who depend on public services.

If we can create more opportunities for professionals in the private sector to work with our public agencies, we will all benefit. In addition to the direct advantages this gives the individuals involved, increased contact between these groups can help to narrow the gap between our public and private sectors and help California realistically to provide the quality care this settlement mandates.

We live in hope.