Unintended implications of child welfare reform for texas foster children s mental health
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Unintended Implications of Child Welfare Reform for Texas Foster Children’s Mental Health - PowerPoint PPT Presentation

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 Fellow Hogg Foundation for Mental Health, University of Texas at Austin

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Unintended Implications of Child Welfare Reform for Texas Foster Children’s Mental Health

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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 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 Children’s Need for Nurturance: Proven Strategies and New Ideas

March 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

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

Services for Texas’ Foster Children Avg. Monthly Cost Per Child 2004N=25,000

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

Flower, McDonald, & Sumski, 2005


  • 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 kelly_gober@mail.utexas.edu

Lynda Frost lynda.frost@mail.utexas.edu

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