1. 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 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 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

2. Issues in Texas’ Spending on Child Welfare and Mental Health 46 th spending in public mental health care: $37.53 versus $80.83 nationally 47 th spending in child welfare 48 th spending in child abuse and neglect: $109 versus $276 nationally

3. Child Fatalities in Texas 44 th 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 Illness: Alumni Study

7. Services for Texas’ Foster Children Avg. Monthly Cost Per Child 2004 N=25,000 40 times higher30 times higher

8. Mental Health-Related CPS Issues High Caseworker Turnover Placement Instability Insufficient Mental Health Services Inadequate Oversight of Mental Health Treatment

9. 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

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 <12 months (Flower, McDonald, & Sumski, 2005) National average is three years (APHSA, 2004)

12. Turnover: Concerns 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 <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)

15. 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

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 Services: Concerns 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 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)

20. 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

21. Recent Legal Reform in Texas: Staff 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 Texas: Medicaid 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 Texas: Information Management Health passport Management information system

26. Questions about Information Management Confidentiality Accessibility

27. Recent Legal Reform in Texas: Judicial 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@mail.utexas.edu Lynda Frost lynda.frost@mail.utexas.edu