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
Issues in Texas’ Spending on Child
Welfare and Mental Health
 46th
spending in public mental health
care: $37.53 versus $80.83 nationally

 47th
 48th
spending in child welfare
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
50
45
40
35
30
25
20
15
10
5
0
40
25.9
23
12
CWLA
Standard
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
25.0%
21.5%
20.0%
15.3%
15.0%
11.9% 11.4%
10.6%
9.4%
8.9%
10.0%
5.0%
5.1%
3.7% 3.6%
3.6%
2.9%
2.0%
0.5% 0.4%
4.5%
0.0%
PTSD
Depression
Social
Phobia
Alumni
Panic
Anxiety
Alcohol
General Population
Drug
Bulimia
Services for Texas’ Foster Children
Avg. Monthly Cost Per Child 2004
N=25,000
$350
$313
$300
$250
40 times higher
$200
$165
$150
$100
30 times higher
$86
$50
$111
$93
$3
$21 $13
$27
$3
$0
Medical
Behavioral
Health
Foster Children
Dental
All Drugs
Psychotropic
Drugs
TANF Non-Foster Children
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
80%
75%
70%
60%
50%
40%
30%
18%
20%
5%
10%
0.10%
0%
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 (BrelandNoble, 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