Child Welfare for the 21st Century

Child Welfare for the 21st Century: Integrating Theory and Practice to Benefit Children

New Orleans, Louisiana

March 21, 2012

Good afternoon, everyone. 

Thank you for that warm introduction, Charley.

I can’t tell you how pleased I am to be in this magnificent city and a guest of this great university.  New Orleans is a place like no other in the United States, with its spicy mix of cultures, amazing food, gracious architecture, and vibrant people.  But it’s more than that—it transcends words.

So thank you for inviting me to Tulane.  I’ m truly honored to address this distinguished audience.

One of the most important parts of ACF’s mission is to care for children who have suffered abuse or neglect and, ultimately, to find permanent homes for those who cannot safely return to their homes. 

The good news is that the child welfare system has made significant progress in reducing the number of children in care.  As a result, we have redoubled our commitment to serving the needs of specific groups of children who remain.   This includes children with serious behavioral and mental health needs for whom permanent placements are more difficult to find.

Today’s session addresses one of my utmost concerns:  how to ameliorate the effects of trauma on the youngest children in the child welfare system.

I want to thank Dr. Zeanah and his team as well as many other researchers who have done pioneering work in this area.

Your work is absolutely salient to our child welfare policy directions.

I want you to know that we’ve studied your findings and we’ve learned from them.  We know that the best policy development is informed by the latest and best research, so we are constantly striving to integrate theory and practice.  That’s why it’s so important that we remain in constant dialogue with each other.

The picture of children in the child welfare in this country is shifting.  As I mentioned before, in the last fourteen years, the foster care caseload shrank 25%--from 559,000 to a little over 400,000. Though the total number of children in care has decreased, for the last five years, about half of children entering foster care are 5 or younger.  Of these, one third is under the age of 1.

We know that the experience of young children in foster care is different from that of older children and that treating them poses particular challenges.

  • Infants in foster care stay longer—those who enter before they are three months old stay almost twice as long on average as older children.
  • They are more likely to be placed with foster families than in other settings, and
  • They are less likely to reunify with their biological families and more likely to be adopted.

Too often the system responds to these kids’ problems by medicating them with psychotropic drugs.  A Government Accountability Office study found last year that in Florida, for example, more than 5 percent of children from birth to five were taking psychotropic drugs, more than one and half times the number of non-foster children.  In Oregon almost four times as many foster kids as non foster kids are taking these drugs.  These are kids aren’t even in first grade yet—many of the drugs they’re taking are not even approved for such young children!  Another study of pharmacy claims in 16 States showed that foster children enrolled in Medicaid were prescribed antipsychotic medications at nearly nine times the rate of other children receiving Medicaid.

One serious mistake the system often makes is to diagnose a child when he or she has just experienced the trauma of removal from the home.  The problem with this, of course, is that what looks like an underlying psychiatric disorder may be a normal reaction to a terrible situation.  That’s why it’s so important to start with cognitive-behavior therapy, family skills training, behavior management or other interventions first.  We don’t deny that medication can be a useful part of an overall treatment plan for troubled kids.  However, it must not be the only modality considered.

Not only are combinations of treatments generally more effective; sometimes non-medication interventions are sufficiently effective in children with mild to moderate symptoms and are recommended before treatment with pharmaceuticals.

It is absolutely essential that we enhance our efforts to make sure that psychotropic meds are prescribed only when needed and in the quantity needed. They should not be prescribed to keep kids quiet or to divert attention from other situations that could be causing problems—like bullying or abuse.

This puts me in mind of the tragic story of Gabriel Myers.  Gabriel was a 7-year-old boy in foster care in Florida when I was the Secretary of the Department of Children and Families.  He committed suicide by hanging himself in the bathroom of his foster home.  This horrible event sparked an intense investigation—we found that Gabriel had been removed from a neglectful mother, placed in several foster homes, suffered sexual abuse at the hands of another child and was on three different psychoactive drugs because he was acting out. 

Even though there were many people and institutions officially involved in his care, nobody was really acting as the loving, responsible parent whom he needed.  The cards were stacked against him, and the system failed him. We must not have any more Gabriel Myers.

So what is ACF doing to address these severe problems among young children in foster care?

If I had to put it one sentence, it would be: we are shifting resources to make sure we support and promote what works.

We are moving away from less effective approaches like parenting classes and generic counseling to interventions that have been proven effective through rigorous evaluation, such as:

  • Cognitive-behavioral therapy
  • Home-visiting (which was established by the Affordable Care Act)
  • And other kinds of psychological first aid.

We are in the midst of a significant effort to address the use of psychotropic medications among kids in foster care.  The recent Child and Family Service Improvement and Innovation Act requires states to tell us how they are going to monitor and treat the health needs of children in care, including emotional trauma related to maltreatment and removal from home.  The plans must include a description of how they will oversee the use of psychotropic drugs. We’re working across HHD agencies to develop new guidelines to help states account for psychotropic drugs and to train employees on their proper use, as well as alternatives to medication.

We’re investing in approaches that will help children heal and recover from abuse or neglect, exposure to violence in their homes or on the streets, and the complicated trauma that results. We’ve issued a series of grants to do this.

We want to assure that these children find stability at school.  To do this, we’ve targeted funding to programs that help children in foster care stay in their school and decrease the number of times they change schools, as well as projects that more efficiently enroll very young children in early education programs.

We’re also focusing on youth who are aging out of foster care.  The transition from adolescent to adulthood is difficult for most young people; it is nearly impossible when a young person has few healthy relationships to draw from, as is the case for many youth who age-out. This set of grants is intended to build relationship skills, and strengthen relationships with family and other adults to ease the difficult transition into adulthood.

We’ve targeted funds to child protective systems seeking to improve their ability to detect and respond to children who show signs of trauma.  These programs focus on identifying children with trauma symptoms and then using interventions that have been shown to help them heal.

We’re encouraging all of our grantees who work with children to concentrate on protective factors—exposing them to experiences that will make them more likely to grow into healthy adults.  I’m talking about protecting them from harm and fear; helping them build healthy relationships with loving adults and with peers; and rewarding their ability to self-regulate.   Educational mastery also helps, so we emphasize the acquisition of grade-level math, reading and writing skills.

We’re also supporting innovative approaches designed to find permanent placements for groups of foster children who tend to stay in care longer than their peers.

  1. Kansas is testing a new program with severely emotionally disturbed children’
  2. California and Arizona are both striving to speed up the placement of African American and Native American children into permanent homes;
  3. Nevada is focusing on children with immediately safety risks;
  4. Illinois is concentrating on children who have been exposed to severe trauma, and
  5. The Los Angeles Gay and Lesbian Community Center is working with LA County to develop a model program to protect the health and well-being of LGBTQ foster youth and to remove barriers to permanence for them.

Another important part of our strategy is our ability to grant child welfare waivers to states.

Again, the number of children in the child welfare system is on the decline. Some of that improvement is because fewer kids are coming in the front door of the system.  And that’s great. When we’re talking about child welfare, an ounce of prevention is worth a ton of cure. 

But there’s a catch 22 built in to the system—a catch that counterproductively rewards failure. The problem is that under existing federal law, if a state or county safely reduces out-of-home care—which is obviously what we want--then federal funding goes down. The IV-E waivers that we’ve been granting for years can change that downward funding spiral. Under the waivers, if out-of-home caseloads and costs lessen, the state retains federal funding.  That money can be invested in ways that the state deems best-- to help children while they stay at home, or reunification, or for services to help children move more quickly towards permanency if reunification is not realistic. 

Even more importantly, the waiver allows states to deal not just with the issues the child is facing, but also with the issues the parents are facing. Under the waivers, we reward achievement, not failure.  We acknowledge that different jurisdictions have different requirements, and that flexibility and more local determination are virtues.

I speak from my experience in Florida.

The waiver allowed us to safely reduce the number of children in out-of-home care by 37 percent. That’s 10,000 fewer children who are in permanent homes instead of state care. The waiver also let us provides services to the whole family, not just the child.  So it took less time to reunify the family and fewer children came back into care.

Understand though-- the waiver is not a panacea.  It must be combined with well-informed leadership and a willingness to do things in a new and better way.  Implemented correctly, it is a powerful tool that can make positive reform in child welfare more likely to happen and more likely to have the desired result.

  • Waivers offer the opportunity to provide an array of flexible approaches, such as:
    • Intensive in-home services,
    • Integration of substance abuse, mental health and domestic violence treatment into child welfare
    • Using foster parents as mentors to biological parents, toward the goal of eventual reunification and
    • Intensively recruiting and training potential foster parents.

When you provide more effective prevention and intervention services like these, more children who can safely remain in the home have the stability of being with their family.  But they will still get oversight and intervention to help make sure that home is a safe place.

When you provide more effective reunification services, families that are capable of caring for their children have the support they need to get their kids back.

When you safely reduce the amount of out of home care, you can focus on improving the quality of the foster homes for the children who really must be in care.

Quality Parenting Initiatives (might want to mention Carole Shauffer’s program,) and other programs to support our foster parents become more achievable.

You can also more effectively link the needs of children with the array of placement options.  I’m thinking of a great program in Florida called the Susan B. Anthony Recovery Center.
This is a residential treatment center where women can keep their children with them while getting treatment to live clean and sober. There’s a double benefit: the moms get the care they need and still keep their children with them.

When you safely reduce out-of-home care, you can also more effectively focus on achieving permanency.  However, the sad fact is that some children are not going to be reunified. Those children deserve a permanent family too.  We must do everything possible to speed the day that they are adopted.

I do not believe that any child is too old for adoption.  I know 17 year olds that have gotten adopted after spending their lives in care.  The adoption happened because someone refused to give up.

In an age of austerity, the President’s budget proposal is supporting our efforts.  The 2013 plan includes an increase in funding of $250 million a year for ten years to support a reform agenda that would provide incentives to states to improve outcomes for kids in care and for those receiving in home services. We hope that Congress will act favorably on this proposal, which was also included in last year’s budget.  I would be remiss if I didn’t mention something that is having a positive impact on the health and well-being of children and young people in this country.

It’s been two years since the President signed one of the most historic pieces of legislation in our history, one that was almost a century in the making—the Affordable Care Act. The law’s provisions have been slowly rolling out—amid some controversy, to be sure. But there are some parts of the law that should be without controversy—and that’s their effect on families and children.  Let me give you just a few highlights of changes that are already taking place:

  • Under the new patient’s bill of rights, insurance companies can’t deny coverage to children because of a preexisting condition like asthma or diabetes.  They can’t cancel coverage for a sick child when the insurer finds a mistake on your paperwork.  These abuses used to be legal.
  • Young adults under the age of 26 can now stay on their parents’ health plans.  As of today, there are at least 2.5 million young people who are benefitting from this provision of the law.

In many cases now, children can get preventive services for free.  Services like:

  • Routine well baby and well child visits
  • Routine vaccinations
  • Oral and vision care…and more

In many states, more families can now qualify for the Child Health Insurance Program. 

As I mentioned before, the law also established a new home visiting program for mothers of infants to provide them the support and information they need to give their children the best start in life.  Programs like this have been shown to prevent child maltreatment and its consequences.

And it set up the Health Professions Opportunity grant program, to train folks with low incomes for promising careers in the booming field of health care.

In the realm of children and families, the ACA has so far been a great success.

I’d like to close by giving you our vision of the new narrative for child welfare.  We would like to see a coordinated system that intervenes to help troubled children in a way that promotes protective, supportive, and emotionally responsive bonds between adults and children.  This means working with both kids and adults wherever they are—in a biological family, in a kinship situation, in foster care or transitioning to adoption.

This approach recognizes that children need emotionally positive, strong, trustworthy and unbreakable relationships in order to thrive in every sphere of their lives. They also need access to physical and mental health care and a high quality education to express their innate talents and fulfill their dreams. 

In sum, we would like to see a system where the words of Frederick Douglass are taken to heart and brought to life:  “It is easier to build strong children than to repair broken men.”

I look forward to working with you to reach that goal.

Thank you.

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