Reducing Psychotropic Medications Requires Systemic Reform

 The over-reliance on psychotropic medication for children in foster care has been drawing a lot of attention both among policymakers and in the media. A recent study reports that in 2012, Pennsylvania’s foster children were nearly three times as likely to be prescribed psychotropic drugs for behavior problems as other children on Medicaid.

Proposals before Congress and various state legislatures attempt to address the excessive use of psychotropic drugs for foster children. But it is important to recognize that over-reliance on psychotropic medications is a symptom of larger problems.

In my five years as a foster care social worker in the District of Columbia, I saw several young people who were given too many psychotropic medications. In every one these cases, serious and general problems with the foster care system played a significant role.

One such problem is the lack of involvement of many foster parents in the care provided to their charges. In my practice as a social worker, it was very rare for foster parents to take children to the psychiatrist. The foster parent was not there to tell the psychiatrist what the child’s symptoms were, or how the child was responding to the medication already prescribed. Instead the social worker, with far less detailed information, was the liaison between the foster family and the psychiatrist.

Most foster parents did not take their child to the psychiatrist because they worked full-time and expected the social worker to take their children to appointments. “Real parents” know they have to take off from work for this purpose. If more foster parents treated their foster children as their own, there would be less reliance on inappropriate psychotropic medications.

Foster parents need to be part of a vigorous treatment team including the psychiatrist, therapist, social worker, Guardian ad Litem, and birth parent. Such a strong team, with the foster parent fully on board, is one way to prevent inappropriate medication. As I’ve argued before, in order to make sure foster parents are willing and able to do this for children with special needs, they need to be paid as professionals for whom parenting is a full-time job.

A major investigative report of California’s system found that of the 3,800 youths living in group homes, more than half were authorized to receive psychotropic drugs. One reason for this may be that group homes are serving the most troubled youth. But any group home relying on medication as a means of control rather than treatment clearly has serious problems.

Poor mental health care for Medicaid recipients is another root cause of the overuse of psychotropic medications. Because Medicaid reimbursement rates are so low, the quality of psychiatric services delivered through it is notoriously poor. One Medicaid psychiatrist would write my client’s prescriptions as we were walking into the office. She had no intention of talking to her patient before we left with the prescriptions, even though Medicaid was being billed for an office visit.

Another psychiatrist insisted on prescribing medication to a patient even though she had been doing well without it. He expressed the fear that in the absence of medicine, the judge on the case would blame him for any misbehavior by the client.

A reduction in the use of medication requires an increased reliance on therapy. President Obama’s plan to reduce psychotropic medications supports state efforts to come up with alternative, evidence-based practices such as trauma-informed therapies. But in the absence of increased Medicaid reimbursement rates, these new therapies will be administered mainly by poorly-reimbursed providers.

Because the poor quality of Medicaid therapists is widely recognized, the District of Columbia contracts with other providers to provide therapy to a small number of clients, the most troubled ones. But most foster children have to rely on mediocre Medicaid therapists.

In order to address the overuse of medication, we need to recognize the broader problems that contribute to it. It makes sense to monitor medication use among foster children and target group homes or psychiatrists who are out of line in their use of medication.

But adding layers of review without addressing the root causes of the problem might just reduce the amount of medication children receive. It will do nothing to ensure they receive the appropriate treatment to meet their needs.

This column was published in the Chronicle of Social Change on July 13, 2015.

Confidentiality Should Not Apply When a Young Child Disappears

On March 19, 2014, a school social worker in Washington, D.C. went to a homeless shelter to obtain a doctor’s note for a student. Eight-year-old Relisha Rudd had been absent from her classroom for almost three weeks without a written excuse. Her family had told school staff that Relisha was ill and under the care of a “Doctor Tatum.”

But when the social worker arrived at the shelter, he discovered that the supposed “doctor” was a janitor and the child was missing. This touched off a frantic hunt for the missing child, who was last seen on March 1.

Tatum, who police believe shot and killed his wife, was found dead of an apparent suicide in a park. Over a year later, the child has not been found and is feared dead. But despite the real fear that this young girl will never be found, records that could shed light on what happened here are being kept confidential.

Relisha’s case has been portrayed as a failure of the District’s crumbling family homeless shelter. To a secondary degree, the school has been held responsible for failing to report Relisha’s absence earlier to the Child and Family Services Agency (CFSA). But the role of CFSA itself in this tragedy has received little attention.

Relisha’s family was known to CFSA. Not only had the family been the subject of several reports of abuse or neglect, but the most recent occurred only a few months before Relisha disappeared. The Washington Postreported that “a social worker noted a lack of supervision and abuse.” Unfortunately, the Post’s coverage did not clarify whether CFSA opened a case to provide services and supervision.

According to the Post, there were numerous indications that the family was in trouble. Relisha’s brothers had frequent behavior problems at school. School staff reported numerous warning signs, such as Relisha missing over 30 days of school and often showing up dirty, and Relisha and her brother waiting for a ride long after other children had left school.

If a case was open, then a social worker was required to see all the children at least twice a month. If there was no open case, then the question is: Why not?

The backdrop to this story is the dramatic decline in the District of Columbia’s foster care caseload: the number of children in care has decreased from 2,007 at the end of 2010 to 1,068 at the end of 2014. CFSA has been touting the success of its initiative to take fewer children into foster care. About 62 percent of its clients are now being served in-home.

That is good news indeed, as long as the children remaining with their families are receiving the monitoring and services that they need to be safe. However, Relisha’s story suggests that may not be the case.

Children who are remaining at home with their families are not receiving adequate services, according to the Center for the Study of Social Policy (CSSP). CSSP monitors child welfare services for the court. Of the cases CSSP reviewed where a child
was receiving in-home services, “only 25 percent were rated as acceptable on ‘Implementing Supports and Services.’”  Moreover, only 30- to 51 percent of the cases reviewed each month had documentation that safety was fully assessed at two or more visits as required by the court. These results give reason to wonder how many potential Relishas are currently out there.

Unfortunately, confidentiality laws prevent the release of information that would let us know how the system broke down in Relisha’s case. The Child Abuse Prevention and Treatment Act (CAPTA) requires that states preserve the confidentiality of child abuse reports and records except in the case of a fatality or near fatality. A “near-fatality” is currently interpreted to be an act that puts the child in serious or critical condition.

But remarkably, a young child who has been missing for over a year does not qualify as a “near fatality.” And citing confidentiality, CFSA has refused to issue any details about its handling of Relisha’s case. Instead, the agency posted a report on its interactions with Relisha Rudd and her family with large sections redacted. Many of these omissions appear to imply that there were gaps in the services provided by agencies including CFSA.

We cannot rely on child welfare agencies to take the necessary measures to prevent tragedies like Relisha’s in the absence of external scrutiny. CAPTA should be changed to require states to release otherwise confidential information in cases where children have been missing for some time and there is substantial reason to believe they are dead.

The safety of children in the system must take precedence over the right of confidentiality. Less than a month ago, volunteer divers were again searching the Anacostia River for Relisha’s body. The citizens of the District should not have to depend on the finding of her body in order to learn whether the government tried to protect her while she was alive.

This column was published in the Chronicle of Social Change on July 7, 2015. 

Educational Stability, Normalcy Best Served by Closer Placements

In the past, the trauma of being placed in foster care was often intensified by placement in a new school. But in 2008, Congress passed the Fostering Connections to Success and Increasing Adoptions Act, which required that a child who is placed in foster care (or in a new foster home) remain in the same school unless it is not in his or her best interest.

But as reported in The Chronicle of Social Change last week, implementation has been hampered by the lack of cooperation from schools. In response, Sens. Al Franken (D-Minn.) and Chuck Grassley (R-Iowa) have introduced a bill to improve education stability for kids in foster care by enhancing collaboration between child welfare agencies and schools.

Fostering Connections made a big difference, at least in the District of Columbia where I worked as a social worker. The first thing we used to do when a child came into care was to register him or her at a new school near the foster home, which was usually in Maryland. With the implementation of Fostering Connections, we were suddenly making arrangements to have our clients transported to their current school in D.C.

This change in practice was positive for many foster children. My first client to benefit was attending a high-performing charter school in the city. Rather than putting her in the low-performing school in the neighborhood of the foster home, we were able to transport her to her school, which was a great source of stability and support for her.

However, in many cases, school stability conflicts with another value that is currently gaining great currency: that of “normalcy” for foster children. Following the lead of several states, Congress recently enacted a law last year that requires states to allow foster children to engage in “extracurricular, enrichment, cultural and social activities.”

But when young people have long commutes that require private transportation, it is often difficult or impossible for them to participate in activities and visit friends. In many urban areas, children removed from families in the inner city go to foster homes in the suburbs because there are not enough foster families in central cities.

Over half of D.C.’s foster kids live in Maryland. Many of these children are being transported to their original D.C. school or to a Maryland school that they attended when they lived in a previous foster home. This trip can be as much as 40 miles for children in foster homes in the outer suburbs. Private transportation providers generally use a van transporting several children to and from different homes and schools, so many young people spend more than an hour in the van as they wait for others to be picked up or dropped off.

Children using private transportation are often unable to participate in extracurricular activities because transportation services rarely do pickups after 5 pm and often require that children be picked up at the same time every day. It is also difficult for foster children to visit friends (a big target of the normalcy law) because of distance and lack of public transportation.

Not only are long rides to school bad for kids, but they are also extremely expensive. Unfortunately, there is no data publicly available about how much governments are spending for school transportation. I know it was a major expense for the two private agencies for which I worked.

I also wonder if the benefit is worth the cost. The private agency I worked for most recently was paying a driver to pick up one of my clients and bring him to school daily. But my client was refusing to go to school about twice a week and was failing all his classes. I’m not sure this was a sensible investment.

There is only one way to meet the twin goals of normalcy and school stability. Rather than drive children all over the metropolitan area to get them to their original schools, we need to keep them close to home. This means trying to recruit more foster homes located in central cities.

The District of Columbia has launched a new recruiting campaign to do just that. But it is hard to believe this effort will succeed in the District and other cities where rapidly rising housing prices are driving away the people who are most likely to be foster parents. We may have to look at paying foster parents a salary or even providing them with housing in order to be able to keep our children where they belong: near their homes and schools.

This column was published in the Chronicle of Social Change on June 30, 2015.

Lack of Will to Keep Siblings Together in Foster Care, But there is a Way

As a social worker in the District of Columbia’s foster care system, I was often saddened to see siblings separated for a variety of reasons. We do not know how many siblings are separated nationwide, but studieshave found that “a substantial number” of children in foster care were not placed with all of their siblings who were also in care. This issue has not been studied at all since 2008.

Gordon Johnson, head of the Illinois Department of Children and Families in the 1980′s, was deeply perturbed by the separation of siblings already traumatized by removal from their families. When he became head of Hull House in Chicago, Johnson developed a new approach that enabled siblings to be placed in the same foster home. In 1998, Johnson brought the program to Florida as the non-profit Neighbor-to-Family (NTF), which now operates at multiple sites in four states.

NTF has several salient features:

• Most importantly, NTF places one sibling group per foster family. In exceptional cases, a very large sibling group might be split between two or more homes, but the foster families are responsible for making sure that the children see each other regularly.
• Foster caregivers are “an integral part of the therapeutic team … making decisions about the future of the children.” They are required to report regularly on the children’s progress, to mentor birth parents, and to help coordinate therapy and medical care. Foster parents need 70 hours of training to become licensed and 50 hours per year thereafter.
• Clinical services are integral to the program. Therapists work directly for the program, ensuring coordination with foster parents and social workers.
• Birth parents and extended family receive intensive services and outreach. Traditional foster care programs have the social worker serve both the parent and the children, which can result in worker burnout and service delays. NTF assigns a separate Family Advocate to each birth family.

Despite NTF’s many strengths, state policies limit the number of children who can benefit from this approach. All states have different foster care payment rates for children depending on their special needs. In some states, siblings with special needs cannot be placed in the same home as children without them, so they must be separated. Some states and localities have worked with NTF to find ways to keep siblings together in that scenario.

Originally, NTF foster caregivers received a salary and benefits. In exchange at least one foster parent per home was required to give up paid employment. That is no longer the case. Many states have prohibited foster parents from being employed by foster care agencies. This forced NTF to stop paying salaries and benefits to foster parents.

Instead, NTF adds a stipend to the regular state foster care payment. Because foster parents no longer receive benefits, NTF no longer requires that one foster parent give up paid employment. However, the program still requires that foster parents put the needs of the child first. They must be willing to take time off work for school meetings, doctor’s appointments, and the like.

Data suggest NTF is working. Children in NTF homes are reunited with their birth families faster than other children in foster care. The average length of stay in an NTF home was 8.57 months in 2014, as compared to the national average of 27.2 months. NTF is rated as a promising practice by the California Evidence Based Clearinghouse on Child Welfare. This rating was based on a study showing that NTF performed better than traditional foster care on indicators including placement stability, placement with siblings, moves to more restrictive settings, and reunification.

Unfortunately, NTF serves only about 500 children in total. Perhaps states and localities are unwilling to spend the additional money this program model requires. Federal support could help make the NTF model the default option for sibling groups. The model could be required for federal reimbursement; alternatively, an enhanced federal reimbursement rate could be provided for children served under this model.

Bureaucratic barriers that separate siblings should be eliminated. States should be encouraged to allow foster parents to be employees, thus allowing the original NTF model to be restored. As I argued in a previous column, professionalizing foster care would help ensure a sufficient supply of foster parents who are passionate about helping children.

This column appeared in the Chronicle of Social Change  on June 22, 2015.

Pay Foster Parents as Professionals

Just about everyone seems to agree that too many young people in foster care are spending too much time in congregate care, group homes and larger residential programs. The Obama administration has proposed requiring an initial justification that a congregate care placement is appropriate for a child, as well as renewed justification every six months that such a placement is still necessary.

Several members of the Senate Finance Committee, including Chair Orrin Hatch (R-Utah) and ranking member Ron Wyden (D-Ore.) have voiced support for limiting congregate care. Hatch proposed legislation last year to tighten restrictions on group homes, eliminating the federal match for group homes for very young children and (after a certain time period) for older youth.

As a former social worker, I too support some type of restriction on congregate placement so that young people are not placed there unnecessarily and do not stay too long. But such restrictions should not be adopted until something is done to increase the supply of high-quality foster homes.

In an earlier column, I wrote about my experience as a social worker in the District of Columbia, where many foster parents treat their foster children like boarders. They refuse to attend meetings, visit schools, or speak to therapists. Unfortunately, bad foster parents are rarely fired in the District unless they outright abuse or severely neglect their children. That’s because there is a shortage of foster parents in the city, as there is in jurisdictions all over the country.

At least one reason for the foster parent shortage is clear: It takes a special kind of person to be a great foster parent. Moreover, foster parents generally receive a stipend that is designed to cover only the cost of caring for a child. Usually this is not much more than $1,000 per month, even for a child with special needs. To get accepted as a foster parent, applicants (even family members) have to show that they do not need the stipend to make ends meet. Thus, most foster parents have to work, and not many working people have the time and energy to do a good job caring for someone else’s child. In my experience, many foster parents are away from the house from 6:00 am to 6:00 pm and are unable or unwilling to go to the child’s school, therapist or doctor.

We should pay for at least one foster parent per home to be a full-time parent. If we did that, we could tap a whole pool of people who want to work with children. There are several programs that do this already on a small scale. Jurisdictions like the District of Columbia, where housing costs are very high, might even want to consider buying houses suitable for two to four foster children and letting foster parents live there rent-free as part of their compensation.

Of course, paying foster parents a full-time salary means screening them more carefully to make sure to rule out those who might be in it just for the money. In addition, requiring intensive involvement by foster parents in the lives of their charges, imposing strict and relevant training requirements with feedback from trainers to program staff, evaluating foster parents strictly on their performance, and dismissing those who don’t measure up, should keep neglectful and greedy foster parents out of the system.

In its budget, the Administration has proposed  “specialized training and compensation for foster parents who provide a therapeutic environment for a child.” This proposal could be the vehicle for a demonstration project to begin moving toward professionalization of therapeutic foster care.

You might ask: How can the nation afford to pay foster parents as professionals? First, the savings from reducing group home placements in some jurisdictions could help pay for professional foster parents. Second, placing two or more children per home could make professional foster parenting financially viable. Clearly, children with therapeutic needs require more time, but a full-time foster parent has more time.

It is critical to deal with the foster parent supply problem before reducing congregate care placements. Let’s not restrict group homes and residential care before we have good, therapeutic homes for children who need them. Otherwise, many young people will end up in unsupportive, uncaring foster homes.

This column was published in the Chronicle of Social Change on June 15, 2015.

Protecting the Next Relisha

In her May 29 Metro column, “New funds for homeless may be legacy of Relisha Rudd,” Petula Dvorak blamed homelessness and a malfunctioning truancy system for the tragic story of Relisha Rudd, omitting the Child and Family Services Agency, whose job it is to protect children in the District.

Relisha’s family was known to the CFSA. The family had been the subject of several reports. There were numerous indications that the family was in trouble. Relisha’s brothers had frequent behavior problems at school, often a sign of trouble at home. School staff reported numerous warning signs, such as Relisha missing more than 30 days of school, Relisha often arriving for class dirty and Relisha and one of her brothers left waiting at school at the end of the day.

If the CFSA had an open case on the family, a social worker was expected to visit the family at least twice a month. It would have been a social worker’s job to make sure Relisha was okay.

The CFSA has been touting its success in taking fewer children into foster care. The acting director reported proudly this year that 62 percent of the children it serves are at home. That is good news indeed, as long as the children who are with their families are receiving the monitoring and services they need to be safe. Relisha certainly was not.

The D.C. Council needs to demand information about the handling of Relisha’s case so that other children will not suffer the same fate.

Marie Cohen, Washington

The writer was a social worker.

This column was published on the Local Opinion page of the Washington Post on June 5, 2015.

Don't Misunderstand Lexie Gruber's Foster Care Experience

At the Senate Finance Committee’s May 19 hearing on reducing the use of group homes in foster care, the testimony that drew the most attention was that of Lexie Gruber. Lexie, a bright and articulate young woman, was removed from her family at the age of 15 and remained in foster care until she aged out.

As a former foster care social worker in the District of Columbia, I was very affected by Lexie’s testimony. But I have concerns that it could be used to justify major new restrictions on group homes.

Lexie described a group home where she received no emotional support from the staff who were ill-equipped to handle her Post Traumatic Stress Disorder (PTSD) and depression. The atmosphere was nothing like a home; residents could not prepare their own food and cabinets were locked to prevent their “stealing” snacks.

Lexie’s testimony was part of a hearing held for the purpose of showing how bad group homes can be for kids in foster care. But not all group homes are the same. In Youth Today, I described the amazing care provided by Boys Town group homes in Washington, D.C. There was no ban on hugging and no locked cabinets at the home I visited. A wall full of photos documents the young men who had spent time there over the past 20 years, many of whom still come back to visit. The “Teaching “Parents” who live there have brought up their own children there along with those assigned to them by the foster care and criminal justice systems. We need to push for closing or improving bad group homes, not eliminating great ones like those operated by Boys Town.

Just as not all group homes are created equal, neither are all foster homes. The locked cabinets and lack of hugs can be seen in many foster homes. One of the saddest moments of my five years as a foster care social worker is when I had to find a new placement for a nine-year-old client who was kicked out of her foster home for disrespectful behavior. When we arrived at her new “therapeutic” home, a locksmith was busy putting a padlock on the foster parent’s bedroom door.

Perhaps the most compelling part of Lexie’s testimony was why she ended up in the care of strangers in the first place. She was initially placed with her uncle, but was removed from him after two months because he “did not have enough bedrooms to meet agency regulations.”

As a foster care social worker, I experienced the same barrier in trying to place clients with relatives. I was intent on placing a client with his sister who lived just over the border in Maryland. I rushed to complete the paperwork and walked it over to the Child and Family Services Agency. Within an hour, I got a call; the request was denied because Maryland required a separate bedroom for my client.

Lexie may have been correct in blaming a lazy social worker for not applying for a waiver in her case, but I know that no waiver was available for my client. Instead of his loving sister, my client went to a foster parent who provided no emotional support or supervision and barely met his physical needs.

At the hearing, Senator Ron Wyden (D-Ore.) asked Joo Yeun Chang of the Children’s Bureau several times what could be done about licensing requirements that prevent foster kids being placed with family. Each time, Ms. Chang responded that the Obama Administration intends to limit congregate care.

But this is a different issue. Of course the federal government could address the licensing issue by denying IV-E funding to states that impose this type of ridiculous requirement. What a shame that, by focusing exclusively on group homes, the administration missed an opportunity to advocate for another of its priorities: keeping children with their families.

This column was published by the Chronicle of Social Change on June 3, 2015.