This past March, 237 foster children spent at least two nights sleeping in state offices in Texas—nearly seven times as many as March 2020. According to the Texas Department of Family and Protective Services, most of those children were older or had severe behavioral or psychological needs.
The department claimed that there were not enough foster parents and not enough beds in residential facilities for these children. The lack of foster parents is a problem in almost every state, and one we can only do so much to fix; government can’t force families to take in foster kids, and even the most qualified and well-meaning parents often don’t feel up to the task of caring for kids with special needs. But the lack of beds in child-care facilities is a problem of our own making, and one Washington should fix before it gets worse. Unfortunately, some child-welfare advocates are standing in the way of a solution.
In 2018, a bipartisan coalition in Congress passed the Family First Prevention Services Act (Family First). Backed by child-welfare groups like Casey Family Programs, the law was part of an effort to allow states to use federal foster-care dollars to pay for the kind of mental health and family counseling services that keep kids out of foster care in the first place. But Family First also sought to limit how much time foster kids could spend in institutions.
It is widely agreed that all else held equal, family rather than institutional settings are best for children. The Family First law arose in part because many child-welfare experts came to believe that states were relying too much on group homes to house foster children. Abuse was rampant in some of these homes, and many were simply not staffed with trained or caring professionals.
Family First thus specified that only a “Qualified Residential Treatment Program” (QRTP) can qualify for federal IV-E matching payments after a child’s first two weeks in such a setting. QRTPs must have a “trauma-informed treatment model that is designed to address the needs, including clinical needs, of children with serious emotional or behavioral disorders or disturbances” and “registered or licensed nursing staff” available at all times. The law thus implied that only children with the severest psychological disturbances should be placed in institutions; everyone else should be with a family.
The effects of Family First were both perverse and predictable. California implemented its own version of the law six years ago—the Continuum of Care Reform Act—which also aimed to reduce reliance on group facilities in favor of more family placements. The state estimated that it would quickly move 65 percent of its group-home population to families, but in the end it was able to transfer only 35 percent. With fewer group beds available than it anticipated, the state had to assign many children to medical and detention facilities even when such settings weren’t needed.
Psychiatric facilities also have fewer beds for kids who do need them. Because the federal government designates psychiatric facilities as Institutes for Mental Disease, they are not eligible to receive Medicaid dollars. (As part of the 1970s deinstitutionalization effort, Washington decided to be much stingier about supporting long-term psychiatric care.) But states often use Medicaid dollars to meet foster children’s health needs.
Cut off from those funds, facilities suitable for children with psychiatric challenges are shrinking or closing. In Massachusetts, kids are regularly “boarding” at hospitals while waiting for psychiatric beds to open. One boy experiencing severe PTSD symptoms, including suicide attempts, spent five days in a hospital emergency room and a month in a regular hospital bed before being admitted to a psychiatric facility.
Without public funding, such facilities cannot afford to operate, and they certainly can’t afford to care for kids in the state’s custody. Kelly Rosati, a consultant on child-welfare issues and adoptive mother to children with mental-health needs, says that kids who have experienced abuse and neglect often experience major depressive disorder, generalized anxiety disorder, and PTSD. “These same children and youth may self-harm and experience suicidal ideation.” Such children, she says, “desperately need two things: appropriate treatment and a safe environment—which includes line of sight, round the clock supervision. These are things no child can get in a family setting.”
Congress could fix this by changing the definition of a QRTP to ensure that kids with behavioral issues have places to go besides hotels or state offices. It could also reclassify psychiatric facilities to make them eligible for Medicaid. Yet many child-welfare advocates oppose these simple fixes. In recent testimony before a House subcommittee, William C. Bell, president and CEO of Casey Family Programs, urged members to “stand firm against any proposed modifications to the Institutions for Mental Disease (IMD) rule or delays in implementing the qualified residential treatment program (QRTP) standards.” He noted that “investing in proven prevention strategies makes considerably more sense than allowing for the ongoing use of these facilities as placement settings.”
From the beginning, Casey and other FFPSA advocates have pushed the idea that, if we just invest in prevention, we won’t need group homes or other institutions. But the evidence doesn’t bear this out. There will always be kids who have experienced levels of abuse and neglect that make it extremely difficult for them to function in a family setting.
The FFPSA says nothing about how states are supposed to recruit more qualified foster families. The families willing to take in special needs kids often do it for the money, and they take in so many children as to make them a group home in all but name. They can’t provide the kind of 24-hour supervision that kids need who may be a danger to themselves or others. And so those children get transferred to one home after another, further reducing their chances of feeling secure and adding to their trauma.
The solution for these kids is to increase the number of beds we have available for placement. We should be recruiting more and better qualified foster parents, using trauma-informed training, for instance. We should have more group-home beds and psychiatric beds, too. These children deserve as many options as possible.
Since the goal of Casey Family Programs and their allies is to reduce dramatically or even abolish foster care altogether, one can only wonder about their true motivations in opposing these simple fixes. Washington should ignore them and put the interests of our most vulnerable children first.