State Child Welfare Policy Guide

2.6 Home and community-based services for children and parents with mental illness

Parents with Mental Illness .  Mental illness can cause mild to severe disturbances in thought and behavior and can have a significant impact on family stability and parenting capacity.  In New York, 16 percent of families involved with the foster care system and 21 percent of those receiving family preservation services include a parent with mental illness.  As many as 70 percent of parents with mental illness are estimated to lose custody of their children – sometimes due to the stigma of mental illness, rather than untreatable conditions that cause actual harm. [i]         

Children whose parents have a mental illness are at risk of developing social, emotional, and/or behavioral problems, although their risk of child abuse and neglect or removal from the home is not clearly documented or understood.  In a 2000 survey by the Child Welfare League of America, fewer than a third of states were able to say whether parental mental health was the primary reason for a child’s placement. [ii]   The overall impact of parental mental illness on children depends on the severity of a parent’s mental illness and the extent of the symptoms.  In many families, the effect of a parent’s mental illness is compounded by other risk factors, such as poverty, lack of employment, housing problems, and substance abuse.  The lack of protective factors, such as the absence of other competent adults in the household, compounds the risks to child well-being. [iii]   One study found that nearly 25 percent of caseworkers for mentally ill adults had filed reports of suspected child abuse or neglect concerning their clients. [iv]   Most state laws include mental illness as a factor to be considered when determining parental fitness, though mental illness alone is not sufficient to lead to loss of child custody or grounds for termination of parental rights. 

Despite the prevalence of both mental illness among American adults and parenthood among those adults, few programs or services are available to meet the needs of parents and their children.  A national survey of state mental health agencies indicated that those agencies have become less responsive over the past 20 years to adults who are parents. [v]   Existing treatment largely focuses on individuals, rather than families.  Although psychiatric rehabilitation strategies have been shown to be effective in improving the functioning of adults with mental illness, their role and functioning as parents has been largely ignored.  In addition, the stigma of mental illness compared to other disabilities and fear of losing custody of their children keep many parents from seeking help. 

Children with Mental Health Problems .  Research indicates that between one-half and three-fourths of the children entering foster care exhibit behavior or social competency problems that warrant mental health care. [vi]   Half of the children in foster care have problematic adaptive functioning scores, behavioral problems, or developmental problems.  Forty percent of children in foster care between the ages of 6 and 17 are diagnosed with a moderate impairment of some type. [vii]   At the same time, the degree to which mental health problems lead to, contribute to, or result from foster care placement is not known.  Many experts postulate that children’s behavioral, emotional and mental disorders are among a constellation of factors that place them at risk of out-of-home placement. 

Young people with mental health disorders fare better at home, in school, and in their communities when they receive appropriate treatment.  Yet, services to evaluate and treat mental health problems of children and youth, as well as resources and supports to help their families care for them, are severely lacking.  It is estimated that 75 to 80 percent of children and youth who need mental health services do not receive them [viii] .  Children who are uninsured and Latino children are especially likely to go un-served. [ix] Indeed, significant disparities in mental health service utilization have been documented for children of color prior to child welfare placement, in court-ordered services, and post-placement. [x]   These disparities are likely to contribute to racial disproportionality within the child welfare system.           

Thousands of parents -- unable to obtain appropriate and affordable mental health treatment for their children and often facing related financial and personal crises -- find themselves compelled to relinquish custody to gain access to services [xi] .  Custodial relinquishment occurs when parents voluntarily transfer legal custody of a child to the state.  In response to a 2000 Child Welfare League of America survey, more than half the states reported that parents relinquish custody to access mental health services, but they were unable to report how often this occurs.  Through a survey of child welfare directors in 19 states and juvenile justice officials in 30 counties, the GAO estimated that more than 12,700 children had been placed in these systems to obtain mental health services.  However, because the study did not include the five states with the highest child populations, this number greatly understates the problem. [xii]   A 2005 report commissioned by the Virginia General Assembly found that one in four children in the Virginia foster care system was there to receive mental health treatment for severe emotional disturbance. [xiii]   Once a child with mental health issues enters the child welfare system, he/she is less likely than others in foster care to achieve permanency and more likely to experience restrictive and costly placements such as hospitalization or residential treatment. [xiv]  

A range of policy strategies are required to prevent custodial relinquishment to obtain mental health services, other unnecessary placement of children with mental health disabilities, and the disruption of families due to parental mental illness.

A.  Evidence-based, home and community mental health services.   Family-based treatments, which engage parents as primary participants in the treatment process for children and youth have been the subject of numerous clinical trials over the past ten years.  A synthesis of this research shows family-based treatment is effective in improving a range of child and adolescent substance abuse problems as well as behavioral and mental health disorders.  Family involvement can lead to “better treatment engagement, retention, compliance, effectiveness, and maintenance of gains.” [xv]   Two types of evidence-based mental health treatment address mental health problems among children in youth:

·         Cognitive Behavioral Therapy (CBT) is a tested treatment that improves anxiety, depression, and if parents are involved, helps reduce disruptive behaviors, ADHD, and possibly post-traumatic stress disorder.  The approach works with a variety of ages. [xvi]   

·         Multi-systemic Therapy (MST) is an intensive, short-term (three to four months), home- and family-focused treatment approach for youth with severe emotional disturbances.  MST intervenes directly in the youth’s family, peer group, school, and neighborhood by identifying and targeting factors that contribute to the youth’s problem behaviors and developing skills in both parents and community organizations.  MST has been established as effective in randomized clinical trials for youth in the juvenile justice system.  Initial results are positive for other populations of youth receiving MST instead of psychiatric hospitalization, including abused and neglected youth and children in psychiatric inpatient facilities. [xvii]

A small number of promising, though not rigorously evaluated, programs specializing in supporting parents with mental illness and their children have developed in the U.S. and other countries.  The Invisible Children’s Project is a model program for parents with mental illness and their children that started in Goshen, New York and is being replicated across the country.  Many participating families are at risk for having their children placed in foster care, and keeping their families together is often participants’ primary goal.  The comprehensive program includes access to 24-hour family case management, support for housing, respite child care, planning in the event of parental hospitalization, advocacy with schools, social services, family court collaboration, parenting training, vocational training, educational support, in-home clinical services, information, referrals, linkages to the community, budget counseling, recreational family activities, and more.  Although the program has not been evaluated using scientifically rigorous methodology, internal studies found a decrease in the number of children placed in out-of-home settings, including foster care.  The data further indicate that the Invisible Children’s Project is particularly effective in helping participants parent more effectively.  Child protective services workers stated that children were returned home or maintained in the home as a direct result of the Project involvement. [xviii]

B. Comprehensive systems of care for children and parents suffering from mental illness and behavioral disorders.   Investment in family and community-based systems of care -- comprehensive approaches for meeting the needs of children, youth and adults who have mental health disorders – combines a range of resources and strategies that help prevent out-of-home placement.  While these systems of care are not part of the traditional child welfare system, the safety and well-being of children affected by mental illness who come to the attention of child welfare agencies depend on their effectiveness. 

Coordinated systems of care feature a range of intervention strategies and services that can be customized to increase positive outcomes for individual children in the care of their parents.  Regardless of individual needs, the focus is on the family as a whole – both to provide the care that children with disabilities need and to assist parents with mental illness in parenting their children.  In addition to the inpatient treatment approaches that characterize most mental health systems, systems of care feature a continuum of in-home and community-based supports, including: 

·         Assessment of parenting strengths, needs and goals

·         Early and periodic assessment of children

·         Comprehensive case management

·         Peer support and self-help

·         Mentoring and supports for parents

·         Child development and parenting skills training

·         Assistance with school issues

·         Medication management

·         Crisis and respite care

·         Trauma counseling

·         Substance abuse treatment [xix]

In addition, systems of care are characterized by multi-agency partnerships that include mental health treatment professionals, child welfare workers, early care providers, teachers, health care providers, and other service providers working together to ensure that protective factors help mitigate the risks that children and families face.  Wraparound services which are designed and implemented on an interagency basis and depend on flexible, non-categorical funding provide assistance tailored to the individual child and family.

According to the U.S. Department of Health and Human Services (DHHS) Substance Abuse and Mental Health Services Administration (SAMHSA), communities in at least 42 states have developed systems of care initiatives to build community treatment for children with serious emotional disturbance.  Wraparound Milwaukee is a coordinated system of community-based care and resources for families of children with severe emotional, behavioral, and mental health problems. Features include a provider network that furnishes an array of mental health and child welfare services; an individualized plan of care; a care coordinator management system to ensure that services are coordinated, monitored, and evaluated; a Mobile Urgent Treatment Team to provide crisis intervention services; a managed care approach including preauthorization of services and service monitoring; and a reinvestment strategy in which dollars saved from decreased use of inpatient or residential care are invested in increased service capacity.” [xx]   For 267 children completing the program and exiting Wraparound Milwaukee in 2005, 92 percent achieved the permanency goal in their care plan. This included 75 percent of children returned to their own homes. [xxi]

Wraparound in Nevada for Children and Families (WIN) focuses on children with severe emotional disturbance who are in the care or custody of a public child welfare agency.  WIN provides intensive clinical case management that supports a comprehensive system of care for these children, many of whom come from families who struggle with complex personal challenges in addition to difficulties keeping their children safe and free from harm.  Of more than 600 children served by WIN, 43 percent of those discharged were returned to their family homes, usually with ongoing in-home and community services. [xxii]

Policy Options:   States can authorize and fund home and community-based services in accordance with either or both of the following service delivery standards:

·         Evidence-based treatment programs for children, youth and parents with mental health problems are available within the child’s home and community as an alternative to out-of-home treatment.

·         The state invests in supporting a statewide, community-based system of care that includes a range of services and supports for children and parents involved with the child welfare system when there is risk of out-of-home placement.