Prioritizing the Mental Health Needs of Children and Youth in the Child Welfare System

As the month of May draws to a close, we are reminded that mental health is integral to whole health - and children who have been removed from their homes need a system that will do the utmost to see to their safety and wellbeing. In recognition of the tens of millions of Americans living with mental health problems, on April 30^th President Obama declared May as National Mental Health Awareness Month. He also declared May as National Foster Care Month, in recognition of the children and youth awaiting permanency and the families, professionals and foster parents who care for them. These are two issues of critical importance to all families and, while important to spotlight in May, must remain a policy focus year round.

The link between mental health and involvement in the child welfare system is notable. Although most children with mental health challenges do not become involved with the child welfare system, and children in foster care do not necessarily have mental health disorders—children in foster care do have disproportionately high rates of social, emotional or behavioral health concerns. Child welfare systems that prioritize mental health and focus on protective factors can deliver better results for children and youth in foster care or for those children in families where there is a risk of removal.

Research in child welfare suggests that children do best in their own families and should remain home with their parents whenever possible. When that is not possible, children should be returned to their families or moved to another permanent home as quickly as possible consistent with safety concerns. There are many circumstances in which family strengthening attempts can prevent removal of a child from the home. These interventions can include home visits, housing assistance and family counseling among other options. Lack of access to these family strengthening services can prove disastrous for families. For example, in extreme cases some families have been forced to relinquish custody of their child to the child welfare system in order to gain treatment for their children who were experiencing serious mental, emotional or behavioral health challenges. Separation from the family is traumatic for children, and should be a last resort if effective attempts at family strengthening have not been productive.

Child maltreatment, including abuse and neglect can have negative impacts on children and youth—particularly if their developmental milestones are not nurtured and supported. Without proper support, these problems can linger throughout a child’s development, causing further physical, mental, emotional or behavioral issues later in their childhood or adolescence. Infants and toddlers who have been removed from their parents can miss developing a sense of trust gained from attachment to their parents. This sense of trust is essential in order for them to develop relationships with adults and peers as they mature. At later ages, children must: develop the physical skills necessary to gain a sense of autonomy, be able to exert some control over their environment in order to develop a sense of purpose, deal with new academic demands and navigate social relationships. Attention to a child or adolescent’s socio-emotional wellbeing is essential to ensuring their successful transition to adulthood.

Children and youth who experience trauma stemming from abuse and neglect can also face disrupted attachment and delayed development of capacities required for building relationships. Among children and youth who are reported for abuse:

• 32% of children from birth to five years old have developmental problems;
• Among school-aged children and adolescents, 10% are at risk of cognitive problems or low academic achievement, 43% have emotional or behavioral problems, and 13% have both;
• Adolescents engage in more risky behaviors than their same-aged normative peers—almost 50% have used alcohol at some time during their lives and over 20% have used other substances.

Research has shown that caregivers can buffer the impact of trauma and promote better outcomes for children even under stressful circumstances when the following Strengthening Families Protective Factors are present:

• Parental resilience
• Social connections
• Knowledge of parenting and child development
• Concrete support in times of need
• Social and emotional competence of children

To achieve the goals of safety, well-being and permanency for youth in the foster care system, policymakers can adopt policies that strengthen reunification, adoption and guardianship. Requiring family involvement in decision-making can aid in reunification, establishing state adoption credits can encourage more adoptions, and setting adequate subsidy and benefit levels can support guardianship.

There are a number of resources for policymakers, advocates and families on supporting the mental health needs of children involved with the child welfare system, including:

• Results-based policies to aid children and youth in foster care
• Results-based policies to promote children’s social, emotional and behavioral health
• Promoting Children’s Social, Emotional and Behavioral Health (report)
• National Child Traumatic Stress Network

Ensuring access to quality child care is a smart investment

Affordable, high-quality child care is of tremendous importance for working families. In most families, all of the adults work outside the home and 32.9% of children under five receive regular child care from non-relatives. Early childhood is a critical phase for a child’s brain development; a stimulating, supportive environment is important for all children, and quality child care is important for children’s health, well-being and readiness for school. Research shows that high-quality child care can have positive impacts on a child’s life in a number of ways - including higher educational attainment and lower rates of social problems.  Further, the benefits of high-quality child care extend beyond childhood well into adulthood.  

With so many working families relying on care outside the home, access to affordable, high-quality child care is not only important for children’s well-being, it is important for national economic productivity. Research  suggests that access to quality child care has a positive impact on parents’ productivity by reducing absenteeism, tardiness and lack of concentration at work. Through reforming child care assistance programs and establishing thorough regulation of child care facilities, policymakers can play an important role in ensuring that more children in working families have a healthy start. 

However, despite the importance of high-quality child care, finding care at an affordable cost is often very difficult for working parents. According to the Center for American Progress, child care for an infant costs more than tuition at a public college in most states; many low-income families spend about half of their income on child care. Even once parents find an affordable child care provider, the quality of care may be very low. Not all states require that child care providers be trained or have background checks. Even licensed providers are not monitored in some states. The lack of quality childcare is a problem that is widespread.  According to Child Care Aware of America, child care programs provided by the Department of Defense for military families scored the highest in their 2013 Child Care Aware rankings of state program requirements and oversight, receiving a ‘B’ grade. 10 states received ‘C’ grades in the rankings, while 21 state programs received a grade of ‘D’ and a shocking 20 states received failing grades. 
 

Proposed regulations to improve the quality of child care

To address the issue of the low quality and high cost of child care for working families, the Department of Health and Human Services (DHHS) released proposed regulations on Monday for child care providers receiving Child Care and Development Fund (CCDF) program subsidies. The proposed regulations include changes in four key areas:

            “(1) improving health and safety in child care;

             (2) improving the quality of child care;

             (3) establishing family-friendly policies; and

             (4) strengthening program integrity.”

The new regulations would add requirements for child care providers to:

o   undergo background checks;

o   have their facilities inspected for compliance with state and local health, fire and building codes;

o   receive health and safety training on topics such as first aid and CPR; and

o   be monitored by the states through unannounced, on-site visits.

Under these new regulations, states would still have the option of exempting relatives and caregivers in the child’s home from some or all of the CCDF requirements so that caregivers such as a child’s grandparent or in-home babysitter are not required to meet the same requirements as a child care center or other professional provider.
 

Many parents assume that child care providers are already required to meet basic standards similar to those outlined in the proposed regulations.  According to a 2010 survey conducted by Child Care Aware of America (formerly the National Association of Child Care Resource and Referral Agencies), most parents believed that some or most child care providers were already required by law to be trained, licensed, background checked and monitored by the state.  However, in reality regulation of child care providers varies greatly state-to-state; some states already have some requirements similar to the proposed regulations in place, while others have far fewer requirements. Parents may find it difficult to get reliable information about the quality of their child care options. To remedy this, the new regulations aim to provide parents with more information about child care providers’ track record on health, safety and licensing as well as the qualifications of the caregivers. States would develop child care information websites and maintain a hotline for parent complaints about child care providers.
 

Many eligible families not receiving child care assistance

One notable provision in the proposal is the establishment of a 12-month period for re-determining a family’s eligibility for assistance and allowing parents who lose their job to remain eligible for a period of time while searching for work. Under the current regulations, parents in some states immediately lose eligibility if they lose their jobs, making it difficult for parents to schedule interviews or follow up on potential job opportunities as they arise. Under the proposed regulations, states would have more flexibility to minimize requirements in order to help eligible families benefit from the program.

Currently, most low and middle-income families have to pay all their child care expenses out of pocket, including most of those who are eligible for CCDF benefits.  While estimates of participation have increased in recent years, most families who are income-eligible for child care assistance do not receive the benefit and those that do typically receive it for less than a year.  The Department of Health and Human Services estimated that in 2009 only 18% of potentially eligible children received subsidized child care. According to the proposed regulations, “[c]urrently, most families receiving CCDF-assistance participate in the program for only 3 to 7 months, and many are still eligible when they leave the program. Parents often find it difficult to navigate administrative processes and paperwork required to maintain their eligibility and State policies can be inflexible to changes in a family's circumstances.” The proposal includes coordination with other programs serving low-income families, which would be used in an effort to reduce the administrative work involved for both parents and state agencies so that a larger number of eligible families receive needed child care assistance.

With research drawing the link between quality child care and healthy outcomes for children, parent productivity and national economic productivity, supporting quality child care is a good investment for states. State policymakers may wish to consider how current regulations in their state compare with the regulations proposed by DHHS and ways that they might advance their work to make child care safer, healthier and more enriching. State policymakers could also consider how to streamline access to child care assistance to ensure that eligible families are able to benefit.

For more information on ways that policymakers can promote the well-being of children and families, please visit PolicyforResults.org and watch for our upcoming results-based policy report on state strategies to support early healthy development.  Check-out CSSP’s Strengthening Families work and our Protective and Promotive Factors Framework to learn more about research-based, cost-effective strategies to in­crease family strengths, enhance child development and reduce child abuse and neglect.

How Family Food Security Supports the Economy and Children's Health

By supporting children’s healthy development policymakers help to provide the foundation needed for children to grow into thriving adults.  A critical aspect of child health is food security.  Several federal and state programs are aimed at ensuring children and families have access to adequate nutrition.  These investments often also have benefits for the economy. Programs like WIC, Healthy Food Financing, School Nutrition Programs and SNAP are all aimed at ensuring food security for poor and low-income families.

The Supplemental Nutrition Assistance Program (SNAP) is a vital lifeline for families; about 75% of households receiving SNAP benefits include at least one child, senior or person with a disability. Over 25% of all US children received SNAP benefits in 2011 according to USDA data.

On November 1, 2013, every U.S. family receiving SNAP benefits will have those benefits cut, making it more difficult for over 47 million people to buy food. On that day the 2009 increase to SNAP that occurred through the American Recovery and Reinvestment Act (ARRA) will expire, and additional cuts will likely be included in the new farm bill. On Tuesday the Senate Agriculture Committee passed a $4.1 billion cut to SNAP benefits over the next 10 years as part of its version of the bill, which would likely result in an average cut of $90 per month for nearly 500,000 households. The House Agriculture Committee passed its version of the farm bill on Wednesday, making even more drastic cuts totaling $20.5 billion over the next decade.

 Prior to the 2009 increase through ARRA, the level of SNAP benefits per family was so low that receipt of the benefits had ‘no detectable impact on child health’ according to a study by Children’s Health Watch. Following the increase, the study found that children in families receiving SNAP benefits were significantly more likely to be ‘well’ -- not overweight or underweight, in good health, developing normally for their age, and having never been hospitalized, compared to children whose families were eligible but did not receive the benefit. Another study by Children’s Health Watch found that when families’ SNAP benefits are reduced, young children are more likely to ‘be food insecure (a known child health risk), be in poor health and have developmental delays than young children in families whose benefits do not decrease’. The study also found that families whose SNAP benefits were reduced were more likely to forego needed health care due to inability to afford care, be food insecure and struggle to pay for heat and utilities than families whose benefits do not decrease.

In addition to the important impact SNAP benefits can have on child health, SNAP also has important economic stimulus effects. Research by the USDA indicates that every dollar of federally-funded SNAP benefits generates between $1.73 and $1.79 in economic activity in industries such as agriculture, retail, wholesale-transportation and food processing. SNAP benefits play an important role in sustaining demand for groceries and preventing job losses in these industries. A study by the Center for American Progress found that for every $1 billion cut from SNAP, 13,718 jobs would be lost. 

Another change in the House version of the farm bill is the elimination of 'broad-based categorical eligibility', which gives states the option of allowing recipients of certain other public benefits to qualify automatically for SNAP. Broad-based categorical eligibility prevents recipients who have already met financial eligibility requirements from needlessly going through the financial need determination process again. Since 2009, the USDA Food and Nutrition Service has strongly recommended that states adopt broad-based categorical eligibility to reduce state workloads, more efficiently helping families in need. Eliminating this option will increase barriers to receiving SNAP for eligible families, placing young children at greater risk for being significantly underweight for their age and living in households that are food and housing insecure. 

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) addresses this critical issue by providing additional support for nutrition and food security among women and young children; nearly 9 million women and children are served by this highly successful program. However, uncertainty about the future of WIC funding presents a challenge for states in ensuring that all eligible applicants are able to participate. Research conducted by the National WIC Association found that many state and local agencies have consolidated or closed clinics, laid-off staff or reduced their service hours in preparation for expected funding reductions due to sequestration. The research findings indicate that this ‘streamlining’ has negatively impacted service delivery resulting in eligible women and children being placed on waiting lists and ‘negatively affecting nutrition education and breastfeeding support’ for participants. The Center for Budget and Policy Priorities estimates that the President’s budget request of $7.142 billion for WIC would be sufficient to serve all eligible applicants, but that a lower level of funding might prevent eligible women and children from benefitting from the program.

School nutrition programs provide an additional boost to food security for children from low-income households. In 2011, the National School Lunch program provided low-cost or free lunches to over 31 million children and breakfast to over 12 million children every school day.   However, if broad-based categorical eligibility is eliminated, many children who currently received free school meals based on their family’s SNAP eligibility would be affected.  According to the Center for Budget and Policy Priorities, an estimated 210,000 children would lose access to free school lunches and breakfasts if broad-based categorical eligibility were eliminated.

Even if families have the benefits they need to provide their children with good nutrition, many low-income families still live in ‘food deserts’ where access to grocery stores and farmers markets selling fresh, nutritious food is very difficult. The Healthy Food Financing Initiative promotes good nutrition and economic development in under-served communities based on a model pioneered by the Pennsylvania Fresh Food Initiative, a public-private partnership that opened or improved 88 grocery stores and increased access to healthy food for 400,000 residents in just five years. The initiative also helped to retain or create 5,000 jobs in such communities throughout the state. For a case study of the Pennsylvania Fresh Food Initiative please visit www.cssp.org. 

In light of these impending cuts, state policymakers may want to consider planning for how to provide SNAP recipients with information about the changes and how to manage an increase in client inquiries about the reduction in benefits. If the option of broad-based categorical eligibility is also eliminated, states may be faced with an increase in workloads involved in completing financial need determination separately for each program.

State policymakers may also want to explore expansion of state and local-level initiatives to promote childhood nutrition and health such as increased state funding for farmers’ markets, school nutrition education and Farm to School initiatives as well as fresh food initiatives inspired by the Pennsylvania model.

Access to healthy, affordable food is fundamental element to ensuring children are healthy and thrive.  For state-based policy strategies to ensure that children are healthy please visit PolicyforResults for strategies to improve access to affordable healthy food and to support healthy school initiatives.   For more on collaborating around results and results-based policy strategies, visit Policyforresults.org.