Beyond child protection: promoting mental health for children and families in the child welfare system.

The child welfare system is in a period of significant reform that offers both opportunities and challenges regarding more effective collaboration between the mental health and child welfare systems. In this article we examine recent federal, state, and local initiatives that have influenced child welfare policy and practice on a national scale, with particular emphasis on those policies that offer opportunities for better coordination of services between mental health and child welfare agencies. To plan for effective services, mental health policy makers and practitioners must be cognizant of available funding streams for child welfare, trends and innovations within the child welfare system, the contextual factors that shape services to the children and families who are under its supervision, and the special characteristics of the population that it serves.

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THE CHILD WELFARE SYSTEM IS charged with the protection, placement, and well-being of children who are abused or neglected or whose parents are otherwise unable to care for them. In this article, we outline recent federal, state, and local initiatives that have influenced child welfare policy and practice on a national scale, particularly those that offer opportunities for organizing services that target the enhancement of child well-being in the area of mental health. We also address issues specific to the child welfare population that should be considered as policy makers and service providers design and implement services to support the mental health and well-being of children and families.

The child welfare system is in a period of significant reform, and mental health policy makers and providers should be cognizant of areas where the child welfare and mental health systems intersect as new approaches to services are developed for these vulnerable children and families. Although it may be argued that child welfare personnel must concentrate a disproportionate amount of their available time and resources on ensuring child safety and on seeking permanent placements, promoting child well-being is an expressed goal of child welfare services, and the provision of appropriate mental health services is critical to meeting that goal. Strong linkages between the child welfare and mental health systems are requisites for a child welfare agenda that places primacy on the emotional well-being of maltreated and abandoned children.

THE CHILD WELFARE SYSTEM IN CONTEXT

Despite more than a century of federal and state initiatives to prevent and reduce child maltreatment, it still remains a prominent social policy concern. The most recent national data, summarizing state reports for 1999, reported estimates that 826,000 children nationwide had substantiated reports of maltreatment, reflecting a victimization rate of 11.8 per 1,000 children (U.S. Department of Health and Human Services [U.S. DHHS], Administration on Children, Youth and Families [ACYF], 2001a). The majority of these children (58.4%) were victims of child neglect, followed by physical abuse (21.3%), and sexual abuse (11.3%). Most children who come into contact with the child welfare system remain at home, although substantial numbers are placed in foster care. For 1999, national estimates were that 171,000 child victims of maltreatment (20.7%) experienced foster care placement, while an additional 49,000 children whose cases were unsubstantiated were placed out of home (U.S. DHHS, ACYF, 2001a).

In addition to the developmental risks posed by the trauma of abuse or neglect, children in the system often face the challenges of poverty; poor housing and neighborhood conditions; and adverse family circumstances, including substance abuse, mental illness, and domestic violence within the family. Given these circumstances, it is not surprising that studies tracking the development of children who have been maltreated often find that they experience pervasive problems in adjustment during childhood (Bolger & Patterson, 2001; Eckenrode, Laird, & Doris, 1993; Flisher et al., 1997) and that the negative consequences of maltreatment may persist into adulthood (Cohen, Brown, & Smailes, 2001; Herrenkohl, Egolf, & Herrenkohl, 1997; Widom, 1996). Studies of children placed in foster care commonly find high rates of emotional and behavioral disorders (Barth, Green, Wall, & the NSCAW Research Team, 2001; Clausen, Landsverk, Ganger, Chadwick, & Litrownik, 1998; Glisson, 1996; Trupin, Tarico, Benson, Jemelka, & McClellan, 1993), with between half and three quarters of children typically exhibiting signs of emotional or behavioral difficulties. Children in foster care also have been found to consume disproportionate amounts of public mental health dollars (Halfon, Berkowitz, & Klee, 1992; Harman, Childs, & Kelleher, 2000). Although there is evidence to suggest that foster care exerts some protective influences for children (Horwitz, Balestracci, & Simms, 2001; Taussig, Clyman, & Landsverk, 2001), it also is the case that children who have been in foster care are likely to continue to experience adjustment problems as they age into adulthood (Courtney, Piliavin, Grogan-Kaylor, & Nesmith, 2001). For the large number of children who come into contact with the child welfare system but who are not removed from their homes, much less is known about service needs and access to care. Similarly, when children exit the system by adoption, the child welfare system has little knowledge about their development and well-being. It is clear, however, that the needs of these children and families are complex, and access to and utilization of mental health services must be a central component of comprehensive and effective services to the child welfare population.

Child welfare services represent a complex set of policies, regulations, and service initiatives at the federal, state, and local levels. It has been argued that child protection has dominated child welfare services over the past few decades, to the exclusion of more broadly defined efforts targeted toward the well-being of the children and families who are served in the system (American Public Human Services Association, 2001). Nonetheless, the current child welfare system offers a continuum of services, including investigation and screening of child maltreatment reports, supportive and treatment services for maltreating and at-risk families, and temporary or permanent placement of a child into an alternate home or other setting.

FEDERAL POLICY INITIATIVES

Child welfare services are primarily the responsibility of the states (and in some cases, the counties), which have considerable power and authority in defining who is eligible for services and how services are to be provided. State policy development is, however, an interactive process that is shaped not only by the needs and values of the local population and the political forces in the state but also by federal legislation, regulation, resources, and incentives. Judicial actions, community-level efforts, and activities by advocacy groups and charitable organizations also influence how state policy is formulated. Moreover, child welfare policy and other child services policy may evolve along different lines, in response to perceived needs of the populations to be served. The following sections outline some of the major legislative and policy initiatives that have had widespread effects on child welfare policy and practice, highlighting areas where conditions are favorable for building relationships between the child welfare and mental health systems (see also Table 1).

Federal programs provide major sources of revenue for state and local child welfare services, and much of the practice at state and community levels is shaped by the need to comply with legislation and regulations that govern the use of federal funds. In this section, we discuss the major federal initiatives that have broadly influenced child welfare policy and practice and that have stimulated new approaches to child welfare service provision, with particular emphasis on those provisions that have implications for providing mental health services to child welfare clients.

The Adoption and Safe Families Act

Passed by Congress in 1997, the Adoption and Safe Families Act (ASFA) provides an overarching framework for child welfare policy and practice on a national scale, and it clearly sets out "safety, permanence, and well-being" for children as the goals of child welfare services. Shortened timeframes for making decisions about permanent homes for children in foster care ("permanence") are a key feature of ASFA and have resulted from concerns about reports of children spending indefinite lengths of time in foster care. Although "reasonable efforts" must be made to reunify families before parental rights can be terminated, judicial "permanency hearings" no later than 12 …