The U.S. child welfare system: a de facto public behavioral health care system.

At a recent child protection hearing, a presiding judge was heard to query “What is a child with emotional problems doing in foster care?” The implication of this question was the judge’s underlying belief that if a child who was a ward of the state had an emotional or behavioral disorder, then surely he or she should be in specialized foster care, residential treatment, or a psychiatric hospital. Although for many who have worked in child welfare setting, this question reveals a startling level of naivete on the part of the judge, this quote eloquently illustrates the importance of the work published by Barbara Burns and her colleagues in this issue of the Journal. If, in fact, half of the children in the child welfare system have clinically significant emotional or behavioral problems, then the child welfare system is a de facto behavioral health care system. Recognition of this reality by all child welfare system partners is the first step to addressing the complex needs of involved youths. Considering current system funding levels, there is absolutely no way any state could afford to address these needs by placing half of their children in specialty treatment settings. Unfortunately, as Burns et al. demonstrate and the judge’s comments might suggest, most child welfare systems do not have sufficient community-based services in place. The result is that many children’s behavioral health needs do not get addressed until they are serious enough to warrant residential or hospital treatment. We know the solution. The system of care philosophy with child-serving systems is the consensus approach (Stroul and Freidman, 1996). Only by carefully building an integrated system in which behavioral health needs are identified and addressed throughout the child welfare system can these frequent and complex needs be met with any consistency (Lyons, 2004). Clearly the implication of these findings is that the child welfare system has a significant responsibility to detect and treat emotional and behavioral problems and disorders as a routine part of involvement with child protective services and out-of-home care. Given the very high risk of mental health needs in this population, preventing the development of these psychiatric disorders among youth who do not currently manifest symptoms also should be a priority. Such a broad responsibility should not been seen as solely an issue of detection and referral to specialty mental health treatment. Rather, all aspects of the child welfare system, from the strategies used to determine whether child abuse or neglect is founded to the training of foster parents, should be planned within the context of designing systems that are responsive to these emotional and behavioral needs. For example, foster home instability has been linked to the development of behavioral problems (e.g., Lawrence, 2002; Orme and Buehler, 2001). Increasing the stability of foster home placements and not requiring a shift in foster parents with any shift in the intensity of services would be a recommended strategy. As an example, Philadelphia’s Department of Human Services has embarked on a process of training all foster parents to be treatment foster parents. The only thing that changes when a child become eligible for treatment foster care is the rate that the foster care agency is paid to support more intensive services. The foster parents continue to get an enhanced rate because of their training regardless of the current status of the child living in their home. Accepted March 9, 2004. From the Mental Health Services and Policy Program, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago. Correspondence to Dr. Lyons, Mental Health Services and Policy Program, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 710 N. Lake Shore Drive, Abbott 1206, Chicago, IL 60611; e-mail: JSL329@northwestern.edu. 0890-8567/04/4308–0971©2004 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000127575.23736.90