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Lack of mental health treatment resources can land children in NC’s troubled child welfare system

 A small child holds the hand of a person wearing jeans. The child is wearing a red hat.
Daniel Rothamel
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Flickr creative commons

In March 2022, John called the police to his home in Mecklenburg County because his 16-year-old son Paul was experiencing a violent behavioral health episode.

John and his wife began fostering Paul and his two younger siblings when Paul was 12 and later adopted all three children. John said child welfare services had been involved in Paul’s life from a young age, and the boy had several behavioral health diagnoses, including ADHD, a disruptive behavior disorder, and an attachment disorder. A child with an attachment disorder struggles to form healthy relationships, and they can have trouble regulating their emotions.

“His behavioral issues became apparent really quick, but we were trying to commit to taking care of him and loving him and keeping the kids together,” John said.

EDITOR’S NOTE: Due to stigma attached to mental illness, this article assigns the pseudonym Paul to an adolescent who has experienced psychiatric hospitalization. His father is identified by his first name only. NC Health News verified their identities and reviewed relevant medical records with the father’s permission.

These violent episodes were not new for Paul. When they happened, John said Paul would scream and throw things, sometimes for more than an hour. No one could calm him down. That March day also wasn’t the first time John had called the police to help with his son. Two years earlier, John said he had to physically restrain his then 14-year-old son when he tried to attack other family members.

After that, John remembers thinking, “If this happens again, we’ve got to find somewhere else for him to live — because we have two other kids… And if this keeps happening, it’s obvious that whatever we’re doing with [Paul] isn’t what he needs, like he needs more help than we can provide.”

At 16 years old, Paul is now over 6 feet tall and 200 pounds, and John said he can no longer intervene. John also says that Paul started using opioid pills and smoking marijuana, which John believes has negatively affected his son’s behavior. So this time when the police came, the parents asked that their son be taken to Atrium Behavioral Health in downtown Charlotte.

“We don’t feel safe. We don’t know what to do. We really need treatment for him. Please help us,” John remembers telling hospital staff as he explained the violent episodes at home.

But Paul told the hospital staff that he was fine and said he didn’t know why he was there, John said, adding that Paul has learned what to say to get out of situations. The next day, John said hospital staff called and said that Paul was ready to be discharged and he needed to come pick up his son.

John told the staff no. He insisted they find a psychiatric treatment facility for Paul. He reiterated that he didn’t feel his family would be safe if Paul came home without some kind of treatment.

“A different person from the hospital was calling me every day, like, very angry, saying ‘I can’t believe that you would leave your kid here. You need to come get him,’” John recalled.

When John refused to pick Paul up from the hospital, he said that hospital staff threatened to call the county department of social services and file a child abandonment case. A few days later, someone from the county department showed up at John’s door.

There have been stories like John and Paul’s playing out across the state for some time, child welfare advocates say. A lack of outpatient mental health treatment options and services for children with complex behavioral health issues puts families and hospital emergency departments in a hard spot when it comes to finding care for these kids.

Lack of treatment options

In recent years, more people have sought mental health care, particularly in the wake of the pandemic. For many in crisis, the first stop is in their local emergency room.

“Because of a lack of resources outside of the walls of our hospitals, behavioral health hospitals and emergency rooms are out of space — to the point of it being a crisis,” an Atrium Health spokesperson told NC Health News in an emailed statement. “Too often, behavioral health patients are ready to be discharged — only to have nowhere to go, and hospitals are forced to house them until a bed opens in a residential type facility or a parent or guardian picks them up.

“There are rare instances when, as a last resort, we need to engage the … social services to intervene to help connect families with social and community resources. We recognize this may create challenges for some families, but it is a necessary step in some cases to ensure those patients in immediate need have support in accessing resources and services,” Atrium’s spokesperson wrote.

Hospital staff being left with no other option but to call their county social services when a child needs help is “an indictment” of North Carolina’s mental health system, said Corye Dunn, an attorney and the director of public policy with Disability Rights NC.

“It’s not because their needs are intractable but because our system is not set up to meet those needs,” she said. “Then it creates this adversarial relationship, where the parents don’t trust the care providers and the care providers don’t trust the parents. Parents are painted as uncooperative or undermining the care planning because they insist that the child’s care meets a reasonable standard.”

Though it’s difficult to quantify just how often this scenario occurs, Dunn said it’s a problem across the state in rural and urban areas. She added that people often hear about the issue of children in mental health crises and think the solution is to create more inpatient psychiatric beds.

“But the problem is we don’t have any supports — even when there is inpatient treatment offered,” Dunn explained. “The lack of community-based support is...allowing kids to go into crisis because they’re not getting what they need at a lower level of intensity. And then on top of that, the lack of community-based services means that it’s very difficult to discharge from an emergency department or a [psychiatric residential treatment facility] or a psychiatric hospital because there’s not an adequate community-based safety net for kids or adults.”

Dunn said that the state’s six LME-MCOs are the groups responsible for managing behavioral health care for those with the most complex needs and for ensuring that there is an adequate network of services available.

“I think we have to ask ourselves why those services don’t exist,” Dunn said.

Why hospitals refer to social services

When a hospital calls a department of social services, they are making a dependency referral as defined under North Carolina statute 7B-101, explained Sen. Sydney Batch (D-Raleigh), who is a family law attorney and child welfare advocate in her work outside in the state legislature. The hospital is telling social services that a parent or guardian is unable to take care of their child and does not have an alternative child care setting.

Other scenarios where this statute could be applied is if a parent was in a coma, entering substance use treatment or a psychiatric hospital and no relative was available to take the child, Batch said.

“So the key with dependency is the parent is unable to care for the child,” Batch said. “And in this situation, as you can imagine, the parent is unable. They can’t control the behaviors. There are a lot of issues with regards to mental health, and a child needs a higher level of care than the parent can provide.”

Batch says she gets similar calls from clients in these situations. She had a client tell her that their child tried to stab them, and now they sleep with a lock on their door and they don’t feel their other children are safe. Meanwhile, the hospital emergency department said that the child was “medically ready” to be discharged.

“I do have empathy for the hospitals because they are now the dumping ground of the mental health system,” Batch said.

It can be particularly challenging if a parent has private insurance. Private payers don’t cover in-home intensive services or therapeutic placements at the same level as Medicaid, Batch explained. Medicaid often provides more services and better coverage for children with behavioral health needs. Every child that enters the foster care system automatically receives Medicaid coverage, which could open up more placement and treatment options.

“And so the only choice that the hospital frankly has at that point is to call social services to say, parents can’t pick the kid up and you’re going to have to intervene,” Batch said. “And at that point, DSS should call the parents and try to come up with some alternatives to help the parents navigate a very complicated and broken siloed mental health system that we have in North Carolina.”

Foster families need more support

But even with Medicaid, Paul lacked the appropriate support until he went into crisis and his father fought for help.

John said Paul had intensive in-home mental health services during the pandemic, but because of social distancing protocols, he claimed the workers never came to their home and only met with Paul over Zoom. John said he always felt like they were just going through the motions and checking off boxes in their care of Paul.

Later, when John discovered Paul was using substances, he tried to get his son help. But unless Paul was actively intoxicated, failed a drug test, or was in crisis, the local substance use programs said they couldn’t help, John recalled. He said everywhere he called suggested the same handful of programs that were always full, and no one had any new ideas.

Then, as John argued with Atrium’s staff about finding long-term treatment for his son, he said he started calling private and public facilities looking for a treatment placement for Paul. Some of the private facilities were “eye wateringly” expensive, John said, with price tags of $15,000 a month out of pocket.

John held off on picking up Paul from Atrium for two weeks until a placement was found at an in-state psychiatric residential treatment facility. Now, more than a year later, Paul is living in an intensive group home, and John said his son is doing really well. There’s a possibility that he’ll even be able to live at home again soon.

The county department of social services did open a case. In the family’s paperwork, it says the reason was because the parents refused to pick up their son from Atrium Behavioral Health. The social worker’s written plan for the family was simply to keep in touch with the hospital and the department of social services and follow medical recommendations for Paul’s treatment.

“It’s very toothless. The hospital and DSS makes these threats towards you. The hospital says, ‘We’re calling DSS.’ And if you’ve never dealt with that before, that sounds really bad. And then you find out later that’s the only play they’ve got,” John said. “Then when DSS gets involved and finds out that you’re a responsible parent trying to get help for your kid, they back off.”

Disability Rights’ Dunn argues that the community has a legal obligation to provide support for children with prior social services involvement — even long after they are adopted.

“I think there is this optimistic notion that if we just recruit more foster parents or adoptive parents, more families to support children, that that is enough. That is important, but it is absolutely not enough,” she said. “We should expect that kids in general — and particularly kids with DSS involvement — may need treatment on an episodic or ongoing basis. So waiting for them to go into crisis as a way to decide how you’re going to hand out services is cruel.”

Attention from state lawmakers

Problems in the foster care system have garnered gut wrenching news stories, including reports about large numbers of children in custody with mental health issues, children boarding for weeks in emergency departments, sleeping in social service offices and being sent out of state for treatment.

North Carolina is one of only nine states in the country that has a child welfare system that’s directed at the state level, but administered by county governments. Of those nine states, North Carolina had the lowest per child investment across all public funding sources in that system, according to a report generated by DHHS in 2018.

 bar graph shows per child investment in child welfare for nine states, with North Carolina's spending ranking at the bottom.
NC DHHS
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Child Trends “Child Welfare Financing Survey SFY2018”
Annual per child investment in child welfare across peers (states with state-led county-administered child welfare systems).

“There is an urgent crisis of children with complex behavioral needs who come into the care of child welfare services. Each week, at least 75 of these children are sleeping in child welfare offices or emergency rooms because there is nowhere else for them to go,” said a DHHS spokesperson in an email to NC Health News.

“North Carolina has long underfunded its child welfare system, ranking last in per-child funding among peer states with decentralized child welfare systems,” the statement continued. “NCDHHS continues to work with lawmakers to make significant, critical investments in the child welfare system that are as urgently needed as policy improvements. NCDHHS is grateful for NCGA’s $5.7M annual investment in kinship subsidies to ensure more children move into a safe and stable home, and we know that greater investment is needed to address our full system.

Departmental leaders have asked for a total of $47.5M to strengthen specialized behavioral health treatment options in community, residential and inpatient settings for kids. The department asked for $20 million to support child welfare and behavioral health workers across the state and another $12.5 million for services to foster care families.

State lawmakers included several provisions in their latest state budget proposals to help address some of these problems, but not at the level that’s been requested by DHHS.

The Senate budget proposal includes $15 million in additional funds to support new and enhanced Medicaid services for children receiving foster care services. The Senate budget includes the creation of a work group to identify “innovative Medicaid service options” to address gaps in care for foster youth. Work group tasks include:

  • Identifying models of community evidence-based practices that support a foster child returning to the child’s family. 
  • Diverting higher-level foster care placements.
  • Identifying short-term residential treatment options to serve children with high needs, which could divert a child away from a psychiatric facility placement. 

The Senate budget proposal also orders the state health department to issue a request for proposals for a single statewide specialty insurance plan for children in the foster care system and their families. A bill that would create this single statewide health plan for children and families involved in the foster care system has been discussed for years. This year’s bill has already passed the North Carolina Senate, but it has been at a halt in the House of Representatives since early March.

The Senate proposal includes a provision of $750,000 in fiscal year 2023-24 to fund the development and implementation of a trauma-informed, standardized assessment for every child entering the foster care system. This screening is intended to assess the trauma experienced by children in the child welfare system. The Senate proposal would require the assessment to be completed within 10 working days of the referral for children ages 4-17. Currently, there is no standard assessment for kids entering foster care.

Meanwhile, both chambers propose that foster care funds be used to provide financial support to kids who are in a permanent family placement, who are eligible for legal guardianship, or who are otherwise unlikely to achieve permanency.

The House budget proposal would appropriate $2 million in recurring money for the foster care permanency initiative and add $5.1 million in recurring dollars in fiscal year 2023-24 and $10.2 million in recurring funding in fiscal year 2024-25 to support increased payments to relatives caring for a child in foster care and to support child welfare staffing and administrative costs.

State lawmakers are hashing out the differences between their budget proposals now, and in the coming weeks they will share their consensus budget plan with the public.

This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.