Chapter 4. What’s Working in Mental Health Care? Leveraging Opportunities to Develop More Effective Services for Children in Foster Care

Sonya J. Leathers, Ph.D University of Illinois at Chicago

Abstract

Children and adolescents in out-of-home care are disproportionately affected by emotional and behavior problems. Despite the positive effects of evidence-based mental health interventions, the availability of empirically-supported interventions is low. Providing effective treatments to children in foster care is critical to improve children’s quality of life and reduce placement disruptions and prolonged stays in foster care. Following a review of the mental health issues experienced by children in care and effective interventions, this chapter discusses the specific supports and deterrents to increasing access to effective services within child welfare systems. Developing effective mental health services will require a range of strategies to counter barriers and increase accessibility. Strategies discussed in this chapter are drawn from initiatives currently underway in the U.S. Examples highlight use of collaborative partnerships and grants to support statewide initiatives to increase access to evidence-based interventions; use of intervention tracking and cost-benefit analysis data to support implementation and sustained use of effective practices; development of more accessible interventions for children in foster care; and leveraging federal and state resources to support activities to build more effective, sustained mental health services.

Introduction

Increasing access to effective mental health interventions for children and adolescents in foster care is critical given their vulnerability to a wide range of difficulties in adulthood (Courtney et al., 2010). Contact with the child welfare system provides the opportunity to support positive adult outcomes with comprehensive services throughout childhood, but effective, accessible services are needed to meet this goal. Recognition of the personal and societal burden of mental health disorders has supported considerable investment in the development of effective mental health interventions for a wide range of childhood mental health issues in the general population (Kazdin & Weisz, 2017). Although evidence-based interventions developed for children in foster care are more limited, effective interventions for foster children include interventions for both trauma symptoms (Cohen, Deblinger, & Mannarino, 2018) and disruptive behavior (Chamberlain et al., 2008; Fisher et al., 2006; Kim & Leve, 2011).

Despite the positive effects of evidence-based interventions relative to services as usual, the availability of many evidence-based interventions is low (Garland et al., 2010; Herschell et al., 2020; Kerns et al., 2014). The low provision of evidence-based services is thought to account for the lack of an association between receipt of mental health services and reduced behavior problems over time for children in foster care (Bellamy et al., 2010). In addition, failing to provide evidence-based treatments to children in foster care potentially contributes to overuse of psychotropic medication (Crystal et al., 2016) and placement disruptions (Fisher et al., 2011), which are associated with negative outcomes such as delinquency and additional moves (Leathers, 2006; Ryan & Testa, 2005). For children who remain in their homes after an abuse allegation, failing to provide evidence-based parenting interventions also increases chances for ongoing difficulties with parenting and higher child externalizing problems (Sanders at al., 2014), increasing risk for entry into foster care.

Building an effective system of care will require a sustained investment by federal and state governments. Understanding the types of evidence-based interventions that could be provided and the barriers that must be overcome to establish regular use of these interventions is a first step in this process. Following a review of the range of mental health issues children in care experience, this chapter provides a brief overview of a straightforward process to identify effective mental health interventions for children and youth [1]in foster care. Child welfare specific supports and deterrents to increasing access to effective services are then outlined. Developing effective mental health services will require a range of strategies to counter barriers and increase accessibility. While many different approaches could support this effort, strategies discussed in this chapter build on initiatives currently underway in the U.S., including use of collaborative partnerships and grants to support statewide initiatives to increase access to evidence-based interventions; use of intervention tracking and cost-benefit analysis data to support implementation and sustained use of effective practices; development of more accessible interventions for children in foster care; and leveraging federal and state resources to extend current monitoring and assessment activities to encourage activities to build more effective mental health services.

Mental Health Needs of Children and Youth in Care

Children and youth in foster care have had a range of adverse experiences that have an enduring effect on their development and emotional and behavioral well-being. Although many of these experiences mirror those in the general population, those contributing to complex trauma experiences, such as parental loss, abuse, parental substance abuse, and violence exposure, occur at a much higher rate among children with histories of foster care (Turney & Wildeman, 2017). Given this intensity of adverse experiences, it is not surprising that studies administering behavior problem checklists find that a high percentage of children—in one nationally representative study, 63% in non-relative care and 39% in kinship care—have clinically significant emotional and behavioral problems, with higher rates reported for adolescents than children (Burns et al., 2004). Another national study suggests that ADHD diagnoses are most common in foster care, affecting 22% of children (Turney & Wildeman, 2016). In this study, caregivers also frequently reported internalizing disorders (anxiety and depression, 14% combined) and behavioral disorders (17.5%). These rates are significantly higher than reported in the general population (3%, 2%, and 3% for anxiety, depression, and behavior disorders, respectively). Similarly, other studies in foster care report high rates of attention deficit hyperactivity disorder (ADHD; 15-20%); conduct disorder (8-20%); and oppositional defiant disorder (8-30%) (dosReis et al., 2001; McMillen et al., 2005; Garland et al., 2001; White et al., 2007). Among youth, particularly high rates of depression (18%) and PTSD (8%) in the past year have been documented (McMillen et al., 2005). In sum, these studies point to elevated symptoms across a range of areas, including both internalizing disorders, disruptive behavior disorders, ADHD, and PTSD in older youth. Few studies have examined rates of attachment disorders, but in one study focused on children with a history of moves, 4.9% of foster parents reported diagnoses of reactive attachment disorder (Leathers et al., 2021), suggesting much higher rates than in the general population, where this disorder is very rare. 

Understanding the level of needs and range of diagnoses among children in foster care is an important starting point, as specific evidence-based interventions typically address specific types of needs (e.g., behavioral parenting training for disruptive behavior). However, it cannot be assumed that appropriate treatment only requires matching the diagnoses of a child in foster care with an evidence-based intervention developed in the general population. The complexity and range of maltreatment and other adverse experiences associated with child welfare involvement profoundly affects many children’s mental health. The etiology and presentation of mental health disorders is likely to vary in child welfare settings given these experiences. High rates of disruptive behavior disorders and ADHD, for example, are likely to be related to different etiological factors that potentially influence treatment effectiveness. Trauma symptoms could overlap with ADHD symptoms related to attention and focus leading to misdiagnosis (Szymanski et al., 2011). Early adverse caregiving experiences also result in neurological differences that increase risk for executive functioning deficits as well as a range of behavior problems and relational difficulties (Bunea et al., 2017; Sandtorv et al., 2018). These differences could result in greater severity or variation in symptoms and require adaptations to treatment models developed in the general population for effective treatment.

Evidence-Based Mental Health Interventions for Children in Foster Care

Evidence-based interventions for children in foster care can be classified into two types: those that have been developed primarily for high-risk children and adolescents in the general population and those developed specifically for children and adolescents in care. Mental health interventions developed specifically for children in care are more likely to attempt to support other positive outcomes that are specific to children in care, such as placement stability. These programs also recognize the unique family structures of children in care, with some, such as treatment foster care models, targeting both foster-parent-child and parent-child interactions to support positive care and reduce behavior problems (Fisher et al., 2006). Unfortunately, these interventions are frequently more expensive to implement and maintain, resulting in few established programs throughout the U.S. and low access.

In contrast, interventions initially developed in the general population that are classified as “evidence-based” are more likely to be available in the community-based mental health service systems that will treat many children in care. These interventions can be classified as effective for children in care based on the results of subsequent studies that indicate positive effects of the intervention with samples of children in care, or in some cases, mixed population studies that include some children in care. Both interventions developed specifically for child welfare and those developed in the general population are important components of an effective mental health service system given the relative advantages of greater access versus greater specificity that might be needed for some children and adolescents in care.

A recommended source to identify evidence-based interventions for use in child welfare is the California Evidence-Based Clearinghouse for Child Welfare (CEBC; see https://www.cebc4cw.org), an online resource that categorizes the level of evidence for intervention models across a range of areas including child and adolescent mental health disorders. In additional to a rating for level of evidence ranging from 1 (supported practice) to 5 (concerning or potentially harmful practice), the site provides a separate rating for level of relevance for child welfare involved children and families. These classifications include high, medium, and low, with a rating of “high” indicating that the intervention was designed for or is commonly used with child welfare-involved families and young people. A rating of “medium” indicates that it was designed for use with clients who are similar to child welfare populations.[2]

At the time this chapter was written, for example, the site indicated that three interventions had sufficient evidence to be classified as “supported practices” for trauma symptoms [3], but just one, trauma-focused cognitive behavioral therapy, also has “high” relevance to child welfare[4]. For disruptive behavior problems, the CEBC indicates that many different behavioral interventions have sufficient evidence to be classified as supported practices, with 10 different programs listed. However, from this broad list, just one, GenerationPMTO (previously called Parent Management Training - the Oregon Model) was also categorized as having high relevance to child welfare. Therapeutic foster care programs are listed under “Resource Parent Programs,” with just the Treatment Foster Care Oregon program for adolescents having the highest ratings for effectiveness and relevance. Notably, all of the practice models rated most effective are cognitive behavioral or behavioral interventions with a focus on increasing caregivers’ positive reinforcement of desired behaviors, reducing harsh punishment, and providing consistent structure to children. All also involve extensive caregiver involvement, with trauma-focused cognitive-behavioral therapy (TF-CBT) involving caregivers and children separately in every session and the interventions for disruptive behavior primarily involving work with caregivers, who learn to support positive behavior through their interactions with the child at home.

The CEBC ratings are updated over time, and in some cases a lag could occur in the time between when a study is published and its findings are incorporated in the ratings. Prior to selecting an intervention for implementation in an agency, recent research on the intervention should be accessed. For example, recent controlled research of one the interventions for disruptive behavior in younger children, Parent Child Interaction Therapy (PCIT), involved adapting the intervention for use with foster parents and found positive effects on disruptive behavior (Mersky et al., 2020), potentially supporting a higher child welfare relevance rating. Exploration of ratings in the CEBC also reveals some areas in which few evidence-based interventions have been developed. In particular, despite the impact of attachment-related issues for children who have experienced complex trauma, there are no practices classified as supported or well-supported to treat attachment issues.

This overview of evidence-based mental health interventions with high relevance to children and youth in care suggests a fairly straightforward approach to building an effective mental health service system for children in care. Interventions can be selected based on the most relevant research. The CEBC website provides contact information to access training in each intervention and an overview of what is involved, and following training, individual agencies or localities should be able to provide the intervention. There is a strong rationale to begin with building capacity to treat trauma symptoms and disruptive behavior problems, given their impact on multiple aspects of functioning and placement stability. Trauma interventions are effective in treating trauma symptoms and other related internalizing symptoms (Morina et al., 2016) and effective interventions are accessible. Unfortunately, implementing and sustaining evidence-based models is complicated by a range of challenges. Although child welfare supports greater access to mental health treatment than in the general population, these barriers will need to be recognized and addressed to support more effective mental health services.

Child Welfare as a Context for Mental Health Intervention: Supports and Deterrents

The child welfare system provides many structural supports to increase access to mental health services. Children in foster care are embedded in service networks with assigned caseworkers whose practices are overseen by agencies that are following state and federal practice and policy guidelines. In an ideal service system, caseworkers, agencies, and the courts would provide important support and oversight of mental health treatment by providing referrals, transportation, and enforcement of service plans. The Administration for Children and Families as well as other federal agencies provide opportunities to support implementation of interventions by monitoring the extent states meet mental health needs in Child and Family Services Reviews and providing financial support for service innovations through IV-E demonstration waivers, cooperative agreements, and discretionary grants (for a discussion of these initiatives, see Ryan et al., 2006; Testa et al., 2019). The National Child Traumatic Stress Network (NCTSN) serves as a state resource and conduit for federal funds to support greater implementation of trauma-informed service models and evidence-based trauma treatments for child welfare involved children and families. Federal policies also influence service system development. For example, a federal initiative now reviews how states monitor use of psychotropic medications (Congressional Research Service, 2017). This has supported recent reductions in use of multiple psychotropic medications and off-label use of antipsychotics and increased pressure to provide more psychosocial interventions for disruptive behavior. External pressure to enhance mental health services for foster children has also occurred through class-action lawsuits and resulting consent decrees (Center for the Study of Social Policy, 2012) as well as policy statements made by professional groups[5].

These initiatives, policies, and consent decrees increase incentives for states and county-administered child welfare systems to develop more effective mental health service systems, and strong progress can be seen in some areas. Mental health or trauma screening processes of some type for children entering foster care are established in nearly every state (Hayek et al., 2014; Pullmann et al., 2018), consistent with federal guidelines[6]. Despite variations in implementation and use of validated screening tools, the majority of children (50-70%) who are indicated to have a significant mental health need receive some type of mental health service while in foster care (Petrenko et al., 2011; Pullmann et al., 2018; Tarren-Sweeney, 2010). Data also indicate that mental health services are allocated to those with more significant symptoms (Fong et al., 2018). Although optimism about these service shifts is tempered by indications of racial disparities in service referrals (Garcia et al., 2013; Kim & Garcia, 2016) and the lack of follow-through on referrals to provide services for many children (Mersky et al., 2020; Petrenko et al., 2011), screening provides a potentially strong conduit for service referrals.

Ideally, positive mental health screenings should trigger a full assessment of children identified as having a possible need for services (Raghavan et al., 2010). This diagnostic assessment would result in identification and use of an evidence-based intervention to address the child’s needs. However, while progress has occurred in use of screening, progress in making appropriate referrals and provision of evidence-based services has been slower. Despite the development of effective interventions for children in care, the majority of children in foster care receive few mental health sessions (Pullmann et al., 2018) and services that do not have clear evidence for effectiveness (Fitzgerald et al., 2015; Leathers et al., 2021). For example, in a study of children with a history of moves, most children with behavior problems were receiving therapy, but this therapy did not include providing foster parents with training, support, and resources to address behavior issues for three-quarters of those in therapy (Leathers et al., 2021). This is of concern given that foster parents frequently identified behavior problems as the reason for services, and these are key components in evidence-based practice models to treat behavior problems.

The slow progress in implementing evidence-based interventions can be in part attributed to all the disincentives noted in the broader implementation literature, including the cost and time investment to implement interventions, perceptions of the intervention, staff turnover, and organizational climate and culture (Glisson & Green, 2011; Golden, 2009; Palinkas et al., 2017; Wulczyn et al., 2008). These are powerful disincentives for implementation, with cost constraints cited by over 85% of mental health agency administrators as a barrier to adopting evidence-based practices (Palinkas et al., 2017). This included both the cost of lost staff billing hours while staff complete training (54% citing as a barrier) and the initial expense of the intervention (47%). Disincentives that are unique to child welfare systems pose additional challenges, including the level of staff turnover, high caseloads in some areas, and the high-stress, crisis nature of child welfare work (Glisson & Green, 2011). These characteristics of child welfare practice pose barriers to both initiating and maintaining evidence-based interventions. Mental health services for foster children are typically funded through Medicaid as fee-for-service with low reimbursement rates or managed care contracts. Just as in the general population, these rates are not typically sufficient for agencies to initiate and sustain evidence-based interventions, which can be expensive to implement due to initial training costs, consultation with certified trainers on a specific number of cases, and specialized supervision that specifically addresses adherence to the intervention model (Edmunds, Beidas, & Kendall, 2013). The primary goal of child welfare practice is to ensure child safety, and in financially-strapped services systems, services focused on child protection and monitoring are prioritized.

The population dynamics in foster care also potentially support a “watch and wait” approach to implementing evidence-based practices and providing more services. Nearly half of children in foster care exit within a year, and just 28% will be in care two years or longer (Child Welfare Information Gateway, 2020). Separation from caregivers and placement moves are negative events that exacerbate or create emotional and behavioral reactions, and adjustment to foster care over time reduces symptoms for some children. Caseworkers, who are often overloaded with their current tasks related to visiting children, documentation, and court attendance, also have incentives to avoid the additional tasks associated with a child’s attendance at therapy by minimizing reports of child behavior problems with foster parents and in ongoing screening assessments.

In summary, despite the development of strong interventions for trauma symptoms, behavior problems, and therapeutic foster care and factors potentially supporting the provision of mental health services within child welfare systems, a range of factors also serve as disincentives to provide more effective services for foster children. From a public health and preventative perspective, failing to provide services is a lost opportunity to intervene with a wider range of children whose life chances could be improved by identification and treatment of the full range of their needs. To overcome these barriers, increased support and incentives are needed to initiate and sustain evidence-based interventions. A vast literature has described both the barriers to implementation of evidence-based practices and implementation frameworks that outline a broad range of targets in implementation efforts (Tabak et al., 2012). The purpose of this chapter is not to comprehensively apply an implementation framework, but instead to propose approaches to support increased use of effective models by leveraging processes that have had some success in either child welfare services or broader mental health service systems. These approaches primarily seek to influence factors in “outer context” (e.g., leadership, policies and federal initiatives) and “bridging factors” (e.g., collaborative partnerships) but do not address many factors in the “inner context” (e.g. organizational characteristics and staffing) that would need to addressed in an individual implementation plan. Implementation of services in any given region or agency will require both an increase in the incentives and availability of effective interventions and a plan to understand and address the barriers that are specific to that region or agency.

The strategies discussed in the next section include use of collaborative partnerships and grants to support statewide initiatives to increase access to evidence-based interventions; use of intervention tracking and cost-benefit analysis data to support implementation and sustained use of effective practices; development of more accessible interventions for children in care; and leveraging federal and state resources to extend current monitoring and assessment activities to encourage activities to build more effect mental health services. For each strategy, examples are provided from recent initiatives in the U.S. Although the examples presented are just a few of the many relevant projects that are shifting practice, they suggest how several strategies might be synchronized to increase use of evidence-based practices.  

Increasing Access to Evidence-Based Interventions Through Statewide or Locality-based Initiatives to Initiate and Sustain Evidence-Based Practices

Children in foster care need greater access to evidence-based practices specifically developed for children in care, such as therapeutic foster care, but also evidence-based practices that have been developed for children in the general population, such as TF-CBT and behavioral interventions. These services are frequently provided to children in care through community-based mental health clinics and, for children who have had a recent abuse allegation, child advocacy centers. Initiatives to implement these treatments in settings serving Medicaid-insured clients have the potential to greatly increase access to more effective care to children in foster care as well as families at risk for child welfare involvement. A statewide effort in Connecticut to implement and sustain evidence-based practices highlights some of the characteristics of a successful initiative. Although this initiative has targeted services provided by community mental health services, it has significantly increased access to services for child welfare-involved children and families. Twenty-five percent of children served by partnering agencies involved in the initiative have child welfare involvement, and multiple projects have focused specifically on treatment of trauma in children and families.

Including Key Partners in Collaborative Approach to Services Development

Connecticut’s initiative is characterized by a longstanding partnership between the state agency overseeing social services across child welfare, mental health, and juvenile justice (Connecticut Department of Children and Families [DCF]); a non-profit child services and policy center (Child Health and Development Institute [CHDI]), which has provided coordination of training; a university partner (Yale University), which has provided consultation and evaluation; and community agencies across Connecticut. This partnership provides key expertise in evidence-based practices and effective training models, and also support for coordination of trainings and data collection. The involvement of both child welfare and children’s mental health services in the initiative and the administrative linkage between the agencies strengthens leverage to support the development of mental health services for children with child welfare involvement.

To date, Connecticut’s most significant practice advancement with high relevance to children in foster care is the establishment of TF-CBT as a widely available treatment. A collaboration between CHDI and DCF beginning in 2007 has provided ongoing, extensive support for statewide dissemination of TF-CBT in community mental health agencies. Using the Institute for Healthcare Improvement’s Breakthrough Series Collaborative quality improvement model from 2006-10, DCF funding supported training of staff from 16 agencies through the Connecticut TF-CBT Learning Collaborative (Randall et al., 2019). This work continued with a second federally-funded multi-component initiative in 2011. Completed in 2016, this initiative included statewide trauma training using NCTSN’s Child Welfare Trauma Training Toolkit, trauma screening for children aged 6 and entering foster care, and support for agency training that included more than 600 clinicians in TF-CBT (Connell et al., 2019).  

A critical factor in the successful implementation of TF-CBT statewide is CHDI’s ongoing role as a coordinating center for training, consultation, and credentialing providers in the model throughout the state (Randall et al., 2019). In fiscal year 2019, the center reported that 56 clinical staff were trained for the first time in TF-CBT and 1,536 children received TF-CBT, including 553 children with child welfare involvement. In this period, children were reported to have a 60% remission rate for both posttraumatic stress and depressive symptoms (Randall et al., 2019).  

External Funding Support for Implementation and Infrastructure Development.

Connecticut has addressed the barriers posed by the financial costs of implementation, particularly in the initial stages, by receiving funding for intervention dissemination initiatives through federal and state sources. In particular, the state’s initiatives have received significant funding from multiple large federal initiatives to support dissemination of trauma treatments through the Administration for Children and Families. The training coordination center, CHDI, also received funding in 2016 from the Substance Abuse and Mental Health Services Administration (SAMHSA) through NCTSN to support dissemination of trauma interventions. This grant was followed by additional funding for a Level 2 Treatment and Services Adaptation Center in 2020. The federal grants received by DCF and CHDI are competitive, requiring staff expertise in grant writing, evidence-based practices and dissemination models, and evaluation. The expertise of the state collaborative partners is likely to have been critical to the state’s success in obtaining continuous grant support throughout their efforts to support implementation of evidence-based practices.

System-Wide Tracking of Use of Components of Evidence-Based Models.

In collaboration with intervention developers, CHDI developed a statewide tracking system to support use of selected interventions (https://www.chdi.org/our-work/mental-health/evidence-based-practices/ebp-tracker/). This online measurement system, the Evidence-Based Practice Tracker, is used to track use of interventions including TF-CBT and the Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH-ADTC) and two school-based trauma interventions (Cognitive Behavioral Intervention for Trauma in Schools and Bounce Back). The system allows clinicians from 30 participating agencies to enter standardized assessments and components of the intervention completed all children they treat with one of these interventions. This provides an indication of fidelity, although self-reported, as well as children’s progress and outcomes over time. CHDI reports that the tracking system is currently used by over 30 agencies and more than 300 clinicians.

Agencies, clinicians, and CHDI can access this information to identify the extent of use of different practices and clinical outcomes. Statewide data indicates that a steady increase in the use of evidence-based interventions has occurred over the past 10 years and that outcomes for children receiving specific evidence-based interventions, particularly TF-CBT or MATCH, are more positive than those receiving services as usual (Lang, 2019). For 46,729 children who received treatment between 2013-17, problem severity scores decreased by 46%-76% (TF-CBT) and 68%-75% (MATCH) more that the decrease for children who received services as usual.

Connecticut’s initiative is described because of its scope and positive effects, but it is not unique. Other states and regions are currently using similar strategies to incrementally build effective service systems. For example, Mersky and colleagues (2020) report use of similar strategies in Wisconsin in a project targeting increased access to evidence-based interventions in two cities with funding from SAMHSA through NCTSN. This project involves a collaboration between a university partner, a hospital-based treatment center, the state child welfare agency, and the Wisconsin Office of Children’s Mental Health. Training will be provided to up to 150 mental health providers in three established, evidence-based interventions for younger children. Data from a controlled trial conducted as a part of this initiative indicate the effectiveness of PCIT when adapted for use with foster parents, providing support for its continued use.

Build Capacity to Track Use of Practices, Outcomes, and Use Cost-benefit Analysis to Support Use of Effective Models of Care

Connecticut’s development of a statewide practice tracker provides a mechanism to understand both use of evidence-based interventions and outcomes for children who complete different interventions over time. From outcome data collected by CDHI, the state is then able to estimate cost-savings over time based on the number of children receiving specific interventions using the Washington Policy Institute’s cost-benefit analysis of the interventions (https://www.chdi.org/ebt/). From their data collected on use of specific interventions, CHDI estimates long-term savings of $132 million since they have initiated tracking. A limitation of this analysis is that clinicians might over-report their use of evidence-based interventions and positive treatment outcomes given the use of the system to assess individual clinicians’ performance. If the initiative eventually affects practices throughout the entire state, changes in key metrics such as arrests, incarceration, and hospitalizations could also provide an indication of the benefits of implementing evidence-based interventions over time. For children in care, this data could also be linked with administrative placement data to identify associations between different services and reduced symptoms as well as other outcomes that are particularly relevant for children in care, such as placement stability and reductions in use of off-label and antipsychotic psychotropic medications. In addition, because the tracking system is not specific to children placed in foster care, the disincentives to provide services earlier in children’s placement trajectories potentially have less impact; earlier service provision provides the opportunity to prevent negative outcomes that would be tracked for children and youth during time in substitute care as well after substitute care.

Connecticut began with initiatives to provide training to support use of evidence-based interventions for children and then initiated tracking of services and outcomes through an online tracking platform, supporting continued use of the interventions by demonstrating the individual benefits to children, the relative use across different agencies, and the potential cost benefits. Other states have sought to increase use of evidence-based practices by developing statewide requirements for reporting practice components or outcomes in the process of Medicaid billing submissions. For example, Washington state began with legislation directing the state’s child-serving social service departments (including child welfare, mental health and juvenile justice) to increase investments in evidence-based practice and initiating use of reporting codes for specific evidence-based practices in Medicaid billing for mental health practices (see Walker et al., 2019). Agencies were not mandated to use evidence-based practices, to reduce the potential for “paper reporting” of services that do not correspond to actual practice.

Although the state’s early effort was unsuccessful, as would be expected given the lack of attention to the multiple factors that would inhibit adoption of new practices, after the state formed a partnership with the University of Washington’s Evidence-based Practice Institute, university partners describe their approach as a “key catalyst for turning legislative intent in to meaningful impact” supporting increased use of evidence-based practice (Walker et al., 2019). However, a limitation in this state’s approach is the absence of an initiative to support training in specific interventions due to the cost of these types of initiatives. Instead, the state has provided every agency with information about evidence-based practices in reporting guides that focus on the components of treatment corresponding to evidence-based practice for different areas. Submission of treatment and session notes as a part of billing and enhanced reimbursement for use of evidence-based components is expected to increase agency uptake of effective interventions and increase use by orienting practitioners and the agency to evidence-based practices, but additional research is needed to understand the degree to which this is occurring.

As Washington’s and Connecticut’s experiences demonstrate, reporting session content requires a significant effort to define practice components and provide agency trainings in use of the system. A cost-effective approach that also provides significant benefits is requiring outcome measurement as a component of billing or service documentation. For example, in Illinois, mental health Medicaid providers are required to use a standardized initial assessment measure and then to submit follow up data at three months. Because this requirement was implemented in conjunction with a state initiative involving agency training in three specific evidence-based interventions, the resulting data was used by university partners to estimate the effects of each of the interventions (see Starin et al., 2014). This produced valuable data as it indicated the positive effects of the training initiatives, with positive effects relative to services as usual occurring particularly for the training on behavioral parenting interventions, which were believed to be a more significant departure from usual practice than the CBT and MATCH interventions. Because the study was not randomized, the effects cannot be attributed to the training initiative, but the data are consistent with the hypothesis that training was associated with more effective services. These results provided support for continued efforts to train providers.

Although outcome data collected within child welfare systems does not have all the advantages of data collected across service systems, assessment and follow-up data collected within child welfare systems also has a similar role to play in the development of more effective interventions. Initial screening and assessment data can be followed up by repeated data collection at 6 months before administrative case reviews, providing the potential for understanding trajectories in severity of needs over time. However, validity of the data when collected at follow-up by caseworkers is often untested, and the extent that measures such as the Child and Adolescent Needs and Strengths (CANS) reflect foster parents’ perceptions of children’s needs and real changes in symptom levels is unclear. One study found that the CANS items (entered by caseworkers every 6 months) had low correlations (r <= .33) with foster parents’ reports of emotional and behavioral problems using validated behavior checklists (Leathers & Xing, 2018). A more efficient system might involve measurement of mental health symptom levels by collecting data directly from caregivers including foster parents and direct care staff. Electronic data collection though a platform such as SurveyMonkey could streamline the process of data collection.

Increase Understanding of Cost-Benefits of Specialized Interventions

Development of more effective community child mental health service systems has the potential to prevent escalation of mental health needs and address the needs of many children in foster care, including those with mild to moderate mental health issues. For children with more complex or severe needs, however, other, more intensive interventions are likely to be needed. Tracking of outcomes will be key to understanding the extent that community mental health services meet the needs of children in care. Outcome data could point to less strong effects for some groups of children, indicating that other practice models or adaptations to the models are needed to improve outcomes. These practice models could involve adaptations to existing models, such as TF-CBT to enhance effectiveness, or could involve use of interventions developed specifically for children in foster care, such as treatment foster care.

A range of different strategies could be used to increase incentives to adopt to more intensive treatment models. As noted, use of a centralized tracking system for children and adolescents across a state would provide the ability to track outcomes over time into early adulthood, even after children leave foster care. This allows for analysis of outcomes and potential benefits of specialized treatments, such as reduction of high-cost events like hospitalizations, residential placements, and detention or incarceration that are frequently experienced by children with more significant needs. While improving children’s quality of life should be enough of a rationale to support dissemination of effective mental health interventions, identification of these cost-benefits is likely to be essential to build political will to support this investment. In particular, multimodal evidence-based treatments for more severe behavior problems such as Multidimensional Family Therapy (MDFT), Multisystemic Therapy (MST), and Treatment Foster Care Oregon – Adolescents (TFCO-A) are expensive to initiate but have the potential to prevent highly disruptive events in young people’s lives with high personal and social costs. While it would seem that these interventions would be widely available given their positive cost-benefit ratios, the lack of locally based cost-benefit information impedes their implementation.

Develop More Accessible Interventions for Children and Youth in Foster Care

Another strategy to increase access to a range of evidence-based treatments is to develop interventions that are less costly to implement and sustain. More widespread use of TF-CBT in comparison to many other evidence-based interventions is due to its consistently positive effects, but facilitated by its accessibility and relatively low training costs. TF-CBT training is supported by publicly available manuals that can be purchased online, and exposure can begin in graduate school with completion of a 10-hour online training at a low cost. Therapist certification then requires an in-person two-day training and 12 hours of consultation calls (provided to groups of five to 12 therapists). Average per-person costs to become certified range from approximately $700-$1,300, depending on the size of the group being trained and the consultant fees. This training structure provides agencies and localities the opportunity to begin implementation with a relatively small expense that can be built upon over time, rather than a large expense that may be difficult to budget and justify in a single year.

Even a moderate cost can pose a disincentive for many agencies and localities seeking to increase use of more effective interventions. For example, PCIT, a relatively inexpensive intervention, requires up to $10,000 in costs to set up equipment for the intervention and $4,000-$4,200 per clinician in training costs which can pose a deterrent in implementation (Goldfine et al., 2008). However, this level of expense can fit into agency budgets or covered by small grants (as provided in Connecticut), and nearly every state in the U.S. has multiple certified PCIT providers (see http://www.pcit.org/united-states.html). The significantly higher initial cost of other interventions that are critically needed in foster care presents more difficulty to overcome. For example, KEEP SAFE includes foster parent parenting training and youth skills groups and has consistently positive effects in reducing daily reports of behavior problems among youth (Kim & Leve, 2011; Kim et al., 2013; Kim et al., 2017; Smith et al., 2011). Despite the program’s high relevance to the needs of children in foster care, it has a low rate of dissemination.[7] This is likely to be related to its high start-up costs ($40,000 to train one facilitator and co-facilitator).[8] Similarly, treatment foster care, which involves hiring foster parents as professionals who are trained and provided with ongoing support to implement in-home treatment with youth have been found to be cost effective as an alternative to residential treatment (Chamberlain & Smith, 2003). Again, however, the high start-up costs of these programs have limited their dissemination, with 95% of therapeutic foster care programs estimated to be agency-developed rather than a specific evidence-based model (Southerland et al., 2017).

It is also important to address the costs of sustaining newly implemented programs. “Fidelity drift,” or the tendency for providers to gradually shift their practices back to previous models is thought to partially account for weaker effects in actual practice than in clinical trials (Edmunds et al., 2013). This tendency can be reduced through consultation with detailed attention to clinical practices. In one child advocacy center, a high level of fidelity was maintained by contracting with a university partner to provide training and ongoing supervision in specific interventions and creating a unique clinical supervisor position (Bond & Drake, 2019). This supervisor monitored practices through chart review, face-to-face supervision providing intensive review of sessions, and audio and videotape session reviews. Obviously, providing these supports comes with a cost; an important next step is understanding the costs and benefits of these supports, including their impact on children’s outcomes.  

To address the critical need for more accessible practice models, intervention developers should study lower cost intervention training and fidelity monitoring mechanisms. This might include videotaped training modules, remote learning, and automated reviews of components of treatment that can be coded through language processing software (Walker et al., 2019). In addition, the development of more accessible models is facilitated by researchers moving away from studying “name brand” interventions that must be disseminated by private companies formed by the developers. Instead, this work seeks to identify the key components of effective treatments in an area and then support the development of training and consultation models that have more positive effects than usual care. For example, MATCH (the intervention disseminated widely in Connecticut that is discussed above) is a modular treatment that incorporates the common components of evidence-based interventions for four different areas (disruptive behavior, depression, anxiety, and trauma symptoms) and maintains the positive effects of evidence-based interventions relative to services as usual (Chorpita et al., 2013). Eventually, training in this type of common components intervention could offer providers an evidence-based intervention to address several different types of mental health issues with more flexibility. Without studies focused on children in foster care, however, it cannot be assumed that an intervention like MATCH would have the same effects as in the general population.

Therapeutic foster care is an area where significant work has been completed to develop a model that is more flexible and lower-cost than currently available evidence-based models (e.g., Treatment Foster Care Oregon). An ongoing project has studied therapeutic foster care as it is typically provided, identified components consistent with evidence-based models in these “services as usual” programs (e.g., more extensive foster parent training), and found that programs that incorporate more of these components have more positive outcomes (Murray et al., 2010). Based on these findings and the components of effective models, the research group developed a training and consultation model to enhance therapeutic foster care with foster parent training in areas including relationship building and behavioral parenting skills. In a controlled study, Farmer and colleagues (2010) found that the children placed in foster homes in the enhanced training and consultation group had significantly fewer problematic behaviors and mental health issues at 6-month follow-up than children who received therapeutic foster care as usual, without the experimental consultation and training. Weaker but still significant positive effects were found at a year for behavior problems. This work is significant because it provides agencies with an alternative to developing their own version of therapeutic foster care and specifies a lower-cost model to implement training components that have been found to be most helpful. Additional work is needed to replicate these findings to understand the types of support foster parents, parents, and children need to maintain positive effects over time.

Consistent with these positive findings in developing therapeutic foster care training models, opportunities to enhance foster care environments to directly benefit children’s mental health should be optimized by enhancing the content of training required of parents and foster parents in traditional and kinship foster care. Again, the cost of “name brand” interventions such as KEEP SAFE, the preventative intervention involving 16 group sessions for foster parents at the start of new placements, might be prohibitive. But use of models developed by adapting the common elements of behavioral interventions has the potential for similar effects and could be provided at the start of placements in lieu of part of the often extensive foster parent trainings that have been found to have little effect on placement outcomes. Similarly, there is a critical need for more effective, accessible parenting training models given how ubiquitous parent training is in service plans (Horwitz et al., 2010).

Enhancing Federal and State Monitoring and Assessment Activities to Improve Mental Health Services

The strategies described in this chapter require a significantly increased commitment to improving children’s mental health services than has previously occurred in most areas of the country. These efforts involve increased leadership, allocation of staff time, and financial commitments, which are significant barriers in states that are still impacted by the Covid-19 pandemic and its financial repercussions. A strategy to increase incentives to make these investments at the state level could involve enhancement of the Child and Family Services Review (CFSR) process, which rates seven outcome indicators in the areas of safety, permanency, and family and child well-being (one outcome which includes health and mental health services). The two rounds of CFSR reviews completed since 2000 highlighted the need for more appropriate treatment of children’s mental health needs, with only a few states receiving the highest rating level based on assessment of mental health needs and access to services (e.g., referral to services after assessment) in the last round. The improvement plans resulting from past reviews have had positive effects on services by supporting widespread use of screening,[9] as discussed previously (Pullmann et al., 2018).

The review process provides a unique opportunity to support use of evidence-based practices, but will need greater specificity in its state rating system to support this. Similar to other outcomes, the CFSR will need to operationalize use of evidence-based interventions and create benchmarks for expected use. Although previous reviews have only specified “appropriate” treatment as a goal and primarily relied on screening rates and referral rates after assessment, further specifying how to operationalize this goal is consistent with the increased understanding of the effects of evidence-based practices relative to services as usual and the role of effective services in reducing negative outcomes. Greater specification of mental health services content is also supported by other federal initiatives that have affected mental health services in the U.S. For example, concern about the potential overuse of psychotropic medications among children and youth in care, particularly use of multiple medications and off-label use of antipsychotic medications, led to congressional review and a federal initiative now requiring that states monitor use of psychotropic medications (Congressional Research Service, 2017). This initiative highlighted the importance of providing effective psychosocial interventions rather than relying on use of medication to address disruptive behavior. As noted in a report following up on progress in seven states, difficulty in accessing evidence-based mental health interventions is a challenge to these efforts (U.S. Government Accountability Office, 2017). Including indicators of use of evidence-based practices could further orient states and agencies to the quality of services received rather than just a child’s referral to services.   

Incorporation of greater specificity in CFSR ratings of mental health services would require states to implement some type of services tracking system, as previously discussed. Although further study of the validity of the data entered is needed, existing studies have found correlations between clinician-reported use of different practices and observed use, suggesting that reported practices corresponds to greater use of practices, although not precisely (Southerland et al., 2017). Requirements to monitor service quality and content could support building increased capacity for data collection monitoring and collection in this area (as it has for other outcomes in the CFSR process). This in turn could support increased attention on the types of interventions that are most effective for different mental health issues and capacity to provide these interventions.

Proposing that the CFSR process incorporate indicators of specific use of evidence-based interventions to address children’s mental health issues could be viewed as beyond the scope of the reviews, which focus primarily on core child welfare services and practices supporting child safety and permanency. However, recent attention to the extent that failures to provide appropriate services can result in real harms to children and youth in the systems entrusted for their care could create greater political will for a higher level of monitoring with a goal to support more effective mental health services. Addressing the mental health needs of children in care is a critical need both due to the role assumed by the child welfare system when children are removed from their parents’ care and the individual consequences and societal costs of failing to meet their needs.

Next Steps and Conclusions

This chapter reviewed several approaches to supporting more effective service systems by increasing incentives to provide interventions with known effectiveness, but it did not address many of the limitations in our knowledge about what works for children in foster care. There are still unaddressed questions about how to enhance the long-term effectiveness of some key interventions, such as therapeutic foster care. Combinations of behavioral parenting interventions used with both parents and foster parents along with services enhancing support might be more effective than behavioral parenting interventions alone, given the complex needs of child welfare-involved families and children and indications that foster parents’ need for support is an independent predictor of placement disruption (Leathers et al., 2019; Tonheim & Iversen, 2019). Additionally, as noted previously, there are currently no effective interventions to treat children with more significant attachment disorders. These disorders are exceedingly rare in the general population but are more common among children in care, and when a broader range of relational issues are considered, could affect many children presenting with mental health issues. These issues could also undermine the effectiveness of interventions primarily developed in the general population.

This chapter was also limited by its primary focus on strategies to increase use of evidence-based practices in outpatient settings and community-based treatment settings such as therapeutic foster care. For some children, more effective, higher-intensity treatments are needed, and there are many unaddressed questions about how to best provide these services. Additionally, school-based services are commonly provided to children in foster care, and very little is known about the effects of these services, their adequacy, and how they are coordinated with other services provided. Finally, other services that are commonly provided to children in foster care, such as mentoring (see Taussig et al., 2019) and service planning models (see Leathers et al., 2019 and Leathers et al., 2021), could play an important role in building support networks, identifying unmet needs, and supporting positive outcomes. Additional research to understand the role of these programs in providing additional benefits beyond formal mental health services is also needed.

Although service system change occurs incrementally, recent progress in creating more effective mental health service systems for children in foster care is encouraging. Screening processes now identify many children with significant needs as they enter foster care, and the majority of identified children receive at least some follow-up services. However, the development of an effective care system obviously requires much more than screening, with effective linkage to evidence-based services following identification of needs. The examples described in this chapter increase incentives to build a sustained, effective service system. Notably, other states and regions are using a range of strategies to incrementally build their service systems, with some taking similar approaches and others pursuing other paths. Other states and regions have not made as much progress in their efforts to shift mental health services, and the challenges they face could be substantial. Child welfare practice is often dominated by crisis management, underfunded services, and high staff turnover, which inhibits capacity to pursue cross-agency and university collaborations, apply for external funding, and manage new initiatives. It is likely that child welfare systems operating with greater resources and strong collaborations will make the most progress in building effective systems of care. But by attending to the enormous individual and societal benefits of providing effective care, it is hoped that evidence-based mental health services will be increasingly accessible to children and youth in foster care.

Author Note

Studies referenced this chapter were funded by the Illinois Department of Children and Family Services (DCFS) and the Health Resources and Services Administration (HRSA). Views and opinions expressed in this chapter do not necessarily reflect those of DCFS or HRSA.

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