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Int J Child Health Hum Dev 2014;7(1): 00-00. ISSN: 1939-5965
© Nova Science Publishers, Inc.
Overcoming barriers to mental health services
for foster children
Bruce D. Friedman
∗
, PhD, ACSW, CSWM,
LCSW, Barbara Reifel, LCSW, Antanette
Reed, MSW and Deanna Cloud, LCSW
California State University, Bakersfield and Kern
County Department of Mental Health, Bakersfield,
California, United States of America
∗ Correspondence: Professor Bruce D Friedman, PhD, ACSW,
CSWM, LCSW, Director, Department of Social Work,
California State University Bakersfield, 25 DDH-9001
Stockdale Highway, Bakersfield, CA 93311-1022, United
States. E-mail: bfriedman@csub.edu
Abstract
Children within the social service system, particularly
foster care, are in need of comprehensive mental health
services. Research has found that foster care children can
primarily be diagnosed with one of four primary diagnoses
that correspond to specific ages-related differences:
adjustment disorders (28.6%), conduct disorders (20.5%),
anxiety disorders (13.8%) and emotional disorders (11.9%).
Thus as the numbers of children entering the system
continues to escalate, the demand for mental health services
also rises. Simultaneously, as the demand increases so have
the barriers for foster children in accessing mental health
services. Many of these barriers are system barriers that
continue to keep utilization rates of foster children
receiving services low. In a rural county with low
penetration rates, a pilot project involving the Department
of Human Services (child welfare agency), the Department
of Mental Health, and the Department of Social Work was
developed to increase the penetration rates for providing
mental health services to foster children by overcoming the
barriers to services. A number of barriers were identified,
including system barriers because of the silos between the
agencies. The project demonstrated the role of the
University in facilitating a change process when
collaborating with two different county agencies. It also
showed the need for cross training staff. Residual benefits
include increased trust, better understanding of the various
jobs and roles of workers, and better communication
between staff of the two county agencies.
Keywords: Foster care, system barriers, university
partnership
Introduction
A child’s development is dependent upon the
relationship between the child and the care giver.
Within the first six months of life, the child develops
a number of behaviors to attract a care giver and to
discriminate between care givers (1). This leads to
developing attachments with specific caregivers in
Bruce D. Friedman, Barbara Reifel, Antanette Reed et al.
2
order to ensure proper development. Bowlby (2)
refers to attachment as the strong propensity for the
young child to seek proximity to and contact with a
specific figure in certain situations particularly when
frightened, tired, or ill. This contributes to a
disposition to behave in a way that is an attribute of
the child’s behavior that only changes slowly over
time. Within the first year of life, a child develops
four main patterns of attachment relationships; secure,
insecure avoidant, insecure ambivalent/resistant, and
disorganized (1). Through this attachment with the
caregivers, the child learns a variety of coping
behaviors on how to deal with various aspects of life.
These attachments are not innate but need to be
developed over time. The way the child develops
these attachments is through continual contact with
the caregiver. Zlotnick, Tam, and Soman (3) showed
that adults who had been in foster care as children
without addressing the health or mental health needs
were more likely to have health and mental health
problems than other adults.
When problems occur in the family structure that
may cause disruptions with the contact between the
child and the care giver causing the child to begin to
regress in his/her development and even not
developmentally progress as desired. In some of these
cases, CPS (Child Protective Services) intervenes and
moves the child into a more supportive environment.
However, there is no telling what the effect that this
move has had on the child and the development of the
child. On the one hand, it is perceived that a more
stable environment should be helpful in that the child
would be able to reestablish positive attachments with
care givers to continue his/her growth development.
On the other hand, there may be some role confusion
because the child had previously developed
attachments with former caregivers and there is
questioning as to the role of the new caregiver and
some difficulty in extinguishing previous attachments
to move forward in establishing new ones.
The assumption is that by placing a child in either
a relative or non-relative home that appears to be
stable, the child will be able to develop attachments
and continue the development process. However,
Burns, et al (4,5) have identified that there are a
number of behaviors that emerge as a result of the
move and that these should be addressed through
some type of mental health services being provided.
Burns et al (5) identified that almost half of the
children who were removed by CPS and were in
placement demonstrated some mental health need and
that those in non-relative placement demonstrated
those behaviors between 30 to 50% more than those
in relative placement.
The provision of mental health services to
children in placement, or foster care, is complicated
since it bridges two different service delivery systems.
On the one hand there is the child protective system,
CPS, which is mandated to protect the child,
including possible removal from the parental home
and placement in a foster home, either relative or non-
relative. Second is the mental health system, which is
charged to provide mental health services for those
individuals (both adults and children) who receive
public benefits, such as Medicaid. This becomes more
complicated since as demand for CPS services has
increased, so have the barriers in the provision of
mental health services (6). This also is complicated by
the definitions used by each of the systems in how
they provide those services. For example, CPS is
required to respond to a situation within a certain
timeframe depending on the severity of the report.
However, mental health does not have the same time
constraints in how they provide services unless it is a
life and death situation or the person is a danger to
self or others.
The question and purpose of this pilot project was
to identify the barriers that exist between the two
services and then to identify ways to overcome those
barriers to improve the mental health delivery system
to children in the foster care system.
Literature review
In a study comparing children in the foster care
system with children receiving Supplemental Security
Income (SSI), dosReis et al (7) identified that those in
the foster care system were more likely to have a
mental disorder (57%) than children receiving SSI
(26%) or fifteen times greater than children receiving
any type of aid (4%). Similarly, Farmer et al (8)
identified that children in either foster care or with
contact with social services were more likely to
receive mental health services than children living in
poverty. In addition, Farmer et al (8) identified that
Barriers to mental health services
3
many of the children in foster care continue exhibiting
mental health behaviors into their adult lives. Halfon,
Berkowitz and Klee (9) identified that foster children
can primarily be diagnosed with one of four primary
diagnoses corresponding to specific age-related
differences: adjustment disorders (28.6%); conduct
disorders (20.5%); anxiety disorders (13.8%); and
emotional disorders (11.9%).
As the numbers of children entering the system
continues to escalate, then the demand for mental
health services should also continue to rise. However,
the current economic conditions have seen dramatic
reduction in the provision of mental health services.
With a growing demand and the reduction in service
delivery, there has been an increase in the barriers for
children and especially foster children to access
mental health services (6). The question is what is the
nature of these barriers and can they be addressed to
streamline the provision of Many of these barriers are
system barriers that continue to keep utilization rates
of foster children receiving services low. This pilot
project was developed to identify the barriers in the
provision of mental health services to foster children
and to identify some strategies to improve the service
delivery of mental health services to foster children in
Kern County, California.
Kern County
Kern County is a rural county and the county seat is
Bakersfield. California has a county system of
governance and the provision of services. A county
system means that each county has a separate, self-
governed delivery system that is supported primarily
by county funds. Although the state does track county
services to see how each county ranks in the delivery,
the operations and coordination of services relies on
each county.
Within Kern County, the utilization rate, or the
rate that children in the foster care system were
receiving mental health services prior to the pilot
project was under 30%. There had been a county
developed committee established to try to improve the
utilization rates, but the rates remained consistent for
about ten years. Up until 2001, there was no social
work program in the County but in 2001, a social
work program was begun at California State
University, Bakersfield. The program was receiving
Title IV-E funding to improve the child welfare
workforce in the County.
Kern County also has a high percentage of
Hispanic families representing about 46% of the
County’s population. A percentage of these families
are undocumented as a result of employment
opportunities in agri-business. In addition, many of
these families speak Spanish in the home, thus
making language a potential barrier to service
delivery.
The question continued to remain of how to
improve the mental health delivery of services for
children in the child welfare system and particularly
in the foster care system. Could the social work
program play a role in the development or
improvement of the delivery of mental health
services?
Methods
The social work program faculty met with the child
welfare service administrator and the director of
children’s mental health services to begin discussing
the creation of a pilot project that would improve the
delivery of mental health services to foster children
by reducing barriers and by using students from the
social work program to assist in the delivery of
services in May 2010. At that time, it was identified
that there had been a committee in existence for about
ten years but the utilization rates had not improved. In
addition, both county agencies were experiencing cuts
in staff due to the California budget crisis and the
potential of creating a pilot project where students
would be involved in the delivery of services seemed
very attractive. It was also identified that whereas the
overall county utilization rate was under 30%, the
provision of mental health services for foster children
between the ages of 0 to 5 was negligible. Thus, the
project initially targeted the provision of mental
health services to the 0 to 5 age foster child.
In addition, it was identified that there were a
number of barriers that existed between the two
systems that may be preventing the timely provision
of mental health services. Some of these barriers
included the differences in mandated charges between
the two agencies. For example, the Department of
Bruce D. Friedman, Barbara Reifel, Antanette Reed et al.
4
Human Services, the department charged with the
provision of child protective services, has a mandate
to investigate a claim either within 24 hours, if the
case is deemed an emergency, or within a week.
However, the Department of Mental Health did not
have the same time mandate and much of the time
that it took for a child to be evaluated and seen by a
therapist was dependent upon the waiting list. In
addition, there was no mandate for a child within the
child protective system to even be seen by a mental
health professional and that sometimes the behaviors
appeared after months of being in placement
necessitating an actual court order for the child to
have a mental health assessment, since once the child
is in foster care, he/she is under conservatorship care
of the State needing a court order for any treatment
provisions. The need for obtaining a court order for an
assessment could take a while and might also raise a
perceived level of competence about the foster parent,
which in reality would not be the situation at all.
Thus, there were a lot of foster children who were just
‘falling through the cracks.’
With the faculty from the department of social
work collaborating with both the administrators and
staff from the two county agencies, the pilot project
was launched with the first cohort consisting of four
students, three of whom were IV-E stipend recipients
and also employees at the Department of Human
Services and one traditional student receiving a
stipend from mental health. It was also identified that
some of the students should be Spanish speaking to
address the high percentage of Spanish speaking
families in the County. The first meeting of all
partners of the project was to be in August 2010,
immediately prior to the beginning of the 2010-11
academic year. The meeting was designed as an
orientation for the students and to begin establishing
the ground rules as to how the project would be
implemented. In addition, since the Department of
Mental Health did not have an MSW to provide the
supervision for the team of students, a faculty member
from the Department of Social Work acted as the field
instructor along with the Department of Mental
Health staff member who had a Masters in Marriage
and Family Therapy as the task supervisor.
Results
Initially, the going was a little slow identifying a
number of barriers. The first was the issue of access to
all the new children into the system. To address that
issue, a request was made to county counsel to request
a standing order that all new children into the foster
care system will be screened within 60 days. This
order was passed, but then there was the issue of how
to identify who those children were? The Department
of Human Services has an emergency placement
facility, Jamison Center, where all children first come
to that center prior to being placed into foster care,
except for many of the 0 to 5 year olds who go
directly into an emergency foster home. Sometimes it
would take a number of days for the children coming
into Jamison Center to enter into the computer
database. However, one of the students identified that
Jamison Center kept a hand written log of each child
entering the Center. By accessing the log, it was
possible to be able to begin the assessment process
early enough for the child to be assessed. There was
still the question of accessing those children who
went directly into an emergency foster home without
first stopping at Jamison.
In addition, it was quickly realized that the 60-
day mandate for assessment was not long enough. It
was identified that the County Regional Center (for
children with developmental disabilities) had 120 day
assessment process and there was a request back to
the county counsel to see whether the order could be
amended to the 120-day initial assessment to conform
with the Regional Center order to assess for
disabilities. This process took longer than anticipated,
but was finally accomplished about eighteen months
after it was initiated.
Another barrier identified was the electronic
databases that were used by each of the two county
agencies. The child welfare agency maintained all
their records on the CWS-CMS record keeping
system; whereas, the mental health agency kept their
records on the Anasazi record keeping system. The
two are not compatible for interchange and it was
quickly identified that there would need to be some
cross training on how to work the two systems. This
led to initially creating teams of students where one
student would learn the mental health system while
the other would be fluent in the child welfare system.
Barriers to mental health services
5
This way, as a team, then each child would be able to
be entered into both systems and there would be joint
communications.
This created another barrier in that it necessitated
that two students had to work on every case, thus
limiting the number of cases that could be seen. As a
result, this was changed the second year of the pilot
student where each student was cross trained on both
systems. However, the other barrier of confidentiality
of the information being entered, especially entering
mental health data into the child welfare system may
violate HIPPA guidelines. Thus, key terms were
identified to let the child welfare workers know that
the child had been screened by mental health without
violating any confidential medical information and
thus being in compliance with HIPPA.
A third barrier arose around the misperceptions of
the workers in each respective agency about the
workers of the other agency. In other words, there was
a lack of trust between the workers toward the other
agency. By having workers cross-trained and working
within the other agency, it became evident that trust
began to build. This led to the students making
presentations to each agency staff and enhancing
greater agency cooperation.
As a result of the students providing the services
and being cross-trained on both systems, there was
approximately a doubling of the county utilization
rate for foster children (increase to 53% from less
than 30%). In addition, with the initial target being 0
to 5 year olds, it was identified that the older siblings
of the population were also being screened, thus
increasing the numbers and helping increase the
overall utilization rate just by adding the siblings of
the 0 to 5 age children. A problem arose at the end of
the academic year and the question of how the project
will sustain itself while there are no students in the
project during the summer months. There was some
discussion about seeing if the next batch of students
could start sooner to address this gap in services;
however, it was resolved that the Department of
Mental Health would hire some temporary help in
order to sustain the program during the summer.
Because of the success of the first year of the
pilot, there were six students who wanted to
participate the second year of the project. Four of the
students were IV-E recipients and current employees
of the Department of Human Services and two of the
students were receiving a California mental health
stipend that was structured similarly to the IV-E
stipend. As previously mentioned each student was
cross-trained and rather than working in teams, were
able to work more independently. This led to a more
efficient way of operating the project. It was also
determined to provide services to all foster children
and not only the 0 to 5 year old children. Thus, any
child newly entered into the foster care program
would be eligible for the standing initial screening
process just to begin access to the mental health
system.
During the second year of the project, the State
began addressing a court order for every county child
welfare agency to work more closely with county
mental health agency. This was classified as the Katie
A decision, and there was some concern about how
counties would address this issue. The mandates are
currently being worked out through a state mandated
core practice model plan that was presented in March
2013. However, as a result of this pilot project, it
initially appears that the relationship between the
child welfare agency and the mental health agency
provide a good foundation for the County to be in
compliance with the Court order.
As the project entered its third year there are
some concerns. Whereas the first two years of the
project recruited the majority of the students from
students who were receiving IV-E stipends and those
individuals were employees of the child welfare
agency returning to school to earn their MSW, the
third year did not have any of the Department of
Human Service employees receiving IV-E in the
class. Thus, the project moved from six students
participating in the project to three this third year.
None of the three were child welfare employees.
What we learned was that this created some access
concerns on reaching the new foster child population.
To address this, the child welfare agency assigned a
liaison to the project that was to assist and to work as
a team member with the project to facilitate access.
What was realized is the value of having an employee
of the child welfare agency as a team member to
facilitate access. It also brought to awareness another
barrier in the assignment of students by the child
welfare agency to this project. Since the previous
Title IV-E students had also been employees and were
juggling their employment responsibilities with their
Bruce D. Friedman, Barbara Reifel, Antanette Reed et al.
6
student intern responsibilities, they were not on the
job for about 40% of the time while completing their
internship hours. To address this, the child welfare
agency used a provision in the placement guidelines
that stated that if a student was assigned to a new job,
then the new placement could be considered as the
internship. Since the pilot project was within the
administrative division of the child welfare agency,
then none of the new positions fit within the criteria
for a placement. This is being explored by seeing if
the project can be placed within one of the standing
divisions within the child welfare agency, such as
family services, in order to make it feasible for
employed students to have this placement experience
as part of their internship degree requirements.
Discussion
This pilot project is demonstrating that a social work
program in a county can have an effect on improving
service utilization rates. In addition, during difficult
times when agencies are being forced to reduce
budgets, which usually translate into staff reductions,
a social work program can be very influential in
providing new and enhanced services.
The pilot project also showed that a social work
program can take a leadership role within the
community to identify barriers to services and
developing strategies that improve the service
delivery system. Thus, the program is not only
educating students to enter the workforce, but the
social work program is able to work with county
agencies to problem solve and identify new
techniques and mechanisms to meet county needs.
Another finding was that the role of IV-E
students in participating in the project was very
beneficial on a number of counts. First, it helped
provide a deeper understanding by child welfare
workers of the role of mental health and
understanding some of the language differences. In
addition, it is providing the ability for child welfare
staff to be cross-trained on the mental health data
management system and vice versa for the mental
health staff with the child welfare data management
system. This helps with improved communications
between the two agencies and better cooperative
relationships.
By the social work program working with the two
county agencies, it was possible to address and
identify barriers and begin to work on addressing
them without prejudice or concern about implications
on either agency. There is no competition for
resources by the social work program at the university
with either county agency, thus, making the
relationship more equal. The downside is that the
social work program, as an educational entity, does
not have the status with county government. Thus,
when it was identified that the 60 day assessment was
too short and needed to be doubled, it was dependent
upon the county agencies to have that agreement
signed by county counsel while the social work
program had to sit on the sidelines and wait for
change to take place. In addition, every year the
academic year comes to a close, there is the question
of how to sustain the project over the summer months
when there are no students conducting their
internships.
With the state initiation of the Katie A core
practice model, the project demonstrated that by
having both child welfare and mental health staff
working together, that services can be improved. It
also demonstrated a better understanding of the
differences and similarities in how both agencies
operate. Child welfare staff became more aware of
HIPPA regulations that govern the confidentiality
requirements of mental health staff while mental
health staff became aware of the time constraints the
law places on child welfare workers for investigating
a claim. The project brought a better understanding of
the nature of the work between the two agencies and
is part of the outcome expected by the Katie A core
practice model.
There continues to be new challenges that are
being confronted as the project proceeds as mentioned
above with the identification of student interns.
However, now there is a better communication system
between the two agencies and the ability to
cooperative work through these issues is enhanced.
Barriers to mental health services
7
Implications for Practice
The pilot project between the social work program
and county agencies was a win-win-win scenario. It
helped the county address a specific need to address
and thus improve the delivery of services to foster
children in the county. Second, it helped to build a
sense of cooperation between the county agencies and
the university. Third, it provided opportunities for the
staff of both agencies to gain a better understanding of
the operations of each other improving attitudes and
understanding about how the other respectively
operates. There was a residual effect of this in that the
county is in compliance with a court order for the two
agencies to work collaboratively. Fourth, it provided a
unique opportunity for the social work program to
become involved with direct delivery of services, thus
creating opportunities for faculty to address and
understand delivery of services within the county
dispelling the notion that the university is an ivory
tower. And finally, it provided a unique opportunity
for the students to be engaged in state of the art
services and enhance their skill level for greater
performance and marketability. Thus, the role of
social work programs to become engaged in
community problem solving issues is important, not
only for the field and the profession, but also for the
learning environment.
Next steps
The project will continue and there continues to be
new challenges to address. As mentioned, the State
introduced the Katie A Core Practice Model in March
and the implications of these practices on service
delivery by the two agencies are being identified.
However, the social work program is involved and is
able to look at these issues objectively and assist the
implementation of the core practice guidelines.
Second, there continues to be the issue of student
internships, how many, and the mix from child
welfare and mental health. This is compounded by
how to interest student employees when the agency
policy makes it difficult to do so. These are
continuing discussions that will be addressed in the
future.
Conclusion
As resources become tighter and the provision of
services becomes more challenged, it is important for
agencies to be able to work more collaboratively to
address community problems. The issue of providing
mental health services to foster children continues to
be a growing problem with the number of age related
disorders continuing to increase and the ability to treat
them diminishing due to reduced resources. In
addition, there is the growing problem of drift
between the various foster services that tend to
contribute to increased problems within the foster care
population (10). These all lead to new ways of
providing services and the role that the university can
play in being the link to more improved service
delivery. Too often there seems to be a disconnect
between what is being taught in the classroom and
what is actually happening in practice and by the
engagement of the social work program in the
development of pilot projects, like the one mentioned
above, then it is possible for university faculty to
begin to understand and address community issues
while helping students learn the most current
techniques to address those problems. This is a model
that is a winner for all participants.
References
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Stewart-Brown S, Weare K, Wilson P. Thinking ahead:
Why we need to improve children’s mental health and
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[3] Zlotnick C, Tam TW, Soman LA. Life course outcomes
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[4] Burns BJ, Costello EJ, Angold,A, Tweed, D, Strangl, D,
Farmer, EMZ, Erkanli A. Children’s mental health
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[7] dosReis S, Magno Zito J, Safer DJ, Soeken KL. Mental
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Submitted: May 10, 2013. Revised: June 23, 2013.
Accepted: July 04, 2013.
