Although the child welfare system is not always foremost on the public consciousness, a recent New York Times article calls attention to the severe consequences that can result when we fail to provide appropriate and consistent care to children with mental illness in the child welfare systems. The article highlights the story of Pericles Clergeau, a troubled young man who fatally attacked Lowell Transitional Living Center staff member Jose R. Roldan in January of 2011. Mr. Clergeau was a resident of the center at the time, arriving in August of 2010 after finding himself homeless after aging out of the child welfare system at age 18.
He spent years being shuffled around Massachusetts state facilities as a juvenile, yet despite a long history of violent outbursts, no record of Mr. Clergeau’s violent behavior accompanied him to each facility. The program staff at Westborough State Hospital, the last facility where Mr. Clergeau lived before he was aged out of the child welfare system, only learned of his violent past due to an anonymous fax. By that point, Mr. Clergeau had eight outstanding warrants for assault.
Mr. Clergeau’s story may be extreme, but it offers us an opportunity to examine the flaws in our mental health and child welfare systems. It is clear that the state foster care and mental health services failed Mr. Clergeau, but what can be done to prevent future incidents?
Action that can and should be taken now is to rectify the mental health oversights that affect many like Mr. Clergeau. His story of being shuffled around the child welfare system is not uncommon. Although child welfare experts agree that stable placement is important, children in the system are displaced frequently, which is often accompanied by upheaval in their medical and psychiatric care. Foster care children often move from one placement to another and typically experience 1-2 changes in placement per year. Placement instability increases the longer a child spends in the system. Placement changes are often accompanied by changes in physicians and other health care providers.
This shift in placements and providers often leads to incomplete health information for children. As a result, children in care often receive incomplete or duplicate immunizations, lack adequate primary care, and fail to receive periodic developmental or mental health screenings. Placement instability contributes to the high cost of care delivered to foster care children, combined with inadequate coordination and limited information-sharing between service providers. When children move from placement to placement, pre-existing conditions are frequently overlooked and health problems grow more acute with each move.
In addition to limited stability, children in foster care also have chronic and complex health care – including mental health needs. According to the National Alliance of Mental Illness, about 1 in 10 children live with a serious mental disorder. This rate increases for children in the child welfare system. Children in foster care use mental health service 8-15 times more than other low-income children enrolled in Medicaid.
Clearly states face a difficult task when it comes to meeting the needs of children in foster care, and in the current economic climate, they are attempting to do more with far less. Part of the reason is budget cuts. According to the Center on Budget and Policy Priorities (CBPP), since 2008 at least 46 states and the District of Columbia have made cuts in all major areas of services, including child welfare. Massachusetts has experienced more than $100 million in cuts to their child welfare system over the past four years.
State mental health departments have also faced severe budget cuts. Funding for mental health services is often cut during tough economic times, and the past few years have been no exception. In the case of Massachusetts, the state has already closed a hospital, laid off a quarter of its case managers, and Governor Deval Patrick has recently proposed to cut about a quarter of the state’s long-term care beds. “It’s harder to get into a state hospital than into Harvard Medical School,” claimed Dr. Kenneth Duckworth, the former medical director for the state’s Department of Mental Health.
With so many state case workers being laid off, long-term relationships with mental health patients that provide continuity of care are severed. States are struggling to adequately meet the needs of children in the mental health system and child welfare systems, and many will continue to fall through the cracks. We need to ensure that children are receiving proper medical and mental health services, and one way to do this is ensure continuity in their care.
There are many ways to improve the continuity of care for these children. One way is the use of electronic medical passports to help improve the continuity of health care for children in the welfare system. These passports would contain an abbreviated health record for these children, and include vital information such as medical problems, medications, as well as family history and basic social service. Whether a child is transferred between foster homes, treatment centers, or hospitals, it would allow this important medical information to be easily transmitted every time a child has to visit a new physician or mental health professional.
Several states and localities have already adopted such programs. Texas, Tennessee, Wisconsin, Arizona, Milwaukee, and Sacramento, California have established electronic medical systems for those in the child welfare system. The results are promising. In Milwaukee, the number of psychiatric hospitalizations for youth has dropped by 80 percent, and the number of youth in residential treatment has decreased by 60 percent since the program was implemented.
If Mr. Clergeau had such a passport as a juvenile, each incident of his violent behavior could have been recorded and transferred to each new facility. This information could have been shared between the child welfare and mental health systems to form a comprehensive picture of his needs. This information could have not only improved his treatment, as well as helped to ensure the safety of the workers with whom he came into contact. Increased communication between all parties involved in our children’s care is vital to their well-being, and the well-being of those around them.