Tackling Toxic Stress

Using Science to Drive New Approaches to Child Welfare

With their eyes on a more healthy, stable, and productive future for the nation’s most vulnerable children and families, federal child welfare officials are broadening their strategy—and giving states both flexibility and funds—to try to enhance caregiving and to reduce the adverse experiences that can trigger toxic stress and its damaging lifelong consequences.

Mothers of preschoolers group with their childrenThe federal Administration on Children, Youth and Families (ACYF), is seizing on the science of early childhood development to integrate social and emotional well-being into its longstanding emphasis on ensuring safety and permanent placements for children who may be experiencing abuse or neglect. To do so, officials at the highest levels are authorizing waivers from rules for states who qualify and making grants to state and local governments, universities, and community nonprofits willing to try to improve services in ways that not only minimize toxic stress but also generate lessons for the field.

Bryan Samuels, ACYF Commissioner, says that compared with a decade ago, “We know so much more about the brain, we know so much more about trauma and toxic stress, that if we want to get to good outcomes for children and families, we can’t ignore their consequences.” For better, more consistent outcomes, Samuels says, “We have to use the basic science, and we have to get smarter about how we move that research into practice.”

“Government and private nonprofits and others can be much more effective if there is one science that really drives practice and policy,” agrees David Sanders, the executive vice president of systems improvement at Casey Family Programs, a Seattle-based foundation focused on foster care and child welfare services nationally.

To promote social and emotional well-being, ACYF, which is part of the U.S. Department of Health and Human Services, is approving state and local projects that better identify children for whom traumatic events may have disrupted development, that increase access to effective interventions, and that strengthen ties across agencies or systems serving vulnerable children and families.

Out of 3.7 million reports of potential abuse or neglect nationally in 2011, about 680,000 children were found to be victims of maltreatment, according to federal data—that’s about 35 times the number of children who are diagnosed with diabetes each year. Most maltreatment comes in the form of neglect (78.5 percent in 2011), which science shows can result in an even wider range of harm to development than physical abuse. Nationally, in 2011, federal data show that over a third of victims nationwide who received services went on to receive foster care—a temporary placement of 3 years or less for the vast majority of children. Overall, the federal government spends about $4.4 billion a year to maintain children in foster care, according to Casey Family Programs, with 408,000 U.S. children in foster care in 2010. Another nearly 1 million children are living at home while their parents or caregivers receive services.

Over the past 15 years, U.S. child welfare caseloads have dropped nearly 30 percent, according to Commissioner Samuels, due in part to efforts at reuniting families and in moving children from foster care into adoptive homes. One result is that the children who have remained in foster care are those most likely to be so affected by abuse and neglect that they have severe emotional and behavioral problems that make it difficult to find permanent homes for them.

The consequences of toxic stress, Samuels says, “travel with that child every place that they go. And the subsequent environments in which they are placed can either help to heal them or to further exacerbate the problem.”

Opportunities for Innovation

Since 2011, Samuels notes, ACYF has devoted almost all of its discretionary grants—about $46 million was awarded to 86 local entities, states, tribes, and territories in 2012—to advance local and state efforts to craft interventions that keep in mind how best to mitigate or prevent toxic stress and trauma in distressed families. Through these grants, Samuels says, ACYF has “tried to elevate the issue of toxic stress and trauma and to really drive people toward thinking about how to intervene from wherever they were sitting,” be it in early childhood or in adoption services.

In another part of its integrated strategy, ACYF in 2012 also approved nine new “child welfare demonstration projects” to experiment with new approaches to improving child well-being, with a focus on crucial social and emotional skills. If successful, these programs could serve as models for remaking child welfare services across the country.

The demonstration projects—known as IV-E (“four – ee”) waivers for the relevant section of the Social Security Act—allow the states significant flexibility in how they spend their child welfare funding, says Nina Williams-Mbengue of the National Conference of State Legislatures (NCSL), where she is director of the children and families program.

The waiver projects do not cost the federal government anything. Rather, states try to figure out how to get better results, within the limits of the money they are already receiving. State child welfare agencies receive federal money based on the number of children they serve.

Such flexibility is critical to the ability to try new interventions, Williams-Mbengue says, and states have been clamoring for it. “It provides an incredible opportunity,” she says, “to experiment and innovate…and to use that money on programs to keep children out of the foster care system or prevent their reentry and promote the well-being of the kids.”

Prior federal initiatives granting states waivers from child welfare funding rules have focused on broad systemic changes, Samuels says, but that is only part of the solution. “To get better results for children and families,” he notes, “you also have to change the programs that you provide and the practices that you engage in.”

A Two-Generation Approach

“Our basic objective here,” Samuels says, “is to encourage states to select a small number of interventions that they think are appropriate for children and families that they’re serving that are likely to reduce the consequences of maltreatment, trauma, or toxic stress and to see if they can organize their systems around supporting those interventions.”

States receiving waivers are required to use evidence-based (or evidence-informed) services and supports, but they are allowed to divert funds, usually limited to foster care placement, and instead use those monies for such services as building parenting skills, drug and mental health counseling, psychotherapy, and supports for families who have recently been reunited as well as efforts to reduce group home care or days spent in foster care.

The nine states that received new waivers in 2012—Arkansas, Colorado, Illinois, Massachusetts, Michigan, Pennsylvania, Utah, Washington, and Wisconsin—will start scaling up new programs in coming months. (See sidebars.) Another two rounds of waivers are expected to be approved, involving a total of up to 20 additional states by 2014. Each demonstration project can last up to 5 years, or longer if approved by federal officials, with an end date of 2019.

Williams-Mbengue of NCSL is enthusiastic about how these new approaches could push the field forward: “You’ll have so many lessons learned, so much evaluative information that other states can adopt.”

Samuels notes that in asking the state and local agencies to look at services through the lens of toxic stress, it is crucial that they take a two-generation approach—addressing parents’ needs, children’s needs, and attending to the parent-child interaction.

As examples, Samuels points to two areas in which discretionary grants were made in 2012: regional partnership grants to benefit children affected by substance abuse and grants for “supportive housing” for families in the child welfare system. Together, those two grants total just over $16 million to 22 new grantees.

In those initiatives, he notes, his agency asked the grantees to think about “How do you change the parents’ behavior in terms of substance abuse or mental health issues?” In addition, he says, they also asked, “How do you change their parenting behavior? And then how do you ameliorate the consequences for the child of growing up in a substance-abusing household or one affected by mental health problems?”
“We put [in] enough money,” Samuels says, “in the hopes that together those three approaches really do change the environment the children are actually being raised in.”


Washington State: Focusing on Prevention

As one of nine states to gain federal approval in 2012 for new child welfare demonstration projects, Washington state is designing an entirely new approach for about half of its 30,000 annual allegations of abuse or neglect. The most serious cases will still receive immediate investigation, and the child likely will be removed from the home. But families deemed to present a low-to-moderate risk to the child will be referred to a new Family Assessment Response (FAR) system, overseen by the state child welfare agency, which will provide services and supports that would allow the child to remain safely in the home.

FAR is being designed to reduce or prevent toxic stress in two fundamental ways: by coaching parents in how to provide consistent, nurturing caregiving and by preventing the need for children to enter foster care, a move that can exacerbate whatever maltreatment prompted the state to remove them from their families initially.

Rather than setting up an adversarial relationship with the families, which traditional child welfare investigations can do, FAR asks for voluntary participation in a collaborative process of determining what the family needs, explains Jennifer Strus, assistant secretary for the Children’s Administration, which is part of Washington state’s Department of Social and Health Services.

Caseworkers first will conduct a comprehensive assessment of barriers to keeping the child safely at home, then help provide concrete supports such as housing vouchers, food, clothing, utility assistance, mental health services, drug and alcohol treatment, medical care, and dental care. They will also connect the family to evidence-based programs that increase parenting capabilities, such as Functional Family Therapy or Parent-Child Interaction Therapy.

Ruth Kagi
Ruth Kagi

State Representative Ruth Kagi has been advocating for years for a shift in Washington to using the approach, which is known nationally as “differential response.” Kagi says she became interested in child welfare issues when she learned that removing a child from his or her
home simply compounds the original trauma children may have experienced at the hands of a parent.

Explains Strus: “With the differential response, there’s a lot less stigma. There’s no investigation, there’s no finding of child abuse or neglect.” She adds: “We hope that…the families are much more willing to cooperate and acknowledge they need help and accept the help.”

With such an approach, Kagi notes, “The focus is on finding solutions…That’s a huge change.” And a meaningful one: Ohio and Wisconsin, for instance, Kagi says, have used differential response and seen a significant drop in the number of children in out-of-home care and an increase in child safety. Says Kagi: “I think it’s going to be an immense improvement in our system.”

Kagi attributes the change in mindset for her and other state officials to learning about the work of the Center on the Developing Child and how important it is “to provide a safe, nurturing, loving beginning for every child because their brain is developing.” The foster care system, Kagi says, is “ripe with children who experience serious trauma and are acting it out every day.”

“The only way to really end this problem,” Kagi notes, “is to prevent it.


Illinois: Aiming to Improve Foster Care

Young children in Illinois, particularly those in Chicago and the rest of Cook County, enter foster care at rates considerably higher than the national average. They also stay in foster care longer than in other states and have low rates of permanent placements, including reunification with their parents.

When Illinois became one of nine states in 2012 to win federal approval for a new child welfare demonstration project, it decided to focus its efforts on improving the well-being of babies and toddlers who were already in foster care. The Department of Children and Family Services is planning to use evidence-based interventions with parents of children ages birth to three to increase the chances of reuniting families by working to enhance caregivers’ capacity “to respond to the regulatory, emotional, and behavioral needs of the young child,” according to a federal summary.

The state will measure parental stress and child development and will classify each case as high-, moderate-, or low-risk. If they are categorized as being at high risk, birth parents and their children will go together to psychotherapy. If they are at moderate risk, they will attend Nurturing Parenting Program sessions for 16 weeks to instill better parenting practices, as well as receive individual coaching to improve certain key competencies.

Cynthia Tate
Cynthia Tate

Cynthia L. Tate, who is implementing the new programs as deputy director of the state’s division of clinical practice and development, also notes the significance for Illinois of the demonstration project providing for the first time an evidence-based training modified specifically for foster parents. Tate says that has not been done previously because foster placements are perceived as temporary, and the emotional attachment in such a placement is different than the attachment a parent is able to make in a permanent family.Tate says the federal waiver opportunity led the state to question, “To what extent do we prepare foster parents for caring for children who have been abused, neglected, and removed from their families?” Officials concluded, she says, “We could do a better job.”

“We have done trauma training for caseworkers, and nobody bothered to train the foster parents,” Tate says. “We found the foster parents were just hungry for it, because they didn’t understand what they were seeing in these kids.”

View more articles from the Tackling Toxic Stress series

Article written by Carol Gerwin, a freelance writer and editor specializing in education and child development, who is based in Newton, Mass.

Published: August 14, 2013

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