Behavioral health concerns and critical gaps in prevention, treatment, and crisis services — especially for children — are major issues facing families across the U.S. today. While behavioral health is a challenge within the general population, the prevalence and severity of needs are significantly higher for children in the child welfare system. The trauma of family separation is profound and can itself lead to or compound behavioral health challenges. Therefore, to address behavioral health, child protection agencies must first acknowledge the damaging effects of out-of-home placement and do everything in their power to keep children safe within their families.

Having safe and supportive placements for children is a critical issue facing many child protection leaders, as is ensuring that children have access to quality mental health services. The issues of placement and treatment should not be conflated, however. Having access to quality mental health treatment and support does not solve a placement issue, and finding a safe and supportive placement for a child does not ensure access to quality mental health assessment, diagnosis, treatment, and support. Too often, particularly when it comes to children with behavioral health concerns considered “high acuity” or “complex,” the lines between treatment and placement concerns and solutions get blurred.

The placement challenges that many jurisdictions are experiencing, with reports of young people living in hospital emergency rooms, psychiatric hospital wards, agency offices, and hotels, have been fueled by a wide open child protection front door, too few alternative pathways for children and families to secure help, and a lack of community-based crisis stabilization and intensive therapeutic support services that could help youth remain safe in their families, or with kin.

Addressing the behavioral health needs of children is a complicated and pressing concern for child welfare systems, in part because leaders must respond simultaneously at multiple levels. In the short term, agencies must prioritize keeping children safe while minimizing time away from family. They also must address the urgent needs of children in their care, through strategies like multidisciplinary teaming and assessment, trauma-focused workforce training, and recruitment and retention of therapeutic foster families. At the same time, leaders responsible for child protection must be active partners in the longer-term work of developing an approach to children’s behavioral health beyond the silo of the child welfare system, one that is trauma-informed, culturally responsive, and can be customized to meet the unique needs of children who are at risk of coming to the attention of — or already in — the child welfare system.¹

Ideally, child welfare leaders will come to the table in partnership with behavioral health, Medicaid, and juvenile justice to advance a system of care approach that meets the needs of children and families early and in the least restrictive way possible, with the goal to reduce the number of children with complex behavioral health needs entering the child welfare system. This requires working across systems in innovative ways to build trust and develop a shared vision.

What is known about prevalence?

Children’s behavioral health is an issue of national concern, and the COVID-19 pandemic exacerbated the range of stressors facing children and families. In 2021, the U.S. Surgeon General issued an urgent advisory on youth mental health, calling for increased access to high-quality, culturally competent mental health care in the places where children and families spend time within their communities, including schools and child care settings. The report concludes that increased access to community-based mental health support helps reduce the escalation of challenges for children and families with mental health needs.

While behavioral health concerns are common among the general youth population, children involved with the child welfare system are much more likely to struggle. In 2019, diagnosed behavioral health conditions were three to four times more prevalent among children in the child welfare system than their peers not in the system. Overuse of psychotropic medications is another concern, as youth in the child welfare system are prescribed these medications at three times the rate of youth not in the system.²

While some children entering foster care have a high-level behavioral health diagnosis that requires specialized care, many develop new or heightened behavioral health challenges as a result of family separation and the impact of being placed in out-of-home settings that do not meet their needs. This underscores the importance of child protection agencies focusing on minimizing time away from family and avoiding removal whenever possible, while still keeping children safe. Children who experience trauma, including from investigation and family separation, may develop challenges with emotional regulation, behavior and relationship building, cognitive functioning, physical health, and brain development.³

Additionally, some parents take the dramatic step of giving up their parental rights, or relinquishing custody to the state, in order to access treatment for their children that is otherwise inaccessible. Though many states have outlawed this practice, there has been little consistent information collected about this issue since the GAO estimated in 2003 that parents placed at least 12,700 children into the child welfare or juvenile justice systems annually in order for the children to receive mental health services.⁴

Key considerations for child welfare leaders

Child welfare leaders are critical partners in efforts to develop a multisystem approach to children’s behavioral health. They are uniquely familiar with the consequences of the lack of such a system and the inadequacy of other prevention supports, and many of the children and families they serve need quality behavioral health care.

The following eight considerations aim to inform how child welfare leaders can approach cross-system work on children’s behavioral health. They were developed through dialogue with a range of stakeholders, including people with lived experience navigating complex behavioral health challenges within the child welfare system, as well as jurisdictional leaders, federal agency representatives, and other partners. These considerations are not intended to be sequential or prescriptive, but instead reflect a range of levers that, depending on the unique situation of a jurisdiction, can help address the behavioral health needs of children at risk of coming to the attention of — or already in — the child welfare system.

1. Actively engage children, parents, and families. Developing systemic solutions to addressing children’s behavioral health requires ongoing dialogue and partnership with families most affected. Families have critical insights about what is needed, and they are uniquely positioned to identify potential pitfalls and point leaders toward effective solutions. Frameworks such as co-design, human-centered design, and community-based participatory research have gained momentum as ways to actively engage families and older children. Engaging people with lived experience through needs assessments and as participants on advisory boards and planning committees are first steps, but families can and should be involved at every stage of planning and decision-making, including helping to design and improve services, programs, and policies.
2. Use data to define, assess needs, and inform solutions. There is no single solution to supporting children with complex behavioral health needs, and deep cross-system analysis is needed at the state and local levels to understand the needs of children being served as well as system capacity and performance. Data, contextualized with stories, can help illuminate who is being served by various agencies, barriers families have faced, and missed opportunities. Leaders need to understand which families are most in need of services, which categories of young people spend time in restrictive settings or experience placement instability, and what supports are necessary to address behavioral health conditions, reduce family separation, and shorten time to permanency. This is especially important for children of color, given unnecessary placement in institutional settings is harmful and Black and multiracial youth are overrepresented in these settings. In addition to administrative data sources that child welfare and behavioral health agencies regularly draw on, geospatial data from platforms like the Community Opportunity Map and Latino Data Hub can be used to examine child and family well-being and the range of social determinants that impact them.

3. Build coordinated, cross-system approaches. Children with complex behavioral health needs and their families typically require a range of services, from health care to housing and more. To proactively address diverse and interrelated needs, it is essential that systems collaborate and coordinate so that families do not have to navigate on their own multiple systems and a maze of decentralized services and providers. Developing an effective multisystem approach to children’s behavioral health requires a shared vision and a willingness to work outside of traditional silos. Multiple funding streams are needed to build a well-resourced system that streamlines access for families and offers the range of needed services across settings. Cross-system efforts are in place in many jurisdictions, and these efforts are increasingly mirrored by efforts to advance coordination at the federal level. Many jurisdictions are embracing a system of care approach that builds partnerships to create a broad, integrated, and coordinated system of supports to meet families’ multiple needs.
4. Create culturally responsive, healing-centered behavioral health supports. Services for children with complex behavioral needs should be culturally responsive, trauma-informed, and healing-centered. As children are best raised by their families when kept safe, increasing access to community-based and in-home services, including mobile crisis response, is essential. Whenever possible, services should be available in the community at sites where children and families spend time, including schools and family resource centers. Comprehensive community-based services and access to specialized supports like therapeutic or treatment foster homes will help ensure that institutional or group settings are a last resort. Peer mental health coaches, indigenous healing practices, and other non-traditional approaches should be part of the continuum of services. The Title IV-E Prevention Services Clearinghouse includes nearly 50 promising, supported, or well-supported programs that address emotional, behavioral, and mental health needs of children.⁵ There remains, however, a need to evaluate more culturally specific interventions to build up the evidence base and expand the range of effective services that can be funded under Title IV-E.⁶ Medicaid, in addition to being a key funding source for behavioral health care, can help decrease barriers to service access through innovations such as removing diagnosis as a barrier to accessing therapeutic services and broadening the types of providers whose services can be reimbursed, to include community health workers and peer coaches.
5. Invest in workforce capacity building and training. Well-resourced, well-trained, and highly skilled child welfare and behavioral health workforces are essential to meet the needs of children and families in a timely and culturally responsive way. Child welfare staff turnover has been associated with more placement disruptions, time in foster care, incidents of maltreatment, and re-entries into foster care. Recruitment and retention of behavioral health professionals also has been a concern for many years and was exacerbated significantly during the COVID-19 pandemic. Jurisdictions are pursuing a range of efforts to address the children’s mental health workforce crisis, including incentives and apprenticeships. Issues like burnout, pay structure, workload, and administrative expectations contribute to high turnover in child welfare, and many jurisdictions are working to stabilize and reinvigorate the workforce. In addition to stabilizing the workforce, ongoing training for staff to build rapport and empathy with children and families, effectively assess needs and provide appropriate supports, and develop clear case plans in partnership with children and their caregivers is essential. Investing in different roles like community health workers and peer coaches — who are part of the local community and often share lived experience with the community members they serve — also is critical.⁷

6. Strengthen community pathways and concrete supports for prevention. Alternate pathways for family support in communities will help reduce the number of children entering the child welfare system. Community-based pathways can take many forms, including: preventative wraparound services available through family resource centers or other community hubs; concrete supports like childcare, housing, and transportation; and long-term investments in the economic empowerment of families and communities, including supporting small business development and social enterprises. Through the Family First Prevention Services Act (Family First), jurisdictions are providing families access to prevention services through community pathways — and without direct involvement of child protective services. In addition, many jurisdictions are investing in concrete services and economic supports for families. Evidence from 31 guaranteed income pilots shows these interventions can reduce familial stress and increase access to basic needs.
7. Increase access to effective legal supports and advocacy. Preventive legal advocacy aims to resolve upstream legal problems to strengthen families, address the social determinants of health, and eliminate unnecessary reports to child protective services. High-quality legal representation is essential to ensuring that children and parents’ legal rights are well protected and the wishes and needs of all parties are effectively voiced. Child protection agencies can now claim administrative costs for attorneys to provide legal representation for children and their parents under Title IV-E. Quality pre-petition or preventive legal representation can help parents and social workers to address matters such as custody and divorce, safe and affordable housing, public benefits, special education, and other issues that often can lead to increased stress among parents. Addressing these poverty-related challenges can help prevent child maltreatment and reduce instances of family separation. This can be especially helpful for parents caring for children with higher emotional and behavioral health needs, as they may require additional supports to ensure that their needs are met.
8. Prioritize kin placement and expand support for kin. Child protection agencies can reduce the number of children with behavioral health challenges entering the child welfare system by prioritizing kin placement and increasing supports available for kin. If child protective services determines that a child must be removed from home to remain safe, that child deserves to be placed with kin, whether with relatives by blood or marriage, or extended family members who are close to the child and family (known as fictive kin). Intensive family finding, use of kinship care, and support of kinship treatment foster care are all ways to minimize time away from family. Like all children in out-of-home care, those placed with kin are entitled to resources and supports that help protect their safety, promote their well-being, and facilitate permanency — ideally through safe reunification with their family. For kin who are supporting children with behavioral health needs, access to crisis care and in-home services and support is particularly important. Kinship navigator programs, which can be funded using Title IV-E dollars through Family First, increase social support, improve family resources, and improve child safety and placement stability.

1 This brief summarizes and draws heavily on the following report: Creating Healing Pathways for Children with Behavioral Health Needs: Key Considerations for Child Welfare Leaders and Partners.

2 Radel, L., Lieff, S., Couzens, C., Ali, M., & Westet, K. (2023). Behavioral Health Diagnosis and Treatment Services for Children and Youth involved with the Child Welfare System. ASPE Office of Human Services Policy.

3 Center on the Developing Child at Harvard University (2016). Applying the Science of Child Development in Child Welfare Systems. Retrieved from www.developingchild.harvard.edu.

4  Though the most recent national study of this phenomenon is the 2003 GAO study, coverage of this practice in mainstream media outlets has continued.

5 Pecora, P.J. (2023). Helping youth heal with emotional and behavioral health needs: A background paper for the Casey work group for youth with unmet complex needs. Seattle: Casey Family Programs, p. 13.

6 Phillips, C., & Sinha, A. (2023). Addressing Gaps in Culturally Responsive Mental Health Interventions in the Title IV-E Prevention Services Clearinghouse. Clinical Social Work Journal, 1-12.

7  U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions. (2007). Community Health Worker National Workforce Study. Washington, D.C.