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Kids First: Systems, Health and Family Well-being

August 18, 2019

Challenges in areas ranging from education to the environment, gender to governance, health to housing don’t exist in a vacuum. Each month, Abt experts from two disciplines explore ideas for tackling these challenges in our monthly podcast, The Intersect. Sign up for monthly e-mail notifications here. Catch up with previous episodes here.

Health. Food security. Opioids. Child welfare.

When parents need support, the services they rely on sometimes fail the family by imposing unnecessary child separations. How can we help systems work together so families can stay together? Allison Hyra and Katharine Witgert have some suggestions.

Read the Transcript:

Eric Tischler: Hi, and welcome to The Intersect. I'm Eric Tischler. Today, I'm joined by Kathy Witgert and Allison Hyra. Allison provides research evaluation and technical assistance in the areas of income, security, workforce, and family self-sufficiency. She's currently directing a project supporting grantees of the Administration for Children and Families that are developing community collaboration to prevent child maltreatment and subsequent entry to the child welfare system.

Kathy has 20 years of public health and health policy experience focused on vulnerable populations. As a senior associate at Abt, she manages research and analysis and provides technical assistance at the state and federal levels. She's worked with clients, including the Centers for Medicare and Medicaid Services, the Health Resources and Services Administration and the Department of Housing and Urban Development.

Thank you both for joining me.

Kathy Witgert: Thanks for having us.

Allison Hyra: Yes, thank you very much.

Eric: Systems that are designed to help people with issues ranging from substance use to housing sometimes fail to take into account the needs of families as a whole and more specifically children. We're going to talk about ways to remedy that, but to start, Allison, can you tell us why it's important that we try to keep kids and parents together even under difficult conditions?

Allison: Sure. So, you know, we've really realized how traumatic it is for children to be removed from their families. Even though folks may look at a situation and say that that's not optimal for child development, there is a true bond between children and their parents, and when they are pulled from their family—often without warning or a full complete description of what's really going on—they're placed in a foster family, which is really terrifying to children. So we are learning, particularly for cases that are not incredibly severe, that it's better to bring services into the house and address the root cause of either the acts of abuse or the acts of neglect in a way that keeps the family in the home together and minimizes and mitigates the negative effects on children.

Eric: So what are some of the causes that lead to neglect in these families?

Allison: Right, so we don't want to say poverty causes neglect; there are lots of low income folks that are doing just great with their kids. But not having access to resources and income makes it a lot harder for parents to meet their kids' daily needs. You can see, you know, if you don't have the funds to cover groceries that week, it's a lot harder to feed your kid than somebody who would just maybe, say, withhold food, which is not that common. So, connecting with families and understanding what are the barriers in their lives to meeting their child's wellbeing and then addressing those root factors, whether it's mental health, substance use, income, housing, social support, goes a much longer way towards stopping the neglect and preventing it in the future.

Eric: Thanks. Kathy, Allison has listed a lot of different issues. How are we addressing those systemically?

Kathy: Well, it's interesting that the health care system might encounter some children and families sort of on the back end of an abuse or neglect situation, when the health care system has also been starting to think about some of those root causes that Allison mentioned. And so, on the healthcare side, they would call them "social determinants of health," but they're really social determinants of overall wellbeing in a lot of different areas of health and functioning.

So some of those same issues—like housing, poverty, transportation challenges—are going to affect health needs and, for children, developmental needs that might be addressed partially in the healthcare system, but also largely outside of the health care system.

Eric: Right. We're talking multiple systems. How are they or are they not coordinating? And how's it going?

Kathy: It's going better than it was, I think. It's a challenge. The systems have different funding streams, different administrations at the federal and state level. They have sort of different cultures and terminologies that they use, but they are all serving the same population of children and families and have the same goals of increasing health and wellbeing for those children and families. So there has more recently been a recognition of the need for the systems to work together, to meet each other, to learn how they communicate, and even to try to integrate some of the financing so that, as an individual accessing a system, I can have all of my needs met and it's not incumbent upon me to figure out the intricacies of each different system and mesh it together myself.

Eric: How are families fitting in amidst these sort of multi-systemic approaches to these issues?

Allison: They're really not, you know? So they're ... Again, going back to this funding stream. Medicaid may be addressing the child's physical health through pediatricians or OT, physical therapy, but the entire system over here—that's housing, that's providing vouchers, Section 8 etc.—they don't communicate at all. So it is really on the families to navigate these incredibly complicated waters that even politicians and policymakers don't understand.

Eric: I'm assuming that's tough to do.

Allison: Right, right. I mean, I think one of the problems is that you find one trusted system, but they don't know enough about the other systems. And the pediatrician isn't in the place—nor do they have the resources or the time—to then dig in to figure out what's going on that's causing stressors in the family or even know of the other resources, the non-medical resources in the community, to refer folks to. There are some pediatric practices that have social workers on staff, and that really goes a long way to then connecting them to social and human services, but a lot don't.

There's some work that's starting, supported by the Centers for Medicare and Medicaid Services, to screen people when they come to a doctor's office visit for what they're calling health-related social needs. So, they’re just starting to ask about housing, food, transportation, a violent living situation, and then to give those healthcare providers resources to help make that linkage.

Kathy: So we're just starting to learn about, sort of, do families think that this is actually an acceptable practice, right? If you went to the doctor, would you want them to ask you, "Do you have enough to eat and do you have a safe place to stay?" It seems like most people are accepting of it, and that physicians are appreciative of having some resources. I think we're still really at the beginning of determining how to make those linkages and how to utilize those resources and really just starting to integrate the systems.

Eric: Right.

Allison: So, for a long time, the child welfare system has been seen as punitive. They don't get involved in families' lives until there has been a substantiated case of child abuse and neglect. And in the last 10 years or so, both the federal government, policymakers, legislators and state governments have really said, "This is backwards. Why are we waiting until a problem has happened, until trauma has occurred in a child's life before we get engaged?"

Through legislation and other efforts, such as the Family First Act, we've started to earmark federal funds and state funds for prevention work. So, things like the Prevention Services Clearinghouse that Abt is putting together is really helping states to identify evidence-based practices and programs that can be inserted into families' lives before they become part of the child welfare system. And states are also working really hard to change families' attitudes around a child welfare system.

So rather than being seen as, "Oh, when that case worker comes, you do not say anything. You wait until they leave. And this is an inside, family issue. We do not talk to the state. We don't want to lose you to the state," to being somebody who can sit down with a family and help identify challenges and link them to resources in a way that families get on track or stay on track without feeling like they have been punished by the state.

And so, I think that's a really important shift in mindset and approach in a way that families can start to see the child welfare system as a partner rather than an enforcer or an authoritarian sort of state-level effort.

Eric: That's a great distinction. So that's how family perception can change. How about between systems, between agencies? What do you guys think we can be doing, or they can be doing, to sort of strengthen that lattice they're creating, which is essentially a safety net for these families and kids?

Allison: Right, right. I mean, part of it is that a lot of professionals are still defined as mandatory reporters. So, if you ask a question about child abuse and neglect, and in many states if you ask a question about prenatal substance use or domestic violence in the house, those are all considered child abuse and neglect factors. So, those helping efforts on the part of health systems can end up being punitive because they are mandatory reporting to the state in a way that then brings in sort of this case worker and investigator, etc.

So I think helping to change maybe the ways that mandatory reporting or enforcement happens on those other systems levels can help increase the honesty and reliability of parent communications with other trusted institutions—like their pediatrician, like their schools—in a way that they can get the services that they need and not feel like they have had a child welfare case opened on them.

Eric: Right, right. And so, Kathy, how about then between those actors outside the family, what can they be doing to sort of better communicate and collaborate better do you think?

Kathy: Yeah. So, on the healthcare side, I think the mandatory reporting came out of a good impulse that, "Gosh, we need to do something about these kids." But we know now that it has sometimes deterred people from talking about abuse or neglect situations with physicians who are often trusted confidants in a lot of ways. And women who might be using substances and become pregnant can be deterred from seeking prenatal care, for example, because they're worried about the consequences.

And it's interesting that the Professional Associations for Obstetricians and Gynecologists, as well as those for the substance-use disorder treatment community, have come out with statements saying that separation of parents and children should be discouraged and just using substances shouldn't be considered abuse or neglect. You have to look at the whole picture and hopefully be able to move people into treatment and keep that family together.

Eric: What would the two of you advocate for to help strengthen this communication, to help connect these dots?

Allison: Right. I mean, I think the more intense wraparound services that you can provide, the better off families are going to be. I think we need to think about two-generational approaches and sort of holistic treatment of a family as opposed to “The child welfare system is over here protecting the wellbeing of the child, the pediatrician's over here protecting the health of the child, the obstetrician/gynecologist is protecting the reproductive system of the woman, and the GP is managing the rest of her body.”

If we can bring those systems together and think about what a family needs to thrive, I think we can go a long way. And one of those things that really doesn't play into any of those systems is that families reside together. So I think supportive housing where services are brought in to deal with the various risk and protective factors that the family is dealing with is probably one of the best ways we can manage the situation. Parents then can stay with their children, and transportation issues, barrier issues, are reduced, and there's a sort of systemic, holistic approach to addressing family wellbeing, which I don't think is a priority of many systems: thinking about family wellbeing. It's usually an individual member's wellbeing.

Eric: What do you think, Kathy?

Kathy: I agree that housing is really a fundamental building block for a lot of these other outcomes that we're all seeking. Kids that move around a lot are going to have more trouble in school and are going to shift systems. They're going to have difficulties with transportation or maybe with getting nutritious food. And so, the healthcare system always sees the back end of it, they're starting to move in that upstream manner and to understand those social determinants and the importance of supporting those in order to have positive health outcomes. I do think that thinking about the family as a unit is a step we haven't quite gotten to yet.

One example that I just thought of from the healthcare side is infant and early childhood home visiting programs. So this will be after someone goes home from the hospital with their new infant, a trained person will come to their home for some period of time. Some of the home visiting programs use a nurse, others use a trained lay person. So there's a whole range of ways to go about this.

But it's basically someone who can come in, see how things are going, provide some education to the parents about, “How do you take care of this baby that just came home with you?” And also monitor for some of those developmental milestones, explain those to the new parents and help them with resources. You know, we know that it's really good to read to your kid, "Well, here's a book and let's read it together," and sort of modeling some of those behaviors. So that's one place where the family unit is acknowledged a little bit, but there's probably a lot of additional opportunities that we could look for that we haven't taken advantage of yet.

Allison: I think that's probably the starkest cutoff. Speaking from personal experience, when you're pregnant, the obstetrician is caring for both the woman and the fetus. Then, once the fetus is born, that's passed off to the pediatrician and the obstetrician is only caring for the woman. And I remember having a problem with breastfeeding, and I'm like, "Do I call the obstetrician because it's my body? Do I call the pediatrician because I'm feeding the baby?" And it's just really unclear to new parents about who to go to for services that really connect the both the parent and the child together.

Eric: So, put you on the spot. What do you recommend to start connecting these dots? How do we get people to start thinking about the family first or it had taken that holistic view?

Allison: Well, thinking about the public health model of home visiting that you were speaking about, there's the Nurse-Family Partnership that's more of a child welfare/child wellbeing approach, which is incredibly evidence-based and has demonstrable effects 30 years later. But integrating both that social support with the sort of health knowledge of screening for postnatal depression, parental substance abuse, I think could go a long way.

Co-location of services is always a great idea, where you can see both the maternal provider and the infant provider at the same time. And then, I think really bringing in social work as a way to connect the continuum of services that is already available in the community but in a mindful way that is aligned with each individual families' risk and protective factors, so you are connecting them to the right services at the right time.

Kathy: Yeah. There are some places where we know, for example, people will often take better health care of their child than they do of themselves. And so they'll go in for well child visits. And so, if you can do the parent checkup at that same time, or offer a flu vaccine to the parents at the same time that you're doing a kid's back-to-school physical. There's really little ways where we can grab onto things. And I think broadening out to the connections with other systems is still really in its infancy and where we have a lot of work to do to find out kind of what works and how to help those systems connect with each other so that they can serve families.

Eric: Well, systems working together to help keep families together sounds like a pretty good place to stop. So, thank you both for joining me.

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