In mid-February, Alameda County foster mother Frances Cleveland* realized that she was near a breaking point.
Since December, she had been caring for Esther, a 14-year-old foster youth from Nevada County, a small jurisdiction located at least three hours from the Clevelands’ home in a suburb of Alameda County just across the bay from San Francisco. Since she moved in with Frances and her husband Gary in early December, Esther’s situation had grown increasingly stressful—emotional outbursts had turned into screaming matches and threats to run away.
The Clevelands were hoping to adopt Esther, but this was the first time they had opened their home to a foster youth and they were at a loss about how to get the teen the help she needed.
“Should I call the cops or do I call you?” Frances remembers asking the social worker from Nevada County who was assigned to Esther’s case. “We wanted to make sure [Esther] wouldn’t hurt herself.”
While this was happening, Esther’s anti-depressant medication had dwindled down to the last two pills. The family still had not been connected to a psychiatrist in Alameda County who could renew her prescription or offer therapeutic mental health services that might ease the transition from a tumultuous stay in foster care to the Clevelands’ quiet suburban street.
Esther’s Nevada County social worker and Frances had both spent hours each week trying to access therapeutic services near the Clevelands’ house that were similar to the weekly visits with a therapist that Esther had been receiving for the last couple years in foster care in different counties.
Finally, a general practitioner in Alameda was able to fill Esther’s prescription, thanks to her MediCal coverage, but Esther would have to wait until March to see a therapist in her new county of residence.
Far from an isolated case, long delays for mental health support are a common experience for the more than 12,500 foster youth who are placed out of county in California.
This is largely due to a long-standing issue with the way that California provides mental health services to foster youth through its MediCal system.
Each of California’s counties has its own mental health system. When an out-of-county youth is sent to a new county, mental health services are not always recognized since the old providers are not part of the new county’s network. The lack of protocols for transferring youth between counties means that it may take months for services to become available in the youth’s new county of residence.
For out-of-county children like Esther who are on a path to adoption, the lack of consistent and timely mental health resources can have especially perilous consequences. Bureaucratic wrangling between counties that delays supportive mental health services often forces youth to endure undue additional trauma and failed placements. This tenuous situation also has serious implications for the state’s most vulnerable children who are due specialized mental health services under the settlement for the state’s landmark Katie A. lawsuit.
Ultimately, brave and overburdened adoptive families are often left on their own to navigate the opaque walls of county bureaucracy.
Finding a Home
When the Cleveland family said they were willing to adopt an older child, social workers were “ecstatic,” according to Frances Cleveland.
Parents are a lot less likely to adopt older foster youth, according to Michelle Young, a permanency specialist with Sierra Forever Families who helped Esther find the Clevelands.
“Most people who are thinking about adoption are often looking to start a family and want either an infant or a child who is under 5,” Young said. “Ages 6 and up becomes a real challenge, and teens are even more difficult.”
California’s foster care system has shrunk by 46 percent since 1998 because the state has improved the way it delivers services to at-risk families and more children have been reunified with their families, according to Gail Johnson Vaughan, executive director of adoption advocacy group Families Now.
The kids in foster care who are waiting to be adopted today are different than they were even 10 years ago, she said.
“The children who are left in the system now have much greater trauma, much longer trauma, kids from families with substance abuse issues,” Johnson Vaughan said. “It’s a real challenge to get families to come forward for them.”
Jill Jacobs, director of Oakland-based Family Builders by Adoption, an agency that seeks to find permanent families for children and youth in the foster care system, says the adoption of children hailing from far-off counties is commonplace.
“Occasionally we place a child who is a dependent of a particular county with a family in that county, but more often than not, that’s not the case,” Jacobs said. “It’s more likely that the child and the family we have mind that’s a good match for that child happens to be in a different county.”
Moving to Alameda County
The Cleveland family met Esther at a matching event in San Jose last October. As they spent more time with Esther, including a visit during Thanksgiving, they were ready to welcome her into their Alameda County home. It was their first adoption.
As she made the three-hour trip to the Cleveland family home in early December with Young, Esther declared that it was “the happiest day of my life.”
But Frances and Gary knew that Esther had significant challenges. Over the previous two years, Esther had cycled through at least nine placements, her most recent being a group home in Sacramento County where she was sent after her grandmother died.
She also had been identified as part of a group of children in or at risk of entering foster care needing intensive mental health services. According to terms of the 2011 settlement of the landmark Katie A. vs. Bonta lawsuit, the state has significantly increased the amount of intensive mental health services to which young people like Esther are entitled.
A recent count placed the number of California foster youth who used Katie A.-related intensive and therapeutic services at the start of the year at 6,873. But across the state, only 193 out-of-county foster youth received these services in the same time period—about 1200 fewer youth than the total expected number.
After coming to the Cleveland home, Esther struggled to adjust to a new life with Frances, Gary and their toddler.
“She would have these intense crying jags, saying ‘you don’t love me as much as you love your daughter,’” social worker Young said.
The Clevelands also noticed that hygiene remained a challenge for Esther as well as finding a way to control her impulsive behaviors and emotional outbursts.
According to Lynn Thull of the California Alliance of Child and Family Services, therapeutic mental health services are especially important for children dealing with immediate trauma, a recurring issue for out-of-county children in foster care.
“This is one of the most vulnerable times for these children,” said Thull, also a clinical therapist. “They’ve not only been taken away from their family of origin and suffered whatever trauma got them into that system, but they now are moved from the community that they knew into a family they don’t know.”
Without mental health services for traumatized children and their families, placement stability may be at risk.
“If [supportive mental health services] aren’t there, we’ve seen way too many of these placements just fall apart and we know by research that every time a placement fails, it’s less likely that a child will ever be part of a permanent family,” Thull said.
Jacobs of Family Builders recounted the story of a pre-teenaged girl who was matched with out-of-county parents who were eager to provide the girl a home. But her placement didn’t work out because the parents didn’t receive regular mental health services in the girl’s new county of residence. Without supportive services, the parents were unable to prevent the girl from hurting herself. Since the placement failed, she’s spiraled into five or six placements and now lives in a group home, waiting for another forever family against long odds.
“No one’s found the right place for her,” Jacobs said. “If we had been able to get services to her earlier, I really believe we would have been able to stabilize the situation.”
In Alameda County, the Cleveland family was desperately searching for services that could provide stability.
But after weeks of calls by both Frances and her Nevada County social worker, the family was no closer to obtaining an appointment with a psychiatrist who could prescribe medication or provide supportive therapeutic services to Esther and the Cleveland family.
“I try to be a pro-active mom and try to take care of her needs, but it’s been very frustrating when I can’t,” Frances said. “Without support, it feels like a very long time when you’re living day in, day out.”
Eventually, Frances was able to fill Esther’s prescription through a primary-care doctor, but missing paperwork and information that did not get transferred from Esther’s prior placements in Sacramento and Nevada counties complicated even this temporary solution.
After more than two months without therapeutic services and an ad-hoc approach to other health services, Frances reached her wit’s end.
The biggest frustration came when she and her husband Gary offered to pay for a therapist for Esther out of pocket, and were told by the social worker from their foster family agency that was not possible. Because the 14-year-old was still a ward of the state, the social worker said, they could only allow her to talk with a county-approved therapist.
“I was getting a little angry,” Frances said. “If you won’t let me take care of her, then you take care of her, but you guys aren’t willing to take care of her,” she remembered thinking.
Overall, Frances describes the workers in Alameda County as mostly helpful. But without a system designed to smoothly transfer mental health services from one county to another, foster parents of out-of-county youth with significant mental health needs are left to dangle.
“Everyone I talked to in the new county really wanted to help, but it was very disorganized,” Frances said. “Everyone seemed to have their hands tied and needed to talk to someone else to make things happen. They would say, ‘I can talk to my supervisor and maybe they can pull some strings to make that happen.’ After I got to more than a dozen people, I almost wanted to give up for a while.”
It takes “a huge amount of persistence” for adoptive parents to access mental health services for out-of-county youth, according to Jacobs. Those youth who receive services are sometimes the beneficiaries of personal ties rather than agreed-upon policy and practice.
“Supportive services should be there,” Jacobs said. “You shouldn’t have to pull strings or have a special relationship or call in a favor to get services for a kid.“
She recalled many experiences of leveraging her own personal relationships with managers in certain counties to get mental health services approved for out-of-county youth. But in counties where Jacobs doesn’t have strong connections, the opposite is true.
“If we happen to have placed a child in a county where we don’t have a significant prior relationship, then it goes nowhere,” Jacobs said. “In the meantime, the family is struggling.”
California is currently mulling a legislative fix to this issue. Assembly Bill 1299 would have forced stakeholders in the state—including representatives of county welfare agencies and mental health systems—to hammer out a way to ensure that out-of-county youth are able to more easily access mental health services in their new county of residence. But on Thursday that bill did not make it out of the California Senate Appropriation Committee, virtually guaranteeing that regular mental health services will continue to elude the state’s out-of-county foster youth.
Making a Home
After hours on the phone each week with different Alameda County mental health providers and social workers, Frances finally found a way to book a therapist appointment through a staff member who helps coordinate Alameda County’s Katie A. services, such as programs that allow youth to receive therapeutic care at home.
But even after Esther finally saw a therapist in March, more than three months after the teen had moved to Alameda County, the situation was far from resolved. Esther had been meeting regularly, at least once a week, with a therapist at the group home. Finding an available therapist has been hard, as well as finding an appointment time that doesn’t require Esther to miss school in Alameda.
In the past six months, Esther has only been able to see a therapist four times.
“Even now, I still feel very doubtful that we will have a regular therapist in the next few months,” Frances said. “We got a call from [the therapist’s] supervisor saying that [the current therapist] is unavailable for the next two weeks and then we don’t know when she’s coming back or if she’s coming back at all. So now we need to find a new therapist.”
Still, Esther has made great strides during her time at the Cleveland home. The family is receiving some wraparound services from Lincoln Child Center’s Project Permanence, programs that include supportive services for the family and a peer mentor for Esther.
And Esther now comes to Frances and Gary to talk when she feels her emotions getting the best of her, instead of having explosive meltdowns.
“She’s a very different person than when she first came to us,” said Frances. “She’s made a lot of progress. Changes in little habits can make a big deal in our lives.”
Esther is now on a path for adoption with the Cleveland family. If everything goes smoothly, the Cleveland family may adopt her by Christmas.
“It’s a rocky road,” Frances said, “but you have to be prepared to be in it from start to finish. You kind of expect adoption to be a lot of work, but without help from the county, it’s even more than we thought.”
* The names of the family and a few details in this story have been changed to protect the identity of the child in their care.
Meiling Bedard and Maria Akhter contributed to the data visualization for this story.
About Out of County, CA
The Chronicle of Social Change is featuring a series of stories about the experiences of out-of-county foster youth in California.
The county-run system that has emerged is riven with conflicting goals, pressures and incentives. Significant disparities have emerged between counties, with stark differences in the types and availabilities of services to children in care.
For California’s 12,626 out-of-county youth—1 in 5 of all children in the system— the journey across county lines is a frequent and largely unacknowledged experience in the state’s mammoth child-welfare system.
As part of our Out of County, CA series, we examine several different placement types to better understand what the decision to send children out of county means—including both the costs and benefits—to a group that often travels hundreds of miles in search of safety, stability and permanency.
We know there are even more stories left to tell for a group that often escapes wider attention. If you’ve got a comment, idea or tip, please let us know. We look forward to your comments and perspective.