This week, the U.S. Surgeon General’s Advisory on Protecting Youth Mental Health outlined steps to support the mental health needs of youth involved in the child welfare system. This followed pediatricians, child and adolescent psychiatrists and children’s hospitals declaring a National State of Emergency in Children’s Mental Health.
As the CEO of the Center for Adoption Support and Education (C.A.S.E.), I could not agree more that we are facing a crisis. COVID-19 brought a devastating impact on children that came into this pandemic with a history of trauma, loss and grief exacerbated by fear of the pandemic itself, more loss and the reality of isolation from peers, teachers, extended family and other significant supports in their lives. Our caseloads, like others, have exploded with youth and families in crisis. The Surgeon General’s report and the emergency declaration must be a call to action to advance real, tangible solutions for populations most at risk u2013 children in foster, adoptive and guardianship families.
Up to 80 percent of children in foster care have significant mental health issues, compared to approximately 18-22 percent of the general population. The Government Accountability Office reported that foster youth are prescribed psychotropic medications at a much higher rate, costing millions of dollars a year. The American Academy of Pediatrics identified mental and behavioral health as the ‘greatest unmet health need for children and teens in foster care.’ The Brookings Institute Center on Children and Families reported children in long-term foster care are over-represented among youth with serious disciplinary problems in schools, high school drop-outs, unemployed and homeless, unmarried pregnant teenagers, substance abusers, and in the judicial system.
We know the problem. Yet, children and youth in foster care u2013 often with the most compromised and traumatic beginnings u2013 get mental health services from the least qualified professionals due to lack of training and low reimbursement rates typical of Medicaid programs. We must advance the Surgeon General’s recommendations that the nation provide mental health services to foster youth and ensure their access to mental health services in community settings whenever possible, but we also must address the need for a trained and competent workforce to meet their needs.
Adoptive parents consistently report their greatest post-adoption support need is mental health services provided by someone who understands adoption. Some reported seeking therapy from as many as ten different therapists before finding one who is adoption-competent, if they find one at all. When the Family First Act passed in 2018, building an adoption-competent workforce was considered a priority. While the Title IV-E Prevention Services Clearinghouse prioritizes mental health, which includes improving the competency of the child welfare workforce, the Training for Adoption Competency (TAC) curriculum still has not been reviewed after two years, which is a requirement for states to have the training be eligible for federal support.
TAC was created through collaboration with nationally recognized experts – including adoption practitioners, researchers, advocates, policy makers, and those with lived experiences to identify the core knowledge, skills, and values competencies that mental health practitioners need to serve members of the adoption kinship network. TAC has received accreditation from the Institute for Credentialing Excellence (ICE) for a five-year period through November 20, 2025 – making TAC part of an elite group of certificate programs dedicated to public protection and excellence in practice. It is the only accredited adoption competency training program in the country. It is also on the California Evidenced-Based Clearinghouse for Child Welfare (CEBC), a nationally recognized body that applies rigorous standards of review to identify effective programs.
During a national emergency in child and adolescent mental health, states should be able to access TAC as a covered innovative training under Family First.
Additionally, the National Adoption Competency Mental Health Training Initiative (NTI), a cooperative agreement between the federal Children’s Bureau and C.A.S.E., developed two free state-of-the-art, standardized, web-based trainings to build the capacity of child welfare and mental health professionals in all states, tribes, and territories to effectively support children, youth, and their foster, adoptive, and guardianship families. In the pilot, we learned that child welfare staff did not understand the impact of loss and grief on children’s mental health and the following completion of NTI training showed the highest gains from pre-to post-test.
This understanding of separation and loss is critical to address the mental health challenges in this population. On the mental health side, clinicians did not understand the core concepts of attachment nor the impact of race and diversity but showed significant gains following completion of NTI Training. Today, over 20,000 child welfare and mental health providers have enrolled in NTI but we still have a long way to go.
Imagine the problems that arise from child welfare workers not being able to support children in their healing from profound loss and grief and then referring them to therapists that do not know how to promote attachment or understand the implications of transracial/transcultural adoption. We will continue to face poor outcomes if providers serving these children and youth do not acquire the foundational knowledge required to address their mental health needs.
Congress has a tremendous opportunity to make NTI permanent as part of reauthorizing the Child Abuse Prevention and Treatment Act so its trainings become the standard for all child welfare agencies, tribes and territories. Furthermore, NTI should be expanded to train court personnel, school-based health clinics or others interacting with foster and adopted youth.
We need pediatricians, child and adolescent psychiatrists and children’s hospitals to partner with us to disseminate these innovative trainings to providers. We can address this crisis by building a sub-specialty of professionals who are permanency and adoption-competent. The Surgeon General could help to advance innovative payment models that would ensure both fair reimbursement rates to providers and access to adoption competent mental health care for these Medicaid-eligible youth.
The good news is that we have existing innovative training programs ready to build the competency of the child welfare and mental health workforce. Through partnership, let’s connect this underrepresented population to mental health providers trained to meet their needs.