Point of View: Mental Health Needs in Kinship

There are 350-400,000 children and adolescents in New York State that are in kinship care. I.e., they are raised by relatives other than their biological parents. Although there is some evidence that these children do better psychologically than those who are in foster care with strangers, there are serious mental health challenges for these kids, for their kin caregivers, and for their biological parents. New York State can and should do more to address these challenges.

This was the overarching conclusion of a workgroup on mental health that AARP and the NYS Kin Caregiver Coalition convened to identify key mental health issues in kincare and to develop recommendations regarding how to address them.

Kin caregivers include grandparents raising grandchildren, aunts and uncles who fill in for their siblings, older brothers and sisters, who are often kids themselves, and other family and friends who are willing to take on parental responsibilities despite the burden it creates in their lives.

Sometimes kin caregivers step in because of the death of the children’s parents, but more often it is because the biological parents are unable to provide basic care for their children. For example, military service members who are deployed away from home may have to turn to their parents or others to raise their children while they are away. Similarly, some parents have non-military work assignments that take them away for long periods of time. Other parents are away from home not because they are serving their country or working to earn a living but because they have been incarcerated for crimes. Others have physical, mental, or substance use disorders that impede caregiving. In many cases the children have been victims of abuse and/or neglect at the hands of their parent(s) or stepparents and may, therefore, have been removed from their homes by the child welfare system for their own protection. When this happens, relatives may become “formal” kin caregivers and get financial support and oversight like unrelated foster parents. But far more often, families make arrangements on their own (“informal” kincare) with limited, or no, assistance from the child welfare system.

The mental health challenges inherent in kincare are numerous. Children who have been separated from their parents almost inevitably experience grief and suffer various forms of trauma that can have a long-lasting impact on their development. Kin caregivers generally experience tremendous stress and are at increased risk for mental and physical disorders, which are often exacerbated because the caregivers do not have the time or resources to address their own needs adequately. The biological parents also often experience grief and trauma, and some have had their children removed because the child protective service believes that they have mental and/or substance abuse disorders and has concluded (not always correctly) that for this reason they are not capable of raising their children.

How can these mental health challenges be better addressed? A group of experts (including kin caregivers themselves) met in December 2009 and another group met in June 2010 to answer this question. Their observations and recommendations were far-reaching and too extensive to report in this column. But here are a few highlights:

  • The mental health and substance abuse service systems are often not able to provide adequate services to kids, kin caregivers, and their biological parents because services are in short supply; because they are often difficult to access due to distance, office hours, language barriers, or cost; and because often they are not provided by staff with expertise regarding this population.
  • All of the systems that serve this population could do more to promote mental health rather than waiting for a disorder to emerge. This includes primary health care, schools, child welfare services, aging services, the criminal justice system, etc.
  • Most service systems have tunnel vision and fail to notice or do anything about the fact that the children they serve may be in kincare or that the adults that they serve are also parents or kin caregivers.
  • The fragmentation of the service systems—a problem noted in all discussions of the limitations of service provision in our society—also affects kincare. It is particularly important to improve the integration of physical and behavioral health services because primary health care provides opportunities to promote mental health, identify mental and substance use disorders, and provide treatment. But integration is also important in schools, child welfare programs, aging services, the criminal justice system, employee assistance programs, and the military and veterans’ service systems.
  • Kin caregivers often do not get physical and mental health care, especially preventive care and regular check-ups, in large part because kin caregivers tend to put their own needs second to those of the kids they are raising. Outreach to encourage them to take care of themselves can be very important to their physical and mental health.
  • The needs of biological parents with mental disorders are often neglected. There is great controversy and confusion about when parents with mental disorders are incapable of providing adequate care for their children, when they need support, and when they can be good parents on their own despite the fact that they have a mental disorder. In addition, psychiatric rehabilitation, which could help parents with serious mental illnesses develop the childrearing skills they need, generally does not focus on this as a major life goal, despite the fact that for many parents with mental disorders raising their own children is their highest personal priority.

Needless to say, addressing these issues is exceedingly difficult—especially during a period of history when the economy makes service expansion largely politically impossible in New York State. Nevertheless, the workgroup identified steps that are possible now that could be extremely valuable later. These include:

1) Make Kinship Care A Policy Priority:

  • Multiple state and local agencies touch on the lives of people involved in kincare, including mental health, substance abuse, health, education, aging, corrections, and more. Each should include kincare among its priorities.
  • Planning processes related to children, health and mental health, aging and more are constantly underway in New York State at both the state and local levels. Few of these address kinship care at all, let alone the mental health challenges of kinship care. But they should.
  • In addition, a number of inter-agency groups have been convened at the state and local level to develop coordinated approaches to address health, behavioral health, and human service needs. All of these planning and advisory groups should include kinship care among their major priorities.

2) Improve the Mental Health and Substance Abuse Systems: Issues of access, outreach, engagement, and quality all need to be addressed by the mental health system not just in general but specifically with regard to the hundreds of thousands of kids in kinship care. Immediately this could include:

  • Establishing a workgroup to review and make recommendations to improve OMH’s clinic standards to assure appropriate attention to the family context and to the challenges involved in reaching and treating family caregivers.
  • Establishing a workgroup to recommend ways to include parenting as an important goal of psychiatric rehabilitation. This would include recommendations for OMH’s guidelines for “Personalized Recovery Oriented Services” (PROS).
  • Developing a training initiative for behavioral health professionals related to the specific emotional needs of kids separated from their biological parents, to the burdens and distress common among kin caregivers, and to the needs of biological parents separated, or facing separation, from their children. This could include a tool kit for mental health and substance abuse services providers: Your Clients May Be Parents or Caregivers.

3) Support Current Efforts to Integrate Physical and Mental Health Services: As noted above, primary health care provides an opportunity to identify and to respond appropriately to behavioral health problems of kids in kincare, their caregivers, and their biological parents. Integrating mental health services into these settings just makes sense. In addition, some biological parents with behavioral health problems may be getting services from specialized mental health or substance abuse programs. In these cases, integrating physical health care into behavioral health centers often makes more sense than expecting them to get care from primary health care providers.

4) Focus on Mental Health Promotion rather than just waiting to respond to diagnosable disorders. One way to do this would be to develop and disseminate a toolkit— “Kids in Kincare and their Caregivers: How You Can Help Them Thrive”—in multiple service systems.

5) Confront the Issue of the Relevance of Mental Disorders to Child Protection by:

  • Convening a joint behavioral health and child welfare workgroup to develop realistic and unbiased strategies and suggestions regarding removal of the child of a parent with a mental and/or substance abuse disorder for child protective service workers and for the Family Courts.
  • Hammering out a position about the state law regarding parental mental illness and terminating parental rights that reflects contemporary knowledge and values.

These recommendations reflect only a portion of the observations and suggestions that came out of the process set in motion by AARP and the NYS Kincare Coalition. A full report will be released later in 2010. It will contain important observations and recommendations about the more than half-million children and kincaregivers in New York State. Hopefully, policy makers and advocates in New York State will realize that services for this population need to improve and should be a priority for a state that prides itself on supporting families.

Michael Friedman served as the facilitator of the Mental Health Kincare Workgroup until he retired at the end of June. He continues to teach at Columbia University’s schools of social work and public health. He can be reached at mbfriedman@aol.com.

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