HHS OIG: Challenges addressing the mental health needs of children in HHS custody

WASHINGTON, Sept. 4, 2019 – Facilities that provide care to children in the Unaccompanied Alien Children (UAC) Program generally conducted required background checks, but faced challenges in hiring, screening, and retaining employees, as well as obstacles addressing the mental health needs of children, according to two reports released today by the U.S. Department of Health and Human Services (HHS), Office of Inspector General (OIG).

In general, care provider facilities serving unaccompanied children in the Office of Refugee Resettlement’s (ORR’s) custody met a range of background check and qualification requirements designed to keep individuals who may pose a risk to the safety and well-being of children from having direct access to children. However, some of the ORR-funded facilities did not have evidence of the required Federal Bureau of Investigation (FBI) fingerprint check or the Child Protective Services (CPS) check results.

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In addition, facilities reported challenges addressing the mental health needs of children who experienced significant trauma. Some children fled violence, were separated from their parents upon their arrival in the U.S., or had other intense trauma, before or after their arrival in the U.S.

The reports cite policy changes in immigration enforcement, including the zero-tolerance policy, and the unanticipated influx of unaccompanied children in 2018 as factors that exacerbated challenges faced by care provider facilities.

“By examining the challenges facilities experienced during the summer of 2018, we identified opportunities for ORR to assist facilities in addressing obstacles when facing stressors like seasonal influxes and increasing numbers of children who have experienced intense trauma,” said HHS OIG Chief of Staff Christi Grimm. “We commend HHS for taking corrective actions to address the findings identified in each of our reports.”

Facilities Generally Conducted Background Checks

The report, Unaccompanied Alien Children Care Provider Facilities Generally Conducted Required Background Checks but Faced Challenges in Hiring, Screening, and Retaining Employees, provides information on care provider facilities’ efforts to conduct required background checks and employ case managers and mental health clinicians who met minimum employee qualifications. The report also provides information about staffing challenges facilities faced related to hiring and retention.

In general, facilities serving children in the UAC program met a range of background check requirements designed to keep individuals who may pose a risk to the safety and well-being of children from having direct access to children. However, a few facilities did not have documentation of the required FBI fingerprint or CPS check results, and some did not ensure that the out-of-state CPS checks were conducted. In addition, more than half the facilities allowed employees to begin employment before receiving the results of either the FBI fingerprint check, the CPS check, or both.

For facilities that are required to conduct additional state-based background investigations, most completed the checks as required. However, at a few facilities there was either no documentation that the checks were completed, or the checks were not completed before the employee’s start date.

In addition to the compliance-related issues, ORR granted six facilities (influx and non-influx facilities) waivers from conducting the CPS checks for employees with direct access to children. ORR has the authority to grant waivers for influx facilities due to the impracticality of compliance for temporary and short-term facilities. However, ORR has no comparable authority to waive background checks for non-influx facilities.

From the review of employee qualifications, OIG found that most facilities hired mental health clinicians who met ORR education requirements; however, more than half the facilities hired case managers who did not meet the ORR education requirements. In addition, facilities reported difficulty maintaining required staffing ratios because of challenges experienced in screening, hiring, and retaining qualified employees.

About half the facilities reported challenges in screening prospective employees, with lengthy waits for background checks cited as the biggest challenge. More than half the facilities reported that hiring mental health clinicians was the greatest obstacle and attributed the difficulty to finding bilingual candidates who met the minimum requirements. Additionally, more than half the facilities reported challenges retaining employees due to low wages, disagreeable hours, and competing job opportunities.

To address these varied challenges, OIG provided a series of recommendations to ORR to improve UAC Program operations related to background checks, education requirements, staffing ratios, and waivers of CPS checks.

Challenges Addressing Mental Health Needs of Children in HHS Custody

The report, Care Provider Facilities Described Challenges Addressing Mental Health Needs of Children in HHS Custody, outlines challenges facilities experienced in addressing the mental health needs of children who had experienced intense trauma and accessing specialized care for children who needed more intensive mental health treatment.

OIG interviewed facility staff who worked directly with children and ORR staff in the field with responsibility for these facilities and performed qualitative analysis of these interviews. As a result, OIG identified the most significant challenges impacting facilities’ ability to provide mental health care. The agency did not assess the quality or appropriateness of mental health care provided to the children.

OIG found that intense trauma was common among children who entered care provider facilities and mental health clinicians reported concerns about their ability to address trauma due to the level of trauma some children presented, unpredictable amounts of time in care, and the relatively short stay at the facilities, from a treatment perspective.

Facilities also reported challenges accessing external specialists when in-house mental health clinicians could not meet the needs of a child. Some facilities were in underserved areas or could not access specialists who were fluent in the languages spoken by children in their care. For example, one medical coordinator noted that the only bilingual psychologist in its network was in a neighboring state.

When mental health clinicians determined children needed a higher level of care, facilities also reported difficulties transferring children to facilities licensed to provide specialized care. OIG stated that at the time of its review in the summer of 2018, facilities reported they were unable to transfer children with significant mental health needs to either of the two residential treatment centers available in ORR’s network because they had waiting lists or were at their total capacity of 50 children.

Addressing children’s mental health needs was especially challenging in 2018 due to an influx of separated children and longer stays in care provider facilities. According to program directors and mental health clinicians, separated children exhibited more fear, feelings of abandonment, and post-traumatic stress than did children who were not separated.

The zero-tolerance policy in 2018 also presented additional challenges for facility staff in gaining the trust of separated children and providing age-appropriate services to a dramatically increased population of children under 12. Faced with a sudden increase in young children, staff reported feeling challenged to care for children who presented different needs than the teenagers they typically served.

Facility staff also reported that longer lengths of stay resulted in deteriorating mental health for some children and increased demands on staff. They attributed longer stays to ORR’s new sponsor screening requirements implemented in June 2018, mandating fingerprint-based FBI criminal history checks of all potential sponsors including parents and all adult members of their household. Facilities reported it became more difficult to identify sponsors willing to accept children after the new fingerprinting requirements were implemented, which delayed placing children with sponsors, adding further stress and uncertainty.

OIG provides several recommendations for practical steps that ORR can take to assist facilities in addressing the mental health care of children in its custody.

In written comments on the reports, ORR concurred with the recommendations and outlined corrective actions it had taken or that are underway to address the findings identified in the reports.

To read these full reports and access other OIG completed work products related to UAC, visit oig.hhs.gov/uac.