A Report on the Bottom Line: Conditions for Children and the Texas of Tomorrow

Bottom Line
CONDITIONS FOR CHILDREN
AND THE TEXAS OF TOMORROW

A Report on the

“If you want to know the end, look at the beginning."
—African proverb

A Report on the Bottom Line © Texans Care for Children

TEXANS CARE FOR CHILDREN
811 Trinity, Suite A | Austin, Texas 78701 | (512) 473-2274 | www.txchildren.org

WHEN WE gIvE TExANs A BETTER sTART TO LIfE, IT MAkEs OuR sTATE MORE PROsPEROus.
A sick, uneducated, unskilled workforce does not propel a state forward. And a child supported in her education and development is more likely to become a contributing community leader, a business professional, a good neighbor. None of us remains untouched by our state’s social standing. When we give children a better start, we impact their future and the future we build for our entire state. For Texans Care for Children, the bottom line for Texas is that decisions Texans make about children’s policy are not just about individuals and their families; they are about the Texas we all choose to live in. In terms of dollars and cents, our state faces an enormous balloon mortgage. We have paid out little towards mounting problems in our population, but our delaying payment does not make these social debts go away. It only makes them more costly over time, and they eventually come due. There are signs that our balloon payment date is approaching. Texas has benefited from natural resources, a premature economic downturn that prepared our financial institutions for the current recession, and a whole lot of land. These gifts to our state have allowed for prosperity for some, despite eroding social outcomes for many other Texans. But the number of those not making it in Texas continues to grow—the uninsured, the inadequately educated, the chronically sick, the poor—and when communities do not have homeowners, customers, skilled workers, and healthy community members, prosperity for any sector becomes untenable. The devastating forecasts depict a Texas that few of us would want to visit, let alone call home. What it will take at that point to get ourselves back on the road to prosperity will not be the discrete investments that are called for today, but rather massive reform and rebuilding to deal with the devastation of compounding unmet social needs. That is the trajectory we are on, but it is not a future we must accept. We can acknowledge our good fortunes and be candid when yesterday’s approach no longer works and even threatens tomorrow’s success. A Report on the Bottom Line seeks to do just that. This report looks at where we have gone right as a state and where we have gone wrong, what we have done and what still needs doing. Inside these pages, you will find a summary of the state of our state through analysis of different aspects of child wellbeing. The aim of the report is to provide a look into how things are and where things will be if Texas remains on its current course. This view into our state is coupled with concrete recommendations—policy level changes, as well as suggestions for what each of us can do—because we understand each Texan has a role in building a brighter future. We remain truly hopeful because the solutions are clear—time tested and supported by research. We can start again with the Texas infants and children of today. They have endless potential for safeguarding the Texas we love and the future we want to see.

Eileen Garcia

A REPORT ON THE BOTTOM LINE

Table of Contents

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TABLE Of cONTENTs

Introduction ........................................................................ 4-9 Child Protection ...........................................................10-20 Family Financial Security ............................................ 21-31 Child and Maternal Health ...................................... 32-47 Children’s Mental Wellbeing .................................. 48-57 Juvenile Justice ............................................................ 58-70 Acknowledgements ............................................................71

Table of Contents

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ABOuT THIs REPORT
At Texans Care for Children, we arrive at each policy recommendation the same way. Throughout the year, we bring together Texas parents, youth, community members, and faith, business, government and nonprofit leaders with an interest in improving outcomes for children. In a series of forums, these groups discuss the pressing challenges children in Texas face, and they identify areas where changes in public policy could help make a difference. Once these groups identify areas of need, Texans Care for Children begins a process of research, reviewing the literature and the existing base of knowledge to identify whether established best practices exist, in our state or elsewhere, that have been shown to really work for children. We identify experts and bring them in to meet with the forums and discuss how a given idea might apply to our state. Where necessary, we conduct original research, seeking data from public agencies, conducting interviews, and gathering input from our forum stakeholders. With this information in hand, the forums meet again to discuss any recommendations under consideration. In each forum, we get Texans’ input on questions like: Would this work here? Are there special issues to consider with the children and families in your particular community? Are there any things the researchers forgot or overlooked? After identifying issues, researching policy responses, and testing the waters in this manner, Texans Care for Children speaks with unique authority to state leaders about the priorities for children on which parents, organizational leaders, legislative and agency staff, and communities across the state can agree. This report represents the results of that process. When endorsed by our board, the complete set of priorities become the agenda for children you find in this document. As the legislative session unfolds, we will take what we have learned into meetings with lawmakers, testify about it in the Capitol, and organize and mobilize Texans to help shepherd it into law. If you are a Texan who cares for children, we invite you to join us in these efforts. To learn more, please log onto www.txchildren.org.

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Is TExAs REAdy TO cOMPETE?

The economy is changing. Progress in Texas, once mostly dependent on natural resources like oil and land, increasingly relies on human ingenuity.
All across the country, states are finding ways to prepare for this shift and address pressing challenges. From model education and health care delivery programs to proven initiatives that prevent child abuse and ensure a strong start in life, forwardthinking states find ways to be smart with their money today and avoid higher costs down the road by fostering potential in their people. Many look at the big picture, knowing money spent on education and training works only once students have basic security, health, and wellbeing in place. These states equip their people for the twenty-first century and prepare them to lead, innovate, and contribute. Texas, by contrast, is letting her people fall behind. As the years pass, more and more of our state workforce, communities, and businesses pay the price. Compared to their counterparts elsewhere in the country, Texans face a growing set of barriers to success. As other states move their people forward, Texas puts up costly roadblocks to progress, something reflected in its last-place ranking on so many indicators of social wellbeing.

An Uneven Playing Field

While other Americans are receiving what they need to grow up to be successful, Texas children are not. They face barriers other U.S. kids don’t.

Compared to the average American child, a Texas child is...
35% more likely to grow up poor 28% more likely to be obese 16% more likely to drop out of school2 51% more likely to be born to a teen mother 93% more likely not to have health care access 33% more likely not to receive mental health care services 83% more likely to be born to a mother who received late or no prenatal care1
Calculations by Texans Care for Children based on data from the U.S. Census Bureau; the National Vital Statistics Report, 2009; Henry J. Kaiser Family Foundation State Health Facts, 2007; Texas State Data Center and Office of the State Demographer, 2006; the National Survey of Children’s Health; and the Annie E. Casey Foundation KIDS COUNT Data Center;
1 Actual percentage may be higher, because figure only compares Texas to 18 states with a similar method for calculating this indicator 2 Actual percentage may be higher because, for this indicator the U.S. figure also includes children in Texas

Introduction

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gOINg OuR OWN WAy, IN THE WRONg dIREcTION

In one sense, Texas is not alone. A handful of other states rank poorly in indicators of child wellbeing . . . they just happen to be our nation’s poorest places. The median wealth of Texans, however, is not far behind that of other Americans (ranking 27th out of 50).

In the company of poor states
TEXAS IS NOT A POOR STATE. Its median household income is close to the nation’s. However, among the seven states that the advocacy organization Every Child Matters determined were worst in overall child wellbeing, Texas stands out. It has the widest gap between overall economic security and economic security in children.

We are the only state to possess the means but not the will to better serve our people.
Steve Murdock, state demographer under Governor Bush, famously warned, if Texas does not reverse course, for the first time in history our community members will be less educated and poorer than the generation before. Murdock also described Texans as increasingly overweight and infirm. These trends together suggest tomorrow’s adults may not be able to meet tomorrow’s challenges—a clarion call that Texas has no time to waste before facing up to her problems. With the effects of one of the worst economic downturns in history still lingering, it is not too late for Texas to strengthen the public structures that can help us prevent further deterioration in our most vital infrastructure, our people.

“Worst States for Children"

State Median % of Children in Poverty Household Income in 2009 in 2009

Arkansas South Carolina Texas Oklahoma New Mexico Mississippi Louisiana
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$ 38,815 $ 43,625 $ 50,043 $ 42,822 $ 43,508 $ 37,790 $ 43,733

26% 21% 23% 22% 25% 29% 27%

Every Child Matters Education Fund, “Geography Matters: Child Well-Being in the States,” April 2008. Online at http://everychildmatters.org/resources/ reports

Texans Care for Children analyzed child wellbeing in the 50 states, based on data reported by the Annie E. Casey Foundation’s KIDS COUNT project and in Every Child Matters’ Geography Matters. Using multiple regression analysis, we found many factors can be linked to a state’s positive or negative ranking for child wellbeing. Several issues within a state’s control, like education, health care, and levels of investment in public structures, had significant links to child wellbeing, while the presence or absence of immigrant populations did not.

Child Wellbeing by the Numbers*
Number of low-tax states ranked in the bottom 10 for child wellbeing: Number of high-tax states ranked in the bottom 10 for child wellbeing: Number of low-immigrant states ranked in the bottom 10 for child poverty: Number of high-immigrant states ranked in the bottom 10 for child poverty: 9 0 4 1 (Texas)

* Rankings for child poverty based on the federal poverty statistics from 2008. High-immigrant and low-immigrant states are those ranked in the top or bottom 10 respectively by the Annie E. Casey Foundation for percentage of all children living in immigrant families (2008) and/or by the Pew Hispanic Center for estimated rate of unauthorized immigrants in the population (2009). Child wellbeing is defined as rankings from the Annie E. Casey Foundation (2010) and the Every Child Matters Fund (2008). Low tax and high tax states are ranked in the bottom or top 10, respectively, for per-capita taxes paid, according to 2008 data from the Tax Foundation.

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If OTHER sTATEs cAN MEET 21sT cENTuRy cHALLENgEs, WHy cAN’T TExAs?
Everyone relies on effectiveness in public structures. We count on them to help keep our food, water, and roads safe and to sustain a better quality of life in our communities. Children, however, are unique: they stand to gain the most when public structures work and are also key to reducing an overreliance on government supports in our society. Decades of research have shown that communities that make a commitment to strong family and child services—be they quality early care programs, prevention-based health services, school meals, or matched college savings accounts—experience better outcomes, such as higher graduation rates, lower rates of juvenile crime, and higher academic achievement and school attendance. This is vital evidence that Texas can reverse a trend toward ill-equipped adults, increasingly dependant on state systems, by building proven foundations for success during childhood. Scientists who research the human brain find no mystery in this. They know childhood and adolescence represent a time of heightened growth in the mind, just as it is for the body. This unique window determines social, cognitive, and emotional patterns for years to come.

When public structures reinforce healthy growth in children physically, mentally, and developmentally, whole populations benefit.

Introduction

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HOW TO RIgHT THE cOuRsE, sO TExAs cOMEs fIRsT

Texas business, community, and civic leaders agree: for the sustainability of our state, nothing matters more than ensuring our people have what it takes to contribute and succeed. Effective models exist, nationally and right here in Texas, that would do just that.

With commitment from state leaders and communities, these ideas, taken to scale, would ensure Texas the bright tomorrow she deserves.
Throughout this report, we discuss issues the Texas child population faces and strategies for addressing them. These strategies represent not the ideas of a faraway think tank, but the solutions identified by Texas’s own home-grown experts: the families, state agency directors and staff, researchers, charitable organizations, legislators, and community, faith and business leaders who engage in dialogue with Texans Care for Children throughout the year. This dialogue is what forms the basis for all the recommendations in this report about improving prospects for Texas children and, with them, all Texans. In the pages that follow, we discuss pressing areas for improvement in children’s safety, financial security, health, mental health and development, and juvenile justice, as well as where these issues overlap. In each section, we also explain the return on investment—the potential gain for Texas in making wiser choices with public dollars, as well as the cost of inaction. We explore how Texas can move ahead for all children, acknowledging that groups of children experience disparities, which holds back progress for all Texans. Note that we use the words white, Latino, black, Native American, and Asian to refer to children except where the data source uses a different word, such as African American or Hispanic. Finally, we provide tailored recommendations for policymakers and members of the community about how to make Texas a better state together.

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THREE REcOMMENdATIONs BELONg NOT IN ONE sEcTION Of THE REPORT, BuT THROugHOuT IT. THEy ARE:

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Ensure youth and families have a voice in policy and program decisions that affect them.
State services and leaders can meet the needs of Texans only if they truly understand those needs, something which requires input from the people most affected by their decisions. Families must have the opportunity to engage in discussions and processes that lead to new policies and to voice concerns about policies once they are in place. When services are provided, Texas can do best by its investment if it first asks what individual families say they need to be successful.

2

Improve coordination among state services and programs.
Too many existing programs and services function in vacuums, unaware of the work of their counterparts, resulting in missed opportunities. State agencies need to do more to share strategies, resources, data, and challenges, so as to eliminate duplication and maximize impact across systems. A huge step forward came in 2009 with the Legislature’s creation of the Council on Children and Families, a commissioner-level body of agencies brought together with parents to plan and budget in coordination, to maximize existing resources. There is great potential for this group to break these agencies from isolation at the top-most levels, and the interaction and efforts stemming from the first few public meetings of this group are promising. Still, many social service structures act not as a system but in silos, fearful and protective of what few resources they have with which to fulfill mandates. Until our agencies have the resources they need—not resources snatched from one agency or program to support another, but sustainable agency funding built on the solid foundation of adequate revenue streams—state services and programs will continue to be set up for failure.

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Hold our state accountable for better outcomes for Texans. Hold public agencies accountable for effective delivery of services, and hold our Texas Legislature accountable for building budgets based on actual need and projections of growth.
Decisions regarding public programs need to happen through open and strategic processes, and agencies must be held accountable for moving the state forward toward identified objectives. Those expectations, however, will only be reasonable when agencies have been empowered to do their jobs with sufficient resources. The demographer’s data show we can expect to get what we pay for: as the state that spends the least on its people per capita, we are positioned for declining human and economic progress. Average Texans do not live free from the pinch of taxes, yet they also do not reap the benefits of strong prevention programs or reliable safety nets during hard times. All over the state, Texans who follow the rules, nonetheless, face bankruptcy or foreclosure when their luck simply turns: a lost job, an unexpected illness in a child, a baby born with special needs. With long waitlists for state programs, marked shortages of health providers and other professionals, and a growing population, the answer is not simply asking our agencies to deliver better. They also must deliver more, something possible only when Texas’s revenue structure is stable, free of loopholes, and fair.

To get detailed source information and access to online research referenced in this report, go to www.txchildren.org/Report
Introduction

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Are we making smart investments?
Because a child’s brain is still developing, children are more sensitive to stimuli than adults and are more vulnerable to the trauma of abuse and neglect.2 The most effective way to protect Texas children from the trauma of abuse and neglect is to prevent maltreatment in the first place and intervene early when there are signs of potential danger. These strategies also represent a smart use of public dollars. Prevention and early intervention services can keep the state from having to pay for the costly consequences of child abuse and neglect in the short term and for generations to come. There are strategies that have been proven effective in breaking intergenerational cycles of abuse and neglect, so adults who were abused or neglected as children do not treat their own children the same way.3 Unfortunately, this pattern is all too common, with the Texas Department of Family and Protective Services reporting that some perpetrators were first confirmed victims of child abuse or neglect in Texas themselves during childhood.4 Prevention programs are community-based interventions that enhance the safety and wellbeing of children and families while eliminating risk factors for child abuse and neglect.5 Prevention builds strength among families before significant problems arise, using culturally sensitive and holistic strategies— ranging from training for parents to family support groups to counseling and referral services—so parents who need help to keep their children safe can get it. Early intervention helps address needs once a child has been identified as being at risk for abuse or neglect in order to keep a child safely with family and avoid removing the child from home.6

CHILD ProTeCTIoN

Child abuse prevention programs first received federal funding through the 1974 Child Abuse Prevention and Treatment Act (CAPTA).7 The 1980 Adoption Assistance and Child Protecting children from abuse and neglect and offering a safe Welfare Act required states to make a “reasonable effort” to and permanent home to children removed from their parents’ preserve families through prevention and reunification care are issues at the heart of child protection. Texas, like all services,8 and more funding became available in 1996 states, has a system in place with the express purpose of prothrough Temporary Assistance for Needy Families (TANF) tecting the most vulnerable children and assuring their basic block grants. Most recently, the Health Resources and safety from harm. While improvements to this Child ProtecServices Administration and tive Services system are ongoing the Administration for and necessary, more work is In recent years, more children have died Children and Families needed. In the last decade, as a result of child abuse or neglect announced the availability more children in Texas than in in Texas than in any other state. of grant funding for the new any other state have died as a Maternal, Infant, and Early result of abuse or neglect.1 Childhood Home Visiting Initiatives that help prevent child abuse and end the cycle of Program in the summer of 2010. Funding will be directed abuse, promote positive placements, and provide better trantoward existing evidence-based, high quality, home-visiting sitions for children leaving the system are critical elements of interventions, which have proven effective in producing creating a state system where all children are protected. significant decreases in child abuse and neglect.9 10

The Department of Family and Protective Services’ Division of Prevention and Early Intervention (PEI) administers state prevention funding. In 2005, the Texas Legislature established the Interagency Coordinating Council for Building Healthy Families to facilitate collaboration among government agencies administering prevention and early intervention services and to evaluate the effectiveness of prevention programs.10 Its evaluation of all DFPS prevention programs found evidence of their effectiveness in terms of both costs and outcomes for children and families. Families receiving PEI services showed greater resilience and had fewer substantiated reports of child abuse or neglect.11 When comparing the results of pre- and post-tests on five family protective factors, all 22 PEI contracts with local providers had higher average post-test scores. Also, of the 6,321 families that completed a prevention program, fewer than 2% had a substantiated case of child maltreatment while receiving services. A year after receiving services, only 1% of participants had a substantiated case.12 The state invests far less in prevention than in child welfare services once abuse or neglect has been identified. In tight budget times, prevention is often the first area to be cut. Texas followed this path in 2003, not regaining lost ground until 2009. The same option is under consideration by lawmakers, with 84% cuts proposed for prevention and early intervention through 2013. Federal funds offer a very limited buffer to state cuts since most federal dollars are reserved for foster care payments and costs incurred after a child has been removed from the home. Only about 10% of federal funds are flexible, allowing states to invest in the services and supports needed most.13

society was over $5.2 billion.17 Texas will continue to incur these costs as long as its investment in child welfare prevention and early intervention remains insufficient to serve all the families at risk of child maltreatment. What Texas Can Do: • Strengthen the state’s investment in research-based prevention programs. • Focus spending on early intervention services like FamilyBased Safety Services to prevent greater costs of out-ofhome care. What You Can Do: • Start a parent support network in your neighborhood. • Visit your legislators to tell them about the importance of child welfare prevention and early intervention services.

Are we protecting all Texas children?
Since 2005, when Texas Child Protective Services (CPS) underwent sweeping reforms, mandated by the Legislature, much has been done to keep children safely out of the system and promote success for those in the state’s care. However, like other child-serving systems, systemic and structural gaps that create varying outcomes for different groups of children remain. Not all Texas children are equally protected from child abuse and neglect, nor are they equally likely to be removed from their families unnecessarily. A full discussion of how children in poverty fare in child protection can be found on pages 19 and 20; the link to race and ethnicity is discussed on pages 14-17; and other factors are highlighted below.

Failure to invest in prevention, early intervention, and effective services for children who have experienced abuse or neglect will not only lead to poor child outcomes, it will Rural Children increase the long-term costs to the public. There is mounting Whether a child lives in a rural or urban community impacts evidence that prevention and early intervention programs their likelihood of being involved in the child welfare system 14 create significant savings to taxpayers. According to an for child abuse or neglect. In Texas, an average of 7 out of every analysis by Prevent Child Abuse America, child abuse and 1,000 children are removed from home due to abuse or neglect. neglect cost Americans an estimated $103.8 billion in 2007 In remote rural areas, that number increases to 9 out of every 15 alone. This figure accounts for the direct, immediate costs 1,000, while in metropolitan areas, it decreases to 6.6 out of of child maltreatment through hospitalization, mental health every 1,000.18 This mirrors the care, the child welfare services findings of the fourth National system, and law enforcement, Incidence Study of Child Abuse Prevention and early intervention programs as well as the indirect, longand Neglect (NIS-4) in which have proven effective in keeping children term costs of increased use a child’s odds of being detersafe, and they create significant savings of special education, greater mined to be at serious risk of for taxpayers. right now, Texas spends $6 juvenile delinquency, related harm was nearly twice as high billion in direct and indirect costs each year mental health service needs, in rural counties as in urban. resulting from child abuse heightened adult criminal acAccording to the study, children 16 tivity, and lost productivity. in rural counties are: In Texas, the direct cost of child abuse and neglect to the child welfare, judicial, law enforcement, mental health, and hospital systems was estimated at just over $1 billion annually. The indirect cost due to heightened juvenile and adult criminal justice involvement, special education, mental and physical healthcare, substance abuse, and lost productivity to • • • • 1.7 times more likely to be abused, 2.5 times more likely to be neglected, 2.2 times more likely to be maltreated, and 2.3 times more likely to be emotionally abused than children in major urban counties.
Child Protection

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It is not known whether these differences reflect actual rates of abuse and neglect or whether child maltreatment is discovered at higher rates in rural counties.19 In addition to higher incidence of abuse and neglect, once children in rural areas enter the child welfare system they are more likely to be removed from their homes, rather than safely supported in their family setting. One study found that in half of all U.S. states the highest out-of-home placement rates are in rural areas. This may be due to a lack of resources, both financial and community, to help at-risk children stay safely at home.20 In fact, insufficient community resources and higher rates of poverty may contribute to the disproportionate involvement of rural children at all levels of the child welfare system. Child welfare policies and programs, most often designed by agencies in urban areas, fail to consider the unique issues children and families in rural communities face. Furthermore, when governments reduce funding for social services, budget cuts often impact rural families disproportionately. While services critical to child protection, such as substance abuse treatment, parenting classes, residential treatment, family preservation, and mental health care, can sometimes be difficult to access in urban areas, in rural communities they may simply not exist.21 In addition to a lack of community resources, rural families are also more likely to live in poverty, a factor that contributes to poor child health outcomes and circumstances that can precipitate child neglect. Much of the employment in rural areas is low-wage, seasonal, and does not require a high level of educational attainment. Between 1973 and 1992, the rate of child poverty in rural U.S. communities grew by 76%.22 As of 2008, 1 in 4 Texas children in rural counties was poor.23 Children with Disabilities Children with disabilities are disproportionately at risk of abuse and neglect. A study conducted by the National Center on Child Abuse and Neglect (NCCAN) in 1993 found that these children are abused and neglected at 1.7 times the rate of children without disabilities.24 The NIS-4 supplements these earlier findings, reporting that, while children with disabilities experienced lower rates of physical abuse, they experienced two times the rate of emotional neglect of other children. They were also 1.5 times more likely to sustain serious injuries as a result of the abuse and neglect they did experience.25 There are several reasons why children with disabilities are disproportionately represented among abused and neglected children. The challenges that accompany raising a child with a disability—the added financial strain of special education and medical care, lack of respite care and social and emotional support—may also increase family stress that can put a child at greater risk of abuse and neglect.26 Age As of August 2009, 20% of all children in Texas’ foster care system were under the age of two.27 Their young age puts them at greatest risk for experiencing developmental delays related 12

to abuse, neglect, interrupted attachment with a primary caregiver, and the trauma of being removed from home. In fact, infants and toddlers in foster care experience developmental delays at six times the rate of other children their age. Fort Bend County, Texas is working to close the gap for the large number of infants and toddlers who enter foster care through the Court Teams for Maltreated Infants and Toddlers Project. It is one of eleven communities across the country to participate in this project. Headed by ZERO TO THREE, it creates partnerships between judges, child welfare professionals, health and child development experts, and community leaders to provide evidence-based services that center on the unique needs of infants and toddlers and their families. The Court Team model has been shown to decrease out-of-home placements and increase pediatric visits and developmental screenings, the frequency of parent-child visits, and the number of children placed into kinship care.28 As Texas continues on a path of reform, not just in policy, but in actual practice, attention to system disparities provides critical insights into where weaknesses in the child welfare system lie. What Texas Can Do: • • • Study what rural abuse prevention interventions are effective and feasible given community resources. Invest in child abuse prevention including family supports like respite care. Support expansion of the Court Teams for Maltreated Infants and Toddlers Project.

What You Can Do: • If you are able to, support a struggling parent in your community through offers of babysitting, help with errands, or a willingness to listen. • If you provide care to a child, look into what support classes or resources are available to you in your community. • If you are feeling overwhelmed in your care of a child or children, ask for help from your family, friends, neighbors and community. • If you suspect a child in your community is being abused, report it to CPS. Call 1-800-252-5400 or report online at www.txabusehotline.org

A path to permanent safety for children of abuse and neglect
Following incidents of child abuse and neglect, vulnerable Texas children most need the stability and protection of a lasting family home. Texas can help identify, pursue, and plan for placements that provide this permanency for children from the moment a child gets placed in the state’s care. In fact, achieving permanency—whether through adoption, legal guardianship, family reunification, or placement with another

relative—ensures the best possible outcomes for a child who has been abused or neglected. Permanency is also a strategy for breaking the intergenerational cycle of abuse and neglect, by providing children who are at their most vulnerable with safe and stable homes in culturally appropriate settings, as well as supportive, reciprocal relationships in which to trust.29 In 2009, Texas Child Protective Services (CPS) caseworkers identified adoption as the goal for half of the 20,875 children in the Department of Family Protective Services’ (DFPS) custody. Other goals included being reunified with their birth family (for 28% of children); being put into the care of another relative or caregiver (for 6%); preparing for independent living after the age of 18 (for 6%), and other long-term placement goals (10%).30 State CPS reforms since 2005 and changes to federal law— such as the Fostering Connections to Success and Increasing Adoptions Act of 2008—have made strides towards improving outcomes and promoting permanency for children and families involved in the child welfare system. Still, there remains significant need for improvement, especially to address the many children who remain in foster care without a permanent placement far too long, and the many children whose placements do not match their true level of need or risk of being abused. Judging the level of risk a particular child faces is difficult. It is CPS’s policy that a child should be removed from the home in any case where there is “immediate danger to the physical health or safety of the child or the child has been a victim of neglect or sexual abuse and that continuation in the home would be contrary to the child’s welfare.”31 This definition requires subjective judgment, which can result in some children being needlessly separated from their families due to risk factors that could be mitigated through enhanced family support; likewise, other children could be in serious danger and not be identified and protected from harm.

Finding an appropriate, permanent placement once a child is removed from the home can be challenging given that each child has unique needs. Children who are removed from their homes remain in CPS care, on average, over two years. Even when it has been decided that reunification with family members is the best course of action for a child, children are still separated from their family for an average of more than 14 months and typically experience more than two placements in that time.32 These lengthy and repeated disruptions to school, cultural activities, and neighborhood and friendship ties can have negative effects on children’s functioning. Behavioral and emotional problems, aggression, and difficulties with coping and adjustment can be normal reactions to removal, but also can lead to instability in out-of-home placements.33 For children who are awaiting permanency, kinship care, which is placement with a relative, offers a promising alternative to temporary placements with foster families. Though kinship care is not the best choice for every child, when it is a safe option, it can provide care in a familiar setting. Evaluation of relative caregiver assistance in Texas has shown kincare to be safer, last longer, and have better outcomes compared to foster care placements.34 Children stay 30% longer in placements with relatives than comparable placements with non-relative foster parents,35 and the likelihood of reunification or permanent custody being awarded to a relative is higher. Children in kinship care are also 41% less likely to be removed from a placement due to risk of subsequent harm. While this may be due in part to the fact that children placed in kinship care tend to be older and have fewer special needs than those in foster care, overall, kinship care increases positive outcomes for children: 95% of children in the DFPS evaluation who had at least one relative placement experienced positive outcomes in the form of reunification, custody to a relative, or adoption, compared to only 65% of children without relative placements.36 Furthermore, kinship care allows children to maintain family and community connections, as well as ethnic

Confirmed Allegations of Child Abuse/Neglect by Type of Abuse, 2009
All Abuse-26.1% Physical Abuse State Total Percent 13,875 17.4% Sexual Abuse 6,316 7.9% Emotional Abuse 648 0.8% Abandonment 205 0.3% Medical Neglect 2,109 2.6% All Neglect-73.9% Physical Neglect 6,570 8.2% Neglectful Supervision 49,588 62.0% Refusal to Accept Parental Responsibility 625 0.8% Total 79,936 100%

Source: Texas Department of Family and Protective Services Data Book 2009

Average Length of Time in Months for Children Leaving DFPS responsibility
Exit Type # of children Average # months in state care Family Reunification 4,423 14.6 Relative Care 3,213 14.2 Adoption 4,859 29.8 Long Term CareEmancipation 1,453 63.3 Long Term Care-Other 549 14.3 Total 14,497 24.5

Source: Texas Department of Family and Protective Services Data Book 2009

Child Protection

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and cultural identity, while reducing the trauma caused through loss and attachment issues.37 Even though kincare is a best practice in child welfare, not all relatives willing to provide a safe, loving home for a child have the financial resources to take that child into their home. National research on the demographics of relative caregivers demonstrates the financial need of these families who help the state to do its job of protecting children removed from their biological home due to abuse or neglect. About a quarter (24%) of children in kincare live with a caregiver without a high school degree.38 A greater proportion of kinship families live in poverty than non-kin foster families. Half of children in kinship foster care live in low-income households, compared with 24% of children living with non-kin foster parents.39 Nationally, the biggest barriers for families to care for a relative child are financial.40 The federal Fostering Connections to Success and Increasing Adoptions Act (Fostering Connections), signed by President George W. Bush, began providing federal funding in 2010 for family members who agree to take permanent custody of a child who would otherwise be in foster care.41 Texas is in early stages of implementing a new program to take advantage of this opportunity. Of all the permanency goals, children in CPS legal custody cumulatively spend more time waiting to be adopted than for any other permanent placement. Increased adoption awareness and improved adoption processes can therefore help promote permanency. CPS has shortened the initial application to become an adoptive or foster parent and increased training for both potential adoptive parents and children eligible for adoption (especially those with multiple or failed placements).42 DFPS also has several ongoing initiatives that promote adoption, including the One Church, One Child campaign, Congregations Helping in Love and Dedication (CHILD), and the Why Not Me? campaign. One Church, One Child was started in Chicago churches to promote the adoption of black children, the children who often wait the longest for permanent placement. Through a DFPS contract, One Church, One Child has developed a pilot program for adoptive parent recruitment in Texas.43 CHILD recruits and licenses foster and adoptive families from congregations of all faiths and provides support services to their foster/adoptive families.44 Why Not Me? focuses on promoting adoption of older children through media ads and educational materials.45 Texas paid $107,071,855 in foster care in fiscal year 2009, in addition to $236,632,407 in federal payments.46 In helping children achieve permanency, the state can save money today while also ensuring children a better future.

What Texas Can Do: • Increase family-based safety services that support families safely staying together. • Invest in services that promote placement stability for children in the state’s care, including day care, respite care, and training for caseworkers, foster parents, adoptive parents, and kinship caregivers. What You Can Do: • Visit www.RaiseMeUp.org, an initiative of Casey Family Programs, to learn about opportunities to get involved with organizations that partner with DFPS to improve the lives of Texas children in the state’s care. • Begin an adoption or foster care awareness program in your community. • If you belong to a religious congregation, start a CHILD program.

ensuring the child welfare system works effectively for all children
A child gets the best start in life growing up in a safe, stable home with caring and protective adults. This is the goal for all Texas children. For children who are not secure from harm, the Child Protective Services (CPS) system is charged with stepping in to protect them from future harm and ensuring them a permanent home. This goal is sometimes met, but the system does not result in the same outcomes for all children. Disparate treatment exists in some form for all children in the CPS system, but in particular for children of color, who are involved in the child welfare system at higher levels than white children.47 It is easy to see from CPS data that the baseline for entering the system is not the same across racial and ethnic groups. If there were more equal representation in the child welfare system, the percentage of each ethnic group in CPS cases would be equal to the rate at which abuse is happening within each group and would continue at this rate all the way through the system. The Texas Legislature, in 2005, called for CPS outcomes Vary by race and ethnicity

100% 80% 60% 40% 20% 0%

Anglo

Hispanic

Other

African American

Children Awaiting Adoption

CPS Involvement CPS Confirmed Victims Children Removed from Home Cases Opened for Services Texas Child Population Children in FOster Care

Source: Texas Department of Family and Protective Services, Data Book 2009

14

Adoptions

a thorough examination of this overrepresentation—called disproportionality—within Texas CPS. There are various reasons, beyond the scope of this report, leading to disproportionate representation of children entering the child welfare system, but the disproportionality explored here is that which occurs once children have entered the state system. A 2010 analysis from the Texas Department of Family and Protective Services (DFPS) found that caseworkers who perceive themselves to have a high level of interpersonal skills, as well as caseworkers who have more African-American children on their caseload, removed African-American children less often. DFPS concludes that “exposure to a greater number of African-American families tends to reduce disproportionate removal decisions.”48 Though this finding is not yet well understood, it is an important guide for future disproportionality research and practice changes. The study also found that the more concerned a caseworker is about the liability of having a child harmed if not removed from home, the more likely the caseworker is to remove Latino children from their home. This finding, too, is not fully understood. Neighborhood factors, such as high crime and lack of community resources,49 may affect CPS investigators’ perceptions of risk, both for the child and for the caseworker personally. A child is most likely to be removed from the home in cases where he or she is perceived to be at high risk of future harm, which is determined by CPS investigators.50 This subjective assessment of risk seems to negatively impact children of color disproportionately. Lack of permanency services—those that support a permanent stable home for a child so that he or she does not languish in foster care— can also lead to disproportionate outcomes for children of color.51 A permanent placement may be adoption, granting permanent custody to a relative, or reunification with parent(s). Keeping children in the same area as their family helps speed reunification and eases the transition to foster or kinship care. However, many areas lack an adequate number of foster homes. Opportunities to identify and support relatives who are willing and able to care for a child,52 especially those who live nearby, also have not been maximized. Placing a child close to home can result in increased likelihood that children of color will achieve permanency as quickly as peers.53 In Texas, Hispanic children are overrepresented in terms of children with a case opened for services (48.2% vs. 44.4% of CPS confirmed victims). For white, Native American, and Asian children, there are points of overrepresentation, underrepresentation, and proportionate representation throughout the child welfare system.54 However, disproportionate involvement is greatest for African-American children, and it increases as the child’s involvement in the CPS system deepens. The disproportionality investigation mandated by the Texas Legislature in 2005 found that black children received fewer in-home services to prevent removal and fewer supports

African-American Children’s representation in CPS Grows as Involvement in the System Deepens

100% 80% 60% 40% 20% 0%

African-American Children 11.8% 88.2% 22.5% 20.6% 79.4% 20.8% 79.1%

All Other Children

27.9% 71.8%

30.8% 68.9%

34.8% 65.3%

e n s e s on latio ctim Service Hom ster Car opti d Vi opu om g Ad ld P rme ned for oved fr n Fo Chi en i aitin onfi s C m pe dr Aw Texa CPS ases O dren Re Chil dren C Chil Chil
Source: Texas Department of Family and Protective Services, Data Book 2009

once in out-of-home care. These gaps remain in many areas. Following removal, black children were more likely to be placed in foster care than with a relative.55 Black children also wait longer to exit the CPS system56 and experience a greater number of foster home placements than white children.57 A greater share of the children adopted in Texas are black than in the population at large, in part because black parents more frequently have their parental rights terminated. While adoption is generally seen as the best option once parental rights are terminated, the fact that black children make up over 1 in 4 adoptions unfortunately means that children of color are being permanently removed from their families at greater rates than their peers. Furthermore, within the total pool of children eligible for adoption, black children are less likely to be adopted58 or to attain permanency through reunification.59 Recent improvements within the child welfare system have helped curb some of these trends so that black and Latino children are now as likely to be permanently placed with relatives as white children.60 African-American Children Stay in CPS Longer
Emancipation 63.3% 69.1% 29.8% 31.2% 14.2% 14.2% 14.6% 15.5% 0 20 40 Months in Care
Source: Texas Department of Family and Protective Services, Data Book 2009

Adoption

Relative Care

African-American Children Average for all Children

Family Reunification

60

80

Child Protection

15

When CPS intervenes in a family because of abuse or neglect, the goal is to create the safety and permanency that we want for all children. However, the act of removing any child from home is traumatic and can have long-term effects on educational outcomes, self-esteem, and family stability. Disparate practices in the child welfare system cause the negative effects of CPS involvement—such as distrust of government and broken families—to concentrate in communities of color.61 The economic impacts of disproportionality are also alarming. Black children spend more months on average in out-of-home care than white children.62 The longer it takes to find a permanent home, the greater the cost to the state. In response to legislatively mandated reform and in partnership with Casey Family Programs, DFPS began developing a plan to confront disproportionality in 2005.63 Since that time, several changes have taken place: • Awareness and planning. DFPS has hired a Disproportionality Specialist for each CPS region and the state office64 to educate stakeholders65 and to form Regional Disproportionality Advisory Committees. DFPS also formed a statewide disproportionality workgroup.66 • Training. All CPS staff now undergo cultural competency and institutional racism training to dismantle system biases that result in children of color being placed in out-of-home care disproportionately.67 After training, staff are expected to have a heightened awareness of the role race plays in case decisions. Also, because CPS staff’s knowledge about which community resources are available in a particular 16

community may influence racial disparities in families’ receipt of services, improving staff training to make them more aware of existing community resources should help this problem.68 Findings in the 2010 DFPS disproportionality assessment—that caseworker familiarity with a culture seems to decrease disproportionate removals from home and that caseworkers’ negative perceptions of services available in an area seems to increase removals—indicate a continued need for training in both areas. • Data. CPS has centralized its system for tracking available foster homes, making it possible to identify appropriate placements for children near their own neighborhood as quickly as possible.69 • Diversity. To better serve a diverse Texas population, CPS has recruited a more diverse staff, including bilingual staff. Since 2005-2006, there has been a 20% increase in black staff and a 17% increase in Latino staff hired.70 • Including families in decision making. Family-centered planning in CPS now happens through Family Group Decision Making, which allows families to confer and collaborate with CPS workers to formulate permanency and safety plans for their children. Results of an ongoing evaluation of this approach suggest it is successful in promoting permanency.71 In its 2010 disproportionality assessment, DFPS found that family conferences have reduced disproportionate outcomes for African-American and Hispanic children for both reunification with parents and placement with relative caregivers.72 Data for 2009 show less disparity in access to these best practices. • Relative caregivers. Increasing supports for kinship care removes barriers that can prevent family members from providing care to their child relatives. Kinship care allows children to remain closer to home, helping speed reunification. Children also stay longer in placements with relatives than with foster parents, and the likelihood of reunification or permanent custody being awarded to a relative is increased. Overall, kinship care increases positive outcomes for children.73 CPS began the Relative Caregivers Assistance program in 2006, which addresses the financial barriers that prevent some relative replacements through an upfront payment of $1,000 and $500 annual payment to help with the costs of caring for a child or sibling group. Between 2005 and 2008, disproportionality decreased slightly in four of the five largest Texas counties,74 indicating CPS’s disproportionality work is having an effect. Disproportionality efforts will need continued evaluation to ensure that child wellbeing is safeguarded and that progress continues to be made on reducing disproportionality.

What Texas Can Do: • Extend Family Group Decision Making to all children in all stages of service in all parts of the state. • Continue CPS staff training in available community resources and mindfulness of personal biases in decision making. What You Can Do: • Participate in the regional disproportionality advisory committee in your area as a community stakeholder.

Supports for transitioning youth
A child “ages out” of foster care when he or she leaves the child welfare system never having found a permanent placement or family. While all foster children are challenged by the trauma of possible abuse and neglect, as well as removal from their families, youth who age out have the added challenge of never having found the stability of a permanent home. At age 18, a child in the Texas foster care system is no longer obligated to remain in the custody of the Texas Department of Family and Protective Services (DFPS), but can voluntarily remain in foster care until age 22 if enrolled in an educational program or employed at least 80 hours per month.75 In Texas, 1,453 youth aged out of foster care in 2009, and, as of August of the same year, 4,225 youth, ages 14-17, were preparing to age out in the next three years.76 The foster care alumni population is expected to continue growing due to a surge in the number of out-of-home child protective placements in the 1990s and early 2000s. Child protection reforms that began in 2005 put greater emphasis on prevention and permanency planning, reducing the number of children entering foster care.77 However, this leaves a “bubble” of children who will be aging out in the coming decade. Prior to state legislation passed in 2009, the court’s jurisdiction ended when youth turned 18—even for the approximately 500 youth who voluntarily remained in foster care. Now the court can continue to have jurisdiction after age 18 if the youth requests it or is not able to care for him- or herself. Many foster youth overcome challenges and do exceedingly well. However, statistics show that foster youth, as a group, struggle more than other young adults:

• A 2003 study found that one third of foster care alumni have household incomes at or below the federal poverty level81—nearly three times the national poverty rate.82 • Thirty percent of homeless adults report having been involved in the foster care system.83 • Roughly 30% of foster youth who age out of care have a diagnosed mental health challenge, such as depression, 84 compared to 25% of adults in the general population.85 • The teen birth rate for girls in foster care is twice that of the general population. Nearly half of all girls who lived in foster care are pregnant at least once by age 19.86 • Among male foster youth and alumni, 30% are incarcerated by age 19,87 and 16% are incarcerated at age 24.88 Each of those outcomes carries a high price for Texas and taxpayers. Allowing foster youth to fall through the cracks represents lost potential and real economic and social expenses for years to come. Former foster children are more likely to be dependent on Medicaid, Temporary Assistance to Needy Families (TANF), and the Supplemental Nutrition Assistance Program (SNAP, formerly food stamps) as adults. These programs range in average monthly costs, but can total $600 per month per person.89 For the 1,468 youth who aged out of foster care in 2008, the cost of increased welfare and prison expenses total approximately $8.5 million a year, without accounting for inflation.90 This does not include lost opportunity costs for former foster youth who could have been successful with added supports, but instead drop out of high school or remain jobless. Also, while 70% of foster youth say they want to attend college,91 less than 5% receive a college degree.92 A study of 122 service providers in New England explored barriers to post-secondary education for youth eligible for federal education and training assistance.93 Results showed that many youth who were aware of available supports did not access them because of prior negative experiences with school and child welfare systems. Failure to have needs like housing, transportation, and mental health met further impede academic achievement.94 Another study by the Government Accountability Office found that fewer than half of the foster youth eligible for federal education and training assistance receive it and “that gaps in mental health, employment, and mentoring services, particularly in rural areas, may have contributed to the low numbers of eligible youth being served.” 95

Recent policy changes provide • Foster care alumni are more opportunities for improved When even a few hundred youth age out of than twice as likely as their outcomes. The federal Fosterfoster care without the supports they need peers to drop out of high ing Connections to Success 78 to be successful adults, the related welfare school. and Increasing Adoptions and prison costs for Texas total more than • Former foster youth are Act (Fostering Connections) $8.5 million per year. more than three times less passed in October 2008 imlikely to have a high school proves access to education and diploma or GED than their health care and extends federal support for foster youth until peers.79 age 21. This support is provided for youth who are employed • After six years of independence from the foster care sysor enrolled in college, a technical/training school, or a work tem, only half of former foster youth hold a job compared training program.96 Texas has extended support until age with 75% of similarly-aged peers.80
Child Protection

17

21 (22 if still in high school) since 2005, so the new federal legislation will provide federal funding for what was previously state funded.97 A bill passed in Texas in 2009 requires DFPS to create a transitional living workgroup—made up of transitional service providers, Court-Appointed Special Advocate (CASA) volunteers, former foster youth, and others—to generate recommendations for improving services to youth leaving foster care.99 Other policies currently in place to help youth transitioning out of foster care include: • Housing initiatives: Finding independent housing that offers the right balance of independence, supervision, and resources young people need can be a struggle, but under Fostering Connections, the federal government will make foster care payments for youth who live in supervised independent living settings.99 • Education and healthcare programs: The Texas Legislature has waived tuition and fees at state universities for former foster children who age out of care or were adopted after the age of 14,100 a policy that recently benefited about 1,700 students per year101 and may soon benefit more, given new laws that give foster care alumni longer (up to age 25) to access the waiver.102, 103 State legislation from 2005 also expanded former foster youths’ access to Medicaid health coverage.104 • Employment programs: State laws to provide employment benefits for qualified former foster youth and to ensure foster youth have access to legal documentation needed to apply for employment, support the goals of better job opportunities for youth transitioning out of care.105,106 • Transition planning: Fostering Connections requires that 90 days before a youth is emancipated a caseworker must help the youth develop a transition plan.107 Texas begins transition planning for some youth as early as age 14. Transition planning generally includes provision of life skills education.108 • Court involvement: Foster youth who remain within a court’s jurisdiction fare considerably better than those who do not,109 with those remaining in foster care beyond age 18 shown to be more likely to pursue higher education, delay pregnancy, and have increased lifetime earnings.110 Texas youth can remain under court jurisdiction until age 21, giving youth continued access to an attorney or guardian to assist them in accessing services.111 Researchers have found every dollar spent keeping youth in foster care until age 21, generates between $1.50 and $2.40, due to higher levels of high school completion, increased earnings, increased tax revenue, and reduced government costs.112,113 • Transition centers: Transition centers offer a one-stop shop for foster care alumni to access community resources. There are only ten transition centers in Texas, which leaves youth in many parts of the state without supports 18

or without an awareness of how to access available supports. Some centers receive some funding from the Texas Workforce Commission,114 but all ten are largely dependent on charitable donations and are struggling with very limited resources to meet the needs of youth who seek their services. • Lasting emotional support systems: A study found that foster youth who had a mentor of their choosing at age 18 fared far better than youth without a mentor.115 Programs such as DFPS’s Circles of Support, which brings together a group of youth-selected adults to help the youth carry out his or her transition plan, may help promote natural mentoring relationships.116 The state can further promote lasting connections by formally incorporating a tool such as a permanency pact—a written agreement between a foster youth and an adult establishing a permanent, supportive relationship117—into its transition services. Currently DFPS gives out information about this type of tool, but it is not part of either program.118 When permanency is not achieved, the state must find other ways to promote youth success. The most significant way to bolster lasting emotional connections is to seek permanency in CPS cases through reunification, placement with someone a youth identifies as a family member, or adoption. Until permanency is achieved, the goal should be to minimize the number of foster care placements a child experiences.119 When the state has not been able to find permanent homes for the children it takes responsibility for, it should use proven interventions to help build a pathway to success for youth who age out of the system. What Texas Can Do: • Promote lasting connections to caring adults by making permanency pacts a standard part of transition services. • Maximize funding under the Fostering Connections Act to expand housing options for transitioning youth. • Increase funding for transition centers, as well as other transition programs and services. What You Can Do: • Become a mentor for an older foster youth • Call or visit your state legislators’ offices to talk about services for transitioning youth in your community.

uNdERsTANdINg ANd AddREssINg POvERTy-RELATEd NEgLEcT
sive Family Preservation Services (IFPS), for example, is a In many cases, conditions that precipitate child neglect in time-limited yet highly involved intervention designed to Texas reflect not a lack of interest by parents but a lack of prevent removal of children from their families by quickly financial resources. An inability to provide reliable food, and thoroughly addressing the issues that put children at shelter, clothing, utilities, medical or child care, diapers, risk. IFPS is characterized by increased face-to-face contact car seats, or other necessities can be grounds for opening with caseworkers, small caseloads, rapid response, and a child neglect investigation. The number of child welfare cases involving neglect far outweighs those involving abuse tangible service provision. A study of more than 2,000 children whose families participated in IFPS found that (74% compared to 26% of all confirmed allegations),120 85% were able to remain safely in their home.126 Previous and a 2006 Department of Family and Protective Service studies in Washington and Utah had similar results.127 (DFPS) study found that more than 60% of Child Protective Services (CPS) investigations resulting in the removal Missouri’s Intensive In-Home Services Program found that of a child involved families whose income was $10,000 7 in 10 children served through the program since 2001 or less. Very poor families face more risk factors for child who otherwise would have been in foster care were able neglect: they are more likely to live in neighborhoods to remain safely with their families four years later.128 This with concentrated poverty, higher rates of single parentprogram tailors interventions hood, and limited community to meet the unique needs 121 resources. A program recently defunded by the of each family. Caregivers Legislature had shown early signs of success may receive a range of serPoor children also are at a and cost-effectiveness: 94% of children vices from parenting classes, higher risk for challenges in the program were able to remain safely housekeeping training, within the state child welfare in their home, compared to only 49% of all counseling, job training, or system. Once children in poor children who have CPS cases opened. access to community services. communities come into CPS Interventions are short-term custody, few foster homes and and concentrated.129 kinship care options are avail122 able in their communities, leaving them more vulnerable In Texas, DFPS began the Strengthening Families Initiative to never finding permanent homes.123 Parents of limited in 2008, at the Legislature’s direction, to provide preservameans also tend to lack access to services to help them tion and reunification services through enhanced in-home overcome complex issues leading to the removal of a child, supports. It was discontinued in mid-2010 as part of the leaving Texans who are poor at higher risk of losing their agency’s legislatively-mandated budget reductions. The 124 parental rights forever. Children from areas where there program gave families in-kind and limited cash assistance are few foster and kinship placements and fewer opportuto help prevent removal, speed reunification, maintain a nities to reunite with their families must be moved farther child’s safety, meet the child’s needs, or enhance family from home, which has been shown to extend the time functioning. Assistance was used to meet a family’s unique 125 children spend in foster care, at a high cost to taxpayers. needs that contributed to the child’s risk of neglect, such as medical bills, GED costs for parents, educational help for Fortunately, in the case of poverty-related neglect, there are the child, or parent coaching. Interventions were intensive often cost-effective supports that can be provided to keep a child safe with family, rather than removing the child, result- and quick: caseworkers were expected to spend 7-10 hours per week with the family and resolve cases within 60ing in trauma to the child and great expense to the state. 120 days. Caseworkers used a strengths-based approach, There are many programs working to alleviate the condicrafting interventions tailored to the distinctive needs and tions of poverty that put children at risk of neglect. Intenstrengths of the entire family system. The program did not
Child Protection

19

last long enough to fully gauge its long-term effectiveness, but early indicators were positive.130 Between January 2008 and May 2009, 4,035 out of 4,284 children served by SFI (94%) remained safely in their homes131 compared with 79% of children in families receiving other Family Based Safety Services and only 49% of children in all cases opened for services.132 Taking a child from his or her family has long-lasting consequences not only for the child and family; it also incurs a substantial responsibility and cost to the state. Supporting families at risk of poverty-related neglect can prevent the need for a child’s removal from home— creating success for that family and minimizing the need for further state interventions.

What Texas Can Do: • Invest in strategies to address poverty-related neglect, such as Texas’s Strengthening Families Initiative. What You Can Do: • Help an overwhelmed parent connect to resources and people they may not know are available to help in the community. • Let your legislators know you support policies that help children stay safely with their families, and urge them to prioritize funds for prevention of child neglect.

To access detailed source information for this section, visit txchildren.org/Report/Protection 20

FAMILy FINANCIAL SeCUrITy
For our state’s future economic growth, children must have their basic needs met today. Children in financially fit homes fare better on indicators of health, education, and future success, compared to their peers in economically struggling families. Among the 50 states, however, Texas has the third-highest percentage of children growing up in low-income families.1 These are families whose earnings are low enough that paying for just the basics, such as child care, housing, food, and clothing, is often a struggle. Many families in Texas live in poverty, with little financial security at all. In fact, Texas children are the nation’s most vulnerable to the three H’s—hunger, homelessness, and health crises—because our state ranks at the bottom nationally for children’s food security, homelessness prevention, and health coverage.2

For all Texans, household median income is close to the national average. For children, though, Texas ranks third from last in economic security. Poverty has long-term effects on children, while prosperity in childhood strongly predicts later wealth in adulthood. About 42% of children born to parents in the bottom fifth of income earners remain in the bottom fifth their whole lives, while 39% of children whose parents are in the top fifth of income earners stay there.3 Studies link poverty to increased stress hormones and decreased blood sugar flow to the brain, impeding learning at a time when children need the most supports to develop basic language, mathematical, reasoning, and memory skills. 4 Almost all low-income children in Texas have parents who work.5 Texas decision-makers and businesses can do more to put children and the state on a path to success. Amid the current economic turmoil, families need secure jobs that Texas falls behind the nation in educational attainment
81.5% 87.6% Texas US 55.1% 58.7% 26.8% 29.9%

pay well, students need to stay in school and pursue their education, and communities need the resources to build long-term prosperity that benefits all Texans. Public policies that allow families to receive the supports that they qualify for, encourage youth to stay in school, promote savings, and reduce predatory lending will put Texans on more solid financial footing—in turn, giving Texas a solid foundation for a prosperous future.

Are we making smart investments?
A powerful way to raise the bar for all Texas children is by improving educational attainment. Texas falls behind the nation in both K-12 and post-secondary educational completion. The state also ranks 42nd in the country in educational attainment by income level (meaning family income plays a major role in determining whether or not a child goes to college).6 Income inequality in Texas has grown steadily over the past couple of decades,7 perpetuating cycles of poverty across generations. Quality early education is one of the practices most consistently found effective at supporting children’s future success and leveling the playing field for disadvantaged children. High quality early education programs, characterized by small class size, highly trained teachers, and
Family Financial Security

100% 80% 60% 40% 20% 0%

High school diploma/GED Texas rank: 51

2-year college degree Texas rank: 40

4-year college degree Texas rank: 35

Corporation for Enterprise Development 2009-2010 Assets & Opportunity Scorecard

21

evidence-based curricula, are shown to improve academic achievement, graduation rates, college attendance, and lifetime earnings, while reducing crime and teen pregnancy.8 According to a report by the Bush School of Government and Public Service at Texas A&M University, high quality pre-kindergarten education in Texas returns over $3 for every $1 spent by reducing costs to the state related to delinquency and by increasing later earnings and workforce participation.9 Similarly, a report by the Economic Policy Institute estimates that universal pre-kindergarten education would begin to pay for itself after nine years and would return benefits of $8 for each $1 spent within 40 years.10 Asset-building programs, such as child savings accounts and individual development accounts, are additional strategies to create a savings- and investment-oriented economy, and that, in turn, promotes economic stability for the entire state. One study found that family access to just $500 to cover unexpected expenses due to illness, job loss, or other emergencies can have the effect of tripling income because families avoid costly credit card and payday lending debt.11 Finally, improving the system of supports that help working families make ends meet can help lift children out of poverty. This means maintaining or expanding benefits while making the delivery of services and supports, such as subsidized child care, housing, transportation, and health

25% 20% 15% 10% 5% 0%

Texas families experience all types of poverty at higher rates than the US
24.8% 22.5% Texas US 14.6% 12.3% 22.8% 17.8%

Asset poverty rate* Texas rank: 34th

Income poverty rate* Texas rank: 41st

Children living below poverty** Texas rank: 43rd

*Corporation for Enterprise Development 2009-2010 Assets & Opportunity Scorecard** US Census Bureau, “Texas: Selected economic characteristics,” 2006-2008 American Community Survey 3-Year Estimates

care, more efficient.12 Work supports and credits such as the Earned Income Tax Credit are more important than ever to the roughly 1.65 million people in Texas—including 908,165 children—who are the working poor13 and whose real wages (those adjusted for inflation) have not grown in the past three decades.14 Rising unemployment and underemployment and increases in health care premiums, among other rising costs, heighten the need for work supports15 that have proven effective before in decreasing poverty.16

Are we supporting financial security for all children?
Growing up as a Texan puts a child at increased risk of living in poverty. Additionally, where a Texas child lives, as well as the assets his or her family has passed down over generations, factor into whether that child is likely to grow up with financial security at home. Rural Children Geography plays a role in understanding gaps between poverty and prosperity. Rural child poverty rates are higher than child poverty rates in non-rural areas. Nationwide, 22% of children in rural areas are poor; in Texas, the child poverty rate in rural areas is over 25%,17 compared with 20% of children in metropolitan areas.18 Among the nation’s counties, several in Texas are ranked as having the highest rates of rural child poverty, such as Zavala County where 62% of children under age 18 live in poverty.19 The problem of deep poverty— income below half of the federal poverty line—is also more pronounced among rural children compared to their urban counterparts. A full 10% of rural poor children live at this extreme level of poverty, compared to 8% of urban poor children.20 Research shows that rural poverty also lasts longer—typically 15% longer—for a rural poor family than an urban poor family.21

22

Legacies of Past Public Policies There are multiple ways of assessing families’ financial security. Income poverty refers to the size of a family’s paycheck. Asset poverty refers to the net worth a family has built up— resources such as a home, savings accounts, and investments that families can turn to if income is disrupted due to things like illness or job loss. Families who are asset poor are those that would fall below the poverty line if income were cut off for three months.22 Historic inequities significantly influence the chances that a household will be asset poor. That is because inheritances and other transfers of wealth from prior generations account for roughly four-fifths of all asset wealth in the United States. For every $1 in net worth a white family possesses, a family of color has $0.13. Similarly, for every $1 in net worth a male-headed household possesses, a female-headed household has $0.57.23

Household type:
% Living below poverty line (income poverty)** % Living in asset poverty* Zero or negative net worth Homeownership

White
9.2% 16.4% 11.7% 72.5%

Minority
21.3% 37.2% 26% 48.2%

Historic inequities in federal legislation impact asset accumulation in Texas today. The Homestead Act, passed in 1862, gave government land grants to families who moved west and settled for at least five years. The Federal Housing Administration, established in 1934, also helped families attain housing stability through mortgage insurance and other home finance products. Finally the GI Bill helped returning World War II veterans pay for higher education and acquire loans and mortgages.24 Though these acts helped many families, they also created gaps in asset wealth by allowing discretion in local implementation. The opportunities created by these statutes helped many white families, while leaving many families of color subject to “red lining” (i.e., refusing to offer mortgages or extend services in certain neighborhoods where minority communities resided). Since land and homes are assets that often stay in families for generations, these bills only deepened racial gaps, and they continue to affect the asset wealth of today’s children.25 For example, since homeownership helps build credit history, families that purchased homes with help from the GI Bill could also take out student loans to send their children to college. Consequently, college enrollment increased across the country for more than a generation and the number of high-paying jobs that did not require college education dwindled, widening the educational attainment and income gaps between whites and people of color.26 Public policies from generations ago, before today’s children were even born, should not determine children’s future success. What Texas Can Do: • Promote educational attainment for all children by funding quality early education and dropout prevention programs. • Expand work supports by increasing available child care subsidies, expanding the supply of affordable housing, and extending emergency unemployment benefits. What You Can Do: • Ensure children in your community receive a quality education by becoming a mentor or tutoring a child. • Offer to help a high school student apply for college. • Help dispel myths by bringing up the role of historic inequities in dialogues about poverty. • Support low-income parents in your community in their efforts to achieve financial stability by volunteering at a community center to teach job skills for financial education, or conduct résumé-writing and job-search workshops.

Statistics are for all U.S. households Source CFED 2007-2008 Assets & Opportunity Scorecard *Source: CFED 2009-2010 Assets and Opportunity Scorecard **Source: American Community Survey 2006-2008

Family Financial Security

23

For this to happen, Texas must address key causes of economic insecurity, including many Texans’ lack of education. Texas, unfortunately, ranks last in the country in high The recession weakening the national economy in recent school completion, a major factor in workers’ earnings.40 years has proven especially damaging for Texan children. In 2005-06, only 65 percent of Texas high school students Although the overall unemployment rate in Texas is below graduated, about 6 percent below the national average.41 the national average, the percentage of children living in Texas is among the 15 worst states for high school dropfamilies where no parent has year-round, full-time employout rates.42 In 2008, high school dropouts had an average ment is about the same in joblessness rate of 54 percent Texas as the national average. and an employment rate of The current economic downturn may (The rates are 26% and 27% 46 percent—22 points below make more than a quarter-million respectively.)27 The sad fact that of high school graduates.43 additional Texas children grow up in poverty. is children are simply more This joblessness is costly. For likely to live with an unemexample, high school dropouts ployed or underemployed from the class of 2008 alone parent, than working-age adults are to be unemployed or will cost Texas almost $30.7 billion in lost wages over their underemployed.28 Texas children are also among the nation’s lifetimes.44 Texas also has the country’s third-highest teen most likely to have entered the recession without a basis of birth rate.45 Teen mothers are more likely to drop out of financial security, suggesting their families need better opschool and raise their children in poverty compared to older portunities to get ahead. mothers.46

How the economic downturn affects children and the future of Texas

Even before the national downturn, the economy was not working especially well for most Texas children. Almost half of children here live in low-income households, where earnings are no more than twice the federal poverty limit. Texas ranks third in the rate of children in low-income families, after the relatively poor states of Arkansas and Mississippi.29 Nearly 1.7 million children in Texas met the federal government’s definition of poor in 2009 (living in households where earnings are no more than $22,050 for a family of four).30 The majority of these children in poverty have parents who work and actively seek work31 and who were born in the United States.32 One-third of Texas’s poor children live with both their parents, who are married.33 The Foundation for Child Development says the recession is deteriorating the health and wellbeing of U.S. children and stands to “virtually undo all progress made in children’s economic wellbeing since 1975.”34 Between 2008 and 2009 alone, more than 160,000 more children in Texas became poor. 35 In total, an estimated quarter-million more children in the state could become poor as a consequence of the recession.36 For all Texans, this could lead to negative economic and social consequences for years to come. The Institute for Research on Poverty placed the economic cost of childhood poverty in the United States at approximately $500 billion per year, due to lost productivity, increased crime, and poor health.37 Based on this data, the annual cost of child poverty for Texas was calculated at $57.5 billion, prior to the economic downturn.38 The recession is projected to bring that annual cost up to $67.1 billion.39 Improving the economic security of Texas children would save Texas tens of billions of dollars, as evidence shows these children would be more likely to grow up to be healthy, productive members of society. 24

As more families fall into poverty during the recession, there is a corresponding increase in the use of public benefits programs. Between the recession’s official start in December 2007 and May 2010, the number of Texas Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps) recipients under age 17 increased by over 600,000.47 More Texas children are being enrolled in the federal free and reduced price lunch program as well.48 Of the state’s roughly 5 million school-aged children in Texas, more than half qualified for the program as of December 2008.49 Enrollment in Medicaid has also increased since the start of the recession.50 Many children who are eligible for public benefits do not receive them. Texas’s support system ranks among the last in the country for the share of eligible people in need who actually receive benefits.51 A spokesperson for the Texas Health and Human Services Commission at one point likened the experience of trying to process enrollment applications for public benefits since the recession began to “drinking from a fire hose.”52 Only about 2 percent of Texas’ poor children receive benefits under the Temporary Assistance for Needy Families (TANF) program, in part due to the difficulty of accessing funds.53 There are ways to remove the barriers that separate Texas families from the critical public benefits that many of their children need and are already eligible for. For example, the Texas Health and Human Services Commission is working to address inefficiencies in its eligibility system for SNAP, improving timeliness of application processing by increasing the eligibility workforce.54 Another way to eliminate red tape includes doing away with rules that require families on Medicaid to re-enroll their children every six months, instead of once a year, to get health coverage. Policymakers will soon have a new tool for understanding

the current economic needs of families with children. In the past, the federal government’s definition of poverty has been criticized for undervaluing the expenses that most families with children find consume the majority of their budget: child care, housing, and health care. This is because the current federal poverty measure—calculated by multiplying the cost of an emergency food diet by three—was developed during the 1960s when food accounted for a third of a family’s expenses. Today, food makes up about one seventh of the average family’s budget. Then, a poor family earned about half the income of the average American; today, they earn about 28%.55 In response to these shortcomings, the U.S. Census Bureau will introduce a new, more comprehensive Supplemental Poverty Measure (SPM) in the fall of 2011. The current federal poverty measure will still be used to determine eligibility for assistance,56 but the new measure will provide information about families’ contemporary financial realities.57 The SPM will take into account things that the existing poverty measure does not, including the impact of public programs on a family’s available resources.58 Texas needs to plan beyond short-term economic gains, and pursue strategies that assure greater economic wellbeing for everyone. Good jobs and a strong educational foundation will deliver better results for children during times of economic turmoil, and better results for the state, as well. However, that will require reforms to our education, workforce development, and public financing systems, as well as

policies related to asset-building and debt avoidance, health care, preventing unplanned teen pregnancies, and ensuring services for families with children. Reducing the dropout rate, helping more Texans qualify for better paying jobs, and making sure families can access the benefits they are eligible to receive represent key factors in an economy that works for Texans of all ages. After all, the future economic viability of Texas rests with today’s children having the resources to succeed in life.59 Our state needs commitment, both from leaders and the public, to ensure a well-functioning economy for all Texans, now and into the future. What Texas Can Do: • Establish a statewide plan to reduce child poverty. • Cut the red tape that stands between families and basic supports by continuing to improve Texas’ eligibility system performance and manpower. What You Can Do: • Blog or write a letter to the editor about the importance of supports for children in tough economic times. • Volunteer for a dropout prevention program in your area. • Organize a food drive for your local food pantry. • Take care of a friend’s or neighbor’s child while the parent fills out applications or attends job interviews.

Family Financial Security

25

parties, including family, nonprofits, businesses, and the youths themselves, can make contributions, which the Texas ranks 48th in the nation for net worth—the total of government will often match for low-income families, an individual’s assets minus debts. Assets may include bank who also may receive financial education. Funds are placed account balances, stocks and mutual funds, a home or other in an investment program, with withdrawals allowed for real estate, businesses, or other investments.60 Promoting purposes of homeownership, entrepreneurship, education, asset building is important to helping families achieve and or retirement. Some CSAs feature “benchmark incentives,” maintain economic secuadditional deposits that reward rity even during times when positive saving behaviors (e.g., youth with a savings or bank account are income is disrupted. pursuing financial education, up to seven times more likely to attend college starting direct deposit, or makthan those with no account, even when An effective way to promote ing good grades).65 controlling for other variables such as family asset building is through income, race, and academic achievement. matched savings programs Children’s Savings Accounts like individual development yield a considerable return on accounts (IDAs), chilinvestment. Investing $1,000 dren’s savings accounts (CSAs), and college savings plans. for 18 years at 6% interest yields $3,000; if contributors Matched savings accounts help families build assets, even save $50 per month, the return reaches $22,000.66 These on very limited incomes. Results of the National IDA Demearnings can mean the difference between a low-wage job onstration, an initiative of the Corporation for Enterprise and a college education for young people who would not Development (CFED), found that: be able to afford post-secondary education otherwise. Texas IDA participants saved over $3.6 million between 2000 • Account holders whose income was at half the federal and 2006, supporting the purchase of over $57 million in poverty limit saved the same amount at 2-3 times the assets.67 rate of those with incomes at 200% poverty. • Of the low-income and very poor families who saved Texas was one of five states to participate in the Saving for more than $100, almost all purchased an asset with their Education, Entrepreneurship and Downpayment (SEED) savings, and among graduates of the IDA program, 95% program, a national demonstration project of child savings still had the asset they purchased after two years. accounts led by the Corporation for Enterprise Development (CFED). As the name suggests, SEED matched • Most of the families purchased an asset with a long-term funds are used to pay for education, establish a business, benefit: a house, a business, post-secondary education, or purchase a home. SEED based its matching structure or an individual retirement account. on the age of the child, similar to the way a retirement • The saving rate was higher even after the IDA was closed portfolio changes as an adult ages. An evaluation of 1,253 (10% continued saving, in contrast to the national averSEED participants, ages 3-18, found, although about half 61 age savings rate of 0.6%). of participant families lived below the poverty line and all IDA legislation at the state level in Texas has faced periods were low-income, after 2.5 years, the average account had of progress and setbacks through the years, but some localiaccumulated $1,540. ties are establishing their own IDAs. The City of San Antonio, for example, began a matched savings IDA program in Savings averaged $41 per quarter per household,68 and 2000 for low-income, working families. The city offers a $4 families who participated in the SEED program said they match for every $1 saved up to $1,000, meaning particifelt this might be their only opportunity to save for their pants can receive as much as $4,000 toward the purchase of children.69 Parents able to save for their children’s future 62 a home or higher education. Since 2000, 502 San Antonio raise their expectations of what is possible for their children: families have purchased an asset through this program, and studies show that children whose mothers have high expecan additional 146 are currently saving.63 tations of them are more likely to make good grades and are more likely to see college in their own future.70 Similarly, a Child Savings Accounts (CSAs) are a type of IDA designed study by the Center for Social Development of 453 youth to maximize return on investment by beginning asset found that those who had a savings or bank account were building as soon as a child is born. CSAs are a particularly up to seven times more likely to attend college than those effective asset-building method because they are shown to with no account, even when controlling for other variables promote educational attainment and reduce intergenerasuch as family income, race, and academic achievement.71 tional poverty. For example, a study of 60 second-grade Parents of SEED participants also reported more planning students and their parents conducted by the Center for for the future, better financial behaviors, improved security, Social Development found that children with college savand higher self-esteem.72 Expanding the program model ings report higher expectations for college attendance than statewide and extending it beyond elementary school to those without.64 Many CSAs feature an initial government include a preschool age cohort would help families accumufunded deposit of $500-1,000 given at birth, and third late more wealth by starting savings earlier.

Helping families build up their assets

26

Texas also helps promote secondary educational attainment through college savings programs such as the Texas Tuition Promise Fund and the Texas College Savings Plan. The Texas Tuition Promise Fund, a prepaid college tuition plan73, 74 offers the same benefits as the Texas Guaranteed Tuition Plan, which closed to new enrollees as of 2003. The latter— a tax-deferred savings account backed by the state, which allowed families to pre-purchase “tuition units” while protecting against rising costs—was not sustainable under tuition deregulation.75, 76 In contrast, state colleges and universities are responsible for making up the difference between the funds available in the Texas Tuition Promise Fund trust and the actual cost of tuition.77 The Texas College Savings Plan is another option that allows families to place college savings in an investment portfolio similar to an IRA and make tax-free withdrawals for eduction expenses.78 Percent of Texas Tuition Promise Fund enrollees by Annual Household Income

In Texas, high school graduates earn approximately 41% more than those without a high school diploma or equivalency, and employees with bachelor’s degrees earn an average of 84% more than high school graduates.80 Because of these increased lifetime earnings, the state can expect a high Not return on programsSpeci support 5.5% Less than $50,000 that ed educational attainment 9.3% due to decreased use of public services and increased tax revenues from families’ increased purchasing power. Fund12.3% $50,001-$75,000 ing Texas Save and Match would be a wise investment and has the potential to expand educational opportunities for the families most in need. family economic security, but also helps build state prosperity.

20.1% $75,001-$100,000 52.7% Over $100,000 build assets not only increases individual Helping families

Percent of Texas Tuition Promise Fund enrollees by education Level

Not Speci ed 9.3%

5.5%

Less than $50,000 12.3% $50,001-$75,000

Not Speci ed 7% Doctorate Degree Some College 8% 11% 39% Bachelor’s Degree

20.1% Over $100,000 52.7%

$75,001-$100,000

Associate’s Degree 5% 3% High School Graduate

27%

Master’s Degree

Sources: Texas Tuition Promise Fund Weekly Product Update, March 9, 2009; Texas Tuition Promise Fund Monthly Report, March 31, 2010

Participant data from the Texas Tuition Promise Fund indicates that it Not Speci ed is disproportionately utilized by higher-income, 79 better-educated families,7%pointing to a remaining gap for Doctorate Degreefamilies. 11% lower-income The Texas Save and Match Program has the potential to Bachelor’s Degree 39% make post-secondary education more affordable for lowincome families and help all Texas children extend their Associate’s Degree 5% education past 3% school. It is structured to offer matchhigh High School Graduate ing grants to help eligible children save for higher educa27% tion, but the legislature has not funded it.
Some College 8% Master’s Degree

What Texas Can Do: • Expand Children’s Savings Accounts by reestablishing the SEED program across the state. Need rollover 24% • Increase savings for post-secondary education by often funding the Texas Save and Match Program.
rollover What You Can Do: Never need 42%

• Start a college savings account for a child in your life. 34% Need rollover • Talk to your legislators about the importance of sometimes investing in children.

24% Never need 42%

Need rollover often

Family Financial Security

27

Moving more families from predatory lenders to mainstream banks
As with other measures of family financial security, the percentage of families accumulating assets through bank accounts in Texas is lower than in other states. Nearly one in three households in Texas is unbanked, meaning no one in that household has access to checking, savings, or money market accounts.81 Even more Texas families are considered under-banked, meaning they have access to some mainstream financial services, but not enough to meet all their needs.82 Unbanked households face regular fees for cashing checks and using money orders to pay routine bills. These fees add up quickly and deplete a family’s resources. The Brookings Institution estimates that the average American worker could save $40,000 over the course of his or her career by using a bank or credit union instead of checkcashing and money orders. If invested wisely, this $40,000 could grow into $360,000 by the end of a 40-year career.83 Connecting more families to mainstream financial institutions is one of the most cost-effective ways to help families build assets. Encouraging families in accessing mainstream financial institutions also helps safeguard them from some existing predatory practices. The unbanked and under-banked have limited options when needing a line of credit, and a largely unregulated industry has developed in response. The Credit Services Organizations (CSO) Act, passed in 1987 in Texas, allows payday lenders to operate as a credit service organization. The express purpose of a CSO is to help individuals repair their credit histories through extensions of credit and counseling.84 CSOs pay a $100 annual registration fee to the Secretary of State regardless of how many storefronts they operate. While the interest rate on payday loans is legally capped at 10%, there is no limit to the service fees CSOs can charge.85 Fees collected by Texas’ estimated 2,800 payday lenders86 amount to $581.9 million annually. Fees typically range from $15-25 per $100 loan,87 The real Cost of a $300 Payday Loan
“Rollover” Loan Fees**

a substantial charge given the average payday loan is around $500.88 These loans must be paid in full after two weeks, a time span that is unrealistic for most borrowers. In essence, the loophole allows payday lenders to avoid the controls, oversight, and consumer protections that banks and credit unions are subject to.89 Payday loans often perpetuate or deepen a family’s inability to make ends meet: a study by the national Center for Responsible Lending found that half of all second loans were taken out immediately, and 87% within two weeks. These repeat loans account for 76% of loan volume.90 A survey of payday borrowers in Texas, conducted by Texas Appleseed, found that the majority needed to take out at least one repeat or “rollover” loan,91 making loan fees the equivalent of a 300-500% annual percentage rate (APR).92 Evidence suggests that eliminating payday loans has little impact on low-income individuals’ overall access to credit: a University of North Carolina study, for example, found the state’s 2006 decision to close payday lending stores had no significant impact on credit access. Rather, among the 159 households surveyed that had experienced a recent financial shortfall, the ratio of households positively affected by the absence of payday lending to those negatively affected was more than three to one.93 Policies to curb predatory lending practices have been enacted at both state and local levels. Of particular note, in 2004 Georgia passed one of the nation’s strictest laws regulating payday lending. Annual interest rates there cannot exceed 16%, and payday lenders cannot pay out-of-state banks to circumvent the cap. The state can impose civil

$600 $500 $400 $300 $200 $100 $0

$240

Original Loan Fees*

$60 $300

Breakdown of payday loan costs

*Loan fees average $20 for every $100 borrowed. **It takes an average of five loan periods to repay a loan in full; no partial payments are allowed. Each time a loan is renewed the same lending fees apply.

28

penalties for short-term lenders in violation of the new rate. In the twelve states that enforce rate caps, savings to their citizens total an estimated $1.5 billion annually.94 Some Texas communities have begun to take action against predatory lending practices. Cities such as Mesquite, Little Elm, Irving, Richardson, and San Antonio have all passed local ordinances that halt the spread of payday lender storefronts.95 Another tactic for promoting sound financial management is encouraging the use of regulated, consumer-friendly products at mainstream financial institutions. New York, for example, deposits state reserves into banks that open branches in underserved communities in order to offset losses banks may incur.96 In 2007, the Federal Deposit Insurance Corporation (FDIC) began a two-year, smalldollar loan pilot program in 31 financial institutions across the country. Three Texas banks, Amarillo National Bank, Main Street Bank in Kingwood, and Liberty National Bank in Paris, are participating in the program. The pilot allows these banks to make loans up to $2,500 at a capped annual percentage rate of 36%. There are no prepayment penalties, the payment terms are longer than those of most payday loans, and the loans are paired with an automatic savings program and financial education. Through the pilot, Texas banks have made over 500 loans averaging $750 each for a total of $400,000. The average APR is 16% over an 8-month average term. Delinquency rates have been very low and payoffs high.97 According to the Federal Reserve’s 2007 survey of consumer finances, over a quarter of families in the lowest-income quintile paid over 40% of their income in debt payments.98 Regulating lending practices and creating viable alternative loan products offer great potential to help families maintain financial stability. What Texas Can Do: • Close the loophole that allows some lenders to avoid regulation by operating as Credit Service Organizations. • Institute a lending interest rate cap at 36% APR or lower. What You Can Do: • Talk to your city council and mayor’s office about establishing a local ordinance that keeps payday lenders out of your community. • Encourage community leaders to start a local Bank On campaign, which raises awareness of the advantages of banking and encourages financial institutions to offer products geared towards previously unbanked populations. • If your community has already initiated a Bank On campaign, find out if your local bank or credit union is part of the Bank On campaign. If not, ask them to join.
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29

NOuRIsHINg TExAs cHILdREN, AN IssuE Of HEALTH ANd REsOuRcEs
All children need good nutrition to be healthy, but many Texas children experience food insecurity, meaning they lack consistent access to adequate food. More than 24% of Texas children under age 18 are food insecure—one of the highest rates in the country.99 Hunger rates are also likely higher today due to the economic recession.100 When nutritious food is unavailable and unaffordable, many families are left to make unhealthy substitutions in their children’s diets, some of which bring serious health consequences. foods. Many rural and inner-city neighborhoods have fewer supermarkets, leaving fast-food restaurants and convenience stores, with their less healthy fare and minimal fresh produce, as sometimes the only option for purchasing food in low-income neighborhoods. Also, nutrient-dense, lowcalorie foods, like fruits and vegetables, are more expensive108 than calorie-dense foods, like foods that are highly processed or that have added fats and sugars that more easily appease hunger.109 Sporadic food insecurity can also lead to binge-eating during peHaving inadequate or inconriods when food is available.110 sistent access to nutritious Overweight and obesity affect Texas is tied for having the nation’s highest food is dangerous for children. people at all socioeconomic rate of children who are “food insecure." Children who experience food levels, but people with fewer insecurity are more likely to resources face especially high face developmental chalbarriers to eating healthfully.111 lenges and delays in the areas It is not surprising then that children who are food insecure of growth, speaking, behavior, and movement. Setbacks in have at least comparable rates of overweight as their foodthese areas can lead to attention, cognitive, and social difsecure peers, with some research identifying an increased ficulties later on and result in gaps in school achievement.101 risk of obesity among some food insecure children.112 rd (One study of more than 10,000 kindergarten and 3 -grade children, for example, found significant delays in reading Community nutrition programs help food-insecure families and mathematical skill development among food insecure achieve improved outcomes for their children.113 Children 102 children compared to their peers. ) The physical and in the Supplemental Nutrition Assistance Program (SNAP, emotional burden of food insecurity may also lead to grade formerly known as the Food Stamp Program), experience repetition, absenteeism, tardiness, anxiety, aggression, and improved academic achievement in elementary school,114 difficulty with social interaction among elementary schooland children in Women, Infants, and Children (WIC) aged children.103 have fewer deficiencies of vitamins, minerals, and iron.115 Due to the program’s nutritional guidelines, children who Children from food insecure households experience poorer participate in the National School Lunch Program consume health, a diminished capacity to fight off illness, and a 30% more fruits, vegetables, and milk than nonparticipants. The higher rate of hospitalization.104 Additionally, food insecuriprogram also has been shown to reduce obesity among food ty is associated with depressive disorders in 15-16 year olds, insecure girls.116 even when controlling for income and other factors,105 and with increased irritability, fatigue, and difficulty concentratUnfortunately, Texas is struggling to provide SNAP bening in children of various ages.106 Lacking essential nutrients efits to all who qualify. Texas has fallen far behind federal in their diet, food insecure children also risk deficiencies of standards resulting in the federal government threatenimportant nutrients such as calcium, magnesium, folate, ing to fine Texas nearly $4 million for errors and lack of potassium, and phosphorus.107 timeliness. Federal law requires SNAP applications to be processed within 30 days, but since the recession began, in Food insecurity in low-income areas can in part be attribmany Texas regions applicants have had to wait up to twice uted to the lack of availability and higher cost of healthy 30

as long just to attend the interview required for application approval.117 The State Auditor’s office identified among the contributors to the SNAP processing challenges inefficiencies in the eligibility determination process.118 The Texas Health and Human Services Commission has worked diligently to improve,119 120 and these efforts are resulting in some significant improvements.121 The audit outlines several steps needed to continue to address these problems, such as allowing SNAP applicants to track application progress online, moving to electronic case files, and using federal funding for SNAP administration.122 Texas continues to struggle with enrollment in SNAP and faces potential cuts to the eligibility system in the coming legislative session.123 The federally-funded Summer Food Service Program bridges the gap during summer months when children do not have access to meals through the National School Lunch Program. The Summer Food Service Program is operated by independent sponsors such as school districts, nonprofits, and parks and recreation departments in communities where at least half of all children qualify for the National School Lunch Program. Although it is designed to feed each child who is eligible for the School Lunch Program, only one in five of these children accessed Summer Food Program meals in 2008. There are too few sites, especially in rural areas, a lack of awareness about the program, and insufficient meal reimbursement rates, all of which limit access to summer meals.124 Supporting these nutrition programs will help ensure that children not only receive enough food, but the right foods to help them reach their potential.

What Texas Can Do: • Increase availability of healthy, affordable food by supporting the presence of full-service supermarkets and farm stands in underserved areas and creating incentives for food retailers of all sizes to offer healthy choices. • Work with community organizations to expand and improve participation in federal nutrition programs by125: o Following the recommendations of the State Auditor’s Office to improve the eligibility and enrollment system for SNAP and other nutrition programs; o Reducing paperwork for parents, schools, and nonprofit organizations that provide meals in order to reduce stigma and boost participation; o Supporting free school breakfast and lunch for all children within schools that have substantial numbers of already-eligible children; and o Increasing outreach efforts and improving meal reimbursementrates to assist more afterschool and summer programs in feeding hungry children. What You Can Do: • Contact your faith community or community group about serving as a summer feeding program site. (Need help? http://texasimpact.org/node/452) • Help start a vegetable garden in your local school. • Talk to your mayor and city officials about the importance of the Summer Food Service Program. (Need help? http://netx.squaremeals.com/SNP/summerfood/sponsors/forms/MayorsChallenge_toolkit.pdf )

To access detailed source information for this section of the report, visit txchildren.org/Report/Poverty
Family Financial Security

31

health measures such as prenatal care and breastfeeding; preventing maternal substance abuse and teen pregnancy; allowing children to see a doctor and grow up in areas where they can get nutritious foods and play outside; and educating all Texans— especially young people—about health will help the next generation of Texans grow up stronger and healthier.

Are we making smart investments?
Not all infant and child health challenges can be prevented—but many can, leading to savings in our health system.1 Making smart investments before a child is conceived and through the early years can stem the need for much costlier interventions later in life.2 Identifying medical and developmental issues early is a critical component of preventive care that can lead to later savings. Many developmental delays are identifiable in infancy and toddlerhood; however, fewer than 50% of children with these challenges are identified before they start school. Children are much more likely to receive developmental screenings and preventive healthcare when they have health insurance. Even then, however, one in five children with a disability will not be identified through a single developmental screening.3 Providing infants and toddlers with continuous access to healthcare can bring substantial savings, averting the need for costlier later interventions. Educating caregivers about child health and development early on has proven to be a cost-effective strategy for improving children’s health. Home-visiting programs, in particular, have proven effective in promoting infant health. These programs serve families with children whose health, safety, or wellbeing is at risk. Home-visiting brings a return on investment estimated at up to $17,200 per child served.4 Parents as Teachers, HIPPY, and Nurse Family Partnership are three home-visiting models that operate in Texas. Parents as Teachers (PAT) pairs new and expecting parents with PAT-certified parent educators who help them prepare for the birth of their child by providing advice and information on early brain development, health, and growth milestones.5 The parent-educator relationship continues until the child reaches kindergarten age, promoting positive parent-child interaction and early learning in the home to support motor skills and social and intellectual development.6 Outcomes show that children in the PAT program are more likely to be immunized and less likely to experience injury.7 PAT is available in over 40 cities across Texas8 and is shown to return $1.23 for every dollar spent, saving the state $800 per family.9

CHILD AND MATerNAL HeALTH
Growing up healthy profoundly affects lifelong health. Unfortunately, children in Texas face unique barriers to a healthy start. For many years, the state has had the nation’s highest rate of children without health insurance. Texas also has one of the nation’s highest rates of child obesity. Infant health, which is mostly improving across the country, has declined in recent years in Texas. Families, communities, schools, and child care settings all have a role to play in ensuring a healthy start for Texans. Eliminating environmental pollutants; promoting infant 32

HIPPY (Home Instruction Program for Preschool Youngsters) serves families of 3- and 4-year olds in the home by helping parents create an intellectually stimulating environment for their children. During home visitation sessions that occur biweekly until the child goes to kindergarten, HIPPY instructors help parents, many of whom have limited education, use books and toys as educational materials. HIPPY is shown to return $1.80 for every dollar spent and save states $1,476 per family.10 Nurse Family Partnership matches nurses with first-time parents, bringing them together from pregnancy through the child’s second birthday. Nurses instruct and assist families on how to care for themselves and their baby during this critical time. The program operates in 26 Texas counties11 and reports improved prenatal health, increased school readiness, and fewer childhood injuries.12 The Washington State Institute for Public Policy estimated that Nurse Family Partnership returns $2.88 for each dollar spent, saving the state up to $17,180 for each family in the program.13 Ensuring access to healthcare lays the foundation for prevention, reducing the need for costlier care in the future. Prenatal care for women has been shown to lead to better infant health,14 and children with insurance are more likely to receive routine preventive care and remain healthier, and less likely to make costly visits to the emergency room.15 Covering kids in public health insurance programs bring a positive return for the bottom line. According to economist Ray Perryman, a dollar cut from the state’s budget for children’s health insurance results in a $1.85 loss to Texas taxpayers, due to higher insurance premiums and higher local taxes, and $2.81 in lost revenue to the state, due to reduced federal matching funds.”16 Reducing childhood obesity would address one of the greatest—and most preventable—threats to children’s health, and one that carries a high price for Texas. Obesity and obesity-related ailments cost Texas businesses and insurers an estimated $3.3 billion in 2005 in health spending, disability costs, lost wages, and decreased productivity.17 If action is not taken to reverse the growing trend in child obesity, the costs will skyrocket.18 Another study by the Texas Department of Health projected the cost of obesity to be as much as $39 billion in direct and indirect costs for overweight and obesity by the year 2040.19 The coordinated school health model is a best practice recommended by the Centers for Disease Control to prevent obesity in children.20 The most widely adopted coordinated school health program in Texas is Coordinated Approach to Child Health (CATCH), which teaches the importance of healthy eating and physical activity to elementary school children in over 1,200 schools across Texas.21 Texas’s coordinated school health models are already paying off. A study of this intervention in four El Paso schools found the net benefit of CATCH (the value of avoided future costs minus the cost of implementing the program) was $68,125.22

Are we advancing the health of all children?
Despite a growing knowledge base and improvements in technology, gaps in infant and child health outcomes persist. Child Obesity Obesity in childhood increases the risk of type 2 diabetes, asthma, and cardiovascular disease.23 Since half of obese children and over 70% of obese youth become obese adults,24 they are also at greater risk of stroke, certain cancers, and high blood pressure in adulthood.25 The burden of these health issues fall disproportionately on children of color. Latino boys and girls born in the year 2000 have a 45% and 53% respective risk of being diagnosed with diabetes during their lifetime, nearly double the 27% risk for white boys and 31% risk for white girls born the same year.26 Ensuring all children have opportunities to exercise is critical. Black and Latino parents report more barriers to their children’s physical activity than do white parents, including transportation issues, concerns for neighborhood safety, and the availability and expense of sports and recreational activities.27, 28 Obesity among Latino children is highest in Texas: according to the National Survey of Children’s Health, 47% of Latino children were overweight or obese in 2007, compared with 26% of black children and 23% of white children.29 Another contributor to these disparities is a lack of healthy foods in neighborhoods where families of color are more likely to live. A 2008 study by the National Academy of Sciences found that white families had three times the access to supermarkets as Latino families,30 and a different study of over 200 neighborhoods found predominantly white neighborhoods had four times as many supermarkets as predominantly black neighborhoods.31 Access to stores that carry fruits and vegetables is associated with a reduction in body mass index, especially among black adolescents.32 Lowincome black and Latino children without reliable access to healthy food are much more likely to face developmental difficulties than “food secure” low-income children in these groups.33 Making nutritious foods available in all neighborhoods will help improve health outcomes for children across the state, closing the gaps between rates of overweight and obesity among different racial and ethnic groups.34 Infant Health There are significant gaps between population groups when it comes to infant mortality rates in Texas. In 2006, 2,476 Texas infants died before their first birthday35—and AfricanAmerican babies die at more than double the rate (13.9 per 1,000 births) of Caucasian babies (5 per 1,000) or Hispanic babies (6.2 per 1,000) in Texas, according to the Department of State Health Services.36 In 2006, 54,000 babies in Texas were born prematurely and 33,000 were born with a low birthweight.37 The rate of African-American babies born weighing less than 5.5 pounds (14%) is nearly double the rate for Caucasians or Hispanics. Research indicates that a
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very low birthweight (VLBW) is common when an infant is delivered preterm, and that preterm births are the primary cause of infant mortality.38 Such studies suggest that the gap in white-black infant mortality is largely driven by the disproportionate percentage of black infants who are born preterm, and by greater mortality reductions in white preterm infants compared to black preterm infants.39, 40 Differences in access to prenatal care and disproportionate access to medical advances may help explain why black babies die at more than twice the rate of white babies.41 Recent research attempting to understand the infant mortality gap suggests that the race and ethnicity of VLBW infants may impact their likelihood of being admitted to the Neonatal Intensive Care Unit (NICU).42 Admission to the NICU can mean the difference between life and death for a VLBW infant. A concerning study of 19 states demonstrated that 72% of infants with VLBW born to Hispanic mothers were admitted to NICUs, compared with 80% of those born to non-Hispanic black or white mothers.43 What Texas Can Do: • Improve maternal, infant, and toddler access to healthcare. • Expand home-visiting programs to reach more Texas children and first-time parents. • Support implementation of coordinated school health in Texas. What You Can Do: • Start a parent support network so that parents can connect with one another to share advice, knowledge, resources, and encouragement. • Host a CHIP/Medicaid enrollment drive in your community. • Teach a child about healthy living: let him or her help with grocery shopping and food preparation, get started on a family exercise agenda, and seek out good ideas for introducing healthier choices at home.

and cancer, extend to those exposed to secondhand smoke as if they were smokers themselves.44 Newborns who were exposed to secondhand smoke, either prenatally or after birth, face heightened risk for sudden infant death syndrome (SIDS). Prenatal exposure also leads to low birthweight and slow lung development, as well as the problems that come with both. Bronchitis, pneumonia, ear infections, and respiratory troubles, such as cough and breathlessness, occur more frequently among children exposed to secondhand smoke. Children with asthma experience more frequent and more severe attacks due to secondhand smoke.45 A report by the Surgeon General concludes that there is no safe level of exposure to secondhand smoke—any exposure is harmful—yet an estimated 40 million children and youth, ages 3 to 19, were exposed to secondhand smoke in the U.S. in the year 2000.46 Twenty-five percent of children, ages 3 to 11, in the U.S. live with at least one smoker, compared with only 7% of nonsmoking adults, putting children at a much higher risk of exposure.47 State and local policies that ban smoking have played an important role in limiting exposure to secondhand smoke. Texas law prohibits smoking in child care centers and foster homes, and restricts smoking to designated areas in public places such as schools, hospitals, transportation systems, and government offices. The state does not, however, place smoking restrictions on most private establishments.48 The number of cities that have passed smoking ordinances is growing. While such restrictions are helpful, the most common place where children are exposed to secondhand smoke is in the home.49 Thus, policies that lead to lower smoking rates in general are likely to extend benefits to children. Methylmercury Mercury is a toxic chemical that is found in several forms in the environment. Metallic mercury, the liquid metal found in thermometers, is most commonly released into the environment as vapors through mining and manufacturing pollution. Methylmercury, the form that poses the greatest health risk to children, is produced by bacteria in the soil and water and can concentrate in edible fish and shellfish tissue at levels much higher than in the natural environment.50 Children are at greater risk of exposure to this toxin because they consume more per pound of body weight and because their nervous systems are still developing. This is especially true for fetuses, premature infants, and, to a lesser extent, full-term babies and young children. Methylmercury ingested by a mother during pregnancy can lead to brain damage, cognitive disabilities, lack of coordination, blindness, seizures, inability to speak, nervous and digestive system problems, and kidney damage in her child.51 Some fish, such as swordfish, shark, king mackerel, and tilefish, contain especially high levels of methylmercury. Therefore, the Food and Drug Administration and Environmental Protection Agency advise women who are pregnant or may become pregnant, nursing mothers, and young children to avoid these

Keeping children safe from environmental toxins
The environment where children live plays a major role in their development and health. Failure to limit harmful substances and pollutants in the environment can adversely affect longterm child wellbeing and achievement. Secondhand smoke, methylmercury, lead, BPA, and air pollution are some of the most widespread—and the most detrimental—environmental factors that affect child health. Secondhand smoke Secondhand smoke, smoke that is inhaled involuntarily, has many negative health effects. Since children’s bodies are smaller and still growing, they are especially sensitive to the negative effects of secondhand smoke. Secondhand smoke contains 250 chemicals known to be carcinogenic or toxic, including formaldehyde, arsenic, and hydrogen cyanide. Many dangers, such as increased risk of heart disease, respiratory problems, 34

types of fish. Others, however, such as shrimp, canned light tuna, catfish, salmon, and pollock have lower mercury content and are considered part of a healthy diet when eaten up to twice a week.52 While checking local advisories for waterways where fish are caught can limit exposure,53 these advisories are only helpful in so far as they adequately warn of possible risk. Lead Lead is a toxic heavy metal that can be found in a wide range of common household items. Children can be exposed to lead in a variety of ways. Nearly 900,000 Texas homes were built prior to 1950, many of which may contain original paint with high lead content. Lead can also be found in cookware, soil, mini blinds, and other household products. Using items or consuming foods imported from countries where lead content is regulated less stringently also increases risk of exposure. Pregnant women who have been exposed to high amounts of lead may pass it on to their unborn children.54 Any amount of lead in the blood stream is harmful and can impede physical and cognitive development. It also affects the kidneys, nervous system, and blood cells and can lead to increased behavioral problems and shortened attention span. Exposure to lead in high doses can cause coma, seizures, or death.55 Bisphenol A (BPA) Another chemical potentially harmful to child health is BPA, used in the manufacture of polycarbonate plastics, the hard plastic used to make some cups, plastic dinnerware, baby bottles, and the lining of metal containers. Traces of BPA can

be found in foods stored in these containers.56 According to the Environmental Protection Agency (EPA), more than a million pounds of BPA are released into the environment each year, resulting in widespread exposure.57 While BPA has not conclusively been proven harmful to children or adults, recent studies show cause for concern over the effects of long-term exposure to low doses of BPA.58 BPA exposure has been linked to brain, behavior, and prostate gland problems in fetuses, infants, and young children.59 The Food and Drug Administration, the National Institutes of Health, and the Centers for Disease Control and Prevention are all planning future, in-depth studies of BPA’s effects.60 The EPA has also officially added BPA to its list of chemicals of concern.61 Air quality The most pervasive environmental factor that affects child development and wellbeing is air quality. Poor air quality affects all children in a polluted area, and it is much more difficult to limit children’s exposure. Poor air quality can be caused by pollution emitted by factories, power plants, oil refineries, vehicles, painting, pesticides, and many other sources.62 Poor air quality aggravates chronic illnesses such as asthma, and can contribute to other respiratory problems like decreased lung capacity and lung tissue inflammation. Longterm exposure to ozone pollution can suppress the immune system and prematurely age or permanently scar lung tissue. Since children make up a disproportionate number of asthma patients, poor air quality can put more children in the hospital
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by increasing the severity and frequency of asthma attacks. Air pollutants such as nitrogen oxides also deteriorate water quality. Carbon monoxide, another harmful emission, has been connected to low birthweight in infants whose mothers had long-term exposure to low levels of the pollutant.63 Creating a cleaner Texas is critical to promoting a healthier Texas. There are many simple things parents and child advocates can do to protect kids from the harmful effects of environmental pollutants, and ways that communities can come together to reduce harm to children. What Texas Can Do: • Pass city ordinances creating smoke-free public places to help ensure that children and pregnant women are not exposed to second-hand smoke. • Support access to smoking cessation programs as part of prenatal care. • Strengthen permitting, enforcement, and public participation in regulatory proceedings related to air quality. • Support increased capacity for effective removal and disposal of lead. • Require DSHS to expand fish consumption advisories for lakes, rivers, and coastal waters to reflect what current research indicates are potentially unsafe mercury contamination levels. • Ban the use of BPA in all plastic products. What You Can Do: • Keep children away from areas where there is secondhand smoke. Do not allow household members or guests to smoke indoors, and do not take children to bars or restaurants where smoking is allowed, even if they have different smoking sections or ventilation systems as neither can eliminate secondhand smoke exposure.64 • Follow your pediatricians’ advice about avoiding giving young children foods that may contain methylmercury, and do not consume foods with potentially high levels if you are pregnant or may become pregnant. • To reduce possible exposure to BPA, discard damaged plastic products, refrain from putting boiling liquid into plastic containers, and avoid purchasing plastics with recycling code numbers 3 and 7. • Do your part to reduce air pollution by reducing idling in your car, maintaining your vehicle, and driving the speed limit. • Be aware of ozone levels, and limit children’s outdoor playtime when there are ozone alerts.

Promoting the health of mothers-to-be
Promoting infant health begins before birth through proper prenatal care for pregnant women and ongoing attention to maternal health. Because teens are more likely to engage in risky behaviors during pregnancy and are more likely to have babies with health concerns, reducing teen pregnancy also promotes the health of Texas infants. Adequate, early prenatal care is shown to promote positive birth outcomes65 by reducing the risk of low birthweight, prematurity, and neonatal and infant mortality.66 Prenatal care involves routine appointments with a doctor or midwife to monitor the progress of the pregnancy and diagnose possible health conditions in mother and baby before they become serious. However, in Texas, 1 in 3 babies—more than 136,000 in 2005—are born to women who either received no prenatal care or none before the second trimester.67 The March of Dimes recommends seeking prenatal care as soon as pregnancy is suspected and, ideally, before conception.68 Texas ranks 40th in the nation in prenatal care.69 A woman may be less likely to seek early prenatal care if her pregnancy is mistimed or unwanted: while 78% of Texas mothers who reported a pregnancy as planned received prenatal care in the first trimester, only 65% who said the birth was unintended did.70 In Texas, only 38% of new mothers report that their pregnancy was “on time.” More than half of mothers—51%—say that the birth was mistimed, meaning

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they did not expect or intend the pregnancy at that time. One in ten new mothers says that the birth was unwanted.71

There are several programs in Texas that help women receive adequate prenatal care. Lone Star Circle of Care is among these, working to increase access to prenatal care while offering integrated health and mental health services.72 Another program, Centering Pregnancy, is a model that integrates health assessment, education, and support in a group setting of Motivational Interviewing (MI) is a technique found to be eight to twelve women. While most group pregnancy educaeffective for intervention in alcohol-exposed pregnancies. In tion classes begin in the third MI, a therapist partners with a trimester, Centering Pregnancy woman to explore her ambivareducing the high teen pregnancy rate may begins at the first prenatal lence about alcohol use, rebe crucial for reducing the rate at which visit and continues past birth.73 fraining from an oppositional Texas mothers are taking risks with their Evaluations have found that approach.84 Two sites in Texas, babies’ health. For example, 22% of pregnant teen mothers and low-income the Harris County Jail and the teens report having used illicit drugs in women in a Centering PregHouston Recovery Campus, the past month, compared to only 3% of nancy group are less likely than used MI in a pilot intervenmothers over age 26. women receiving individual tion called Project CHOICES prenatal care to give birth to (Changing High-Risk Alcohol preterm or low birthweight babies. Research also finds high Use and Increasing Contraceptive Effectiveness).85 A study satisfaction rates with Centering Pregnancy, decreased rates of of Project CHOICES participants at these Texas sites, as well emergency room hospitalization, especially in the third trimes- as others in Virginia and Florida, found that, six months ter, and higher rates of initiation of breastfeeding compared to later, 69% of women had reduced their risk of alcoholtraditional services.74 exposed pregnancy to zero.86 Currently, thirteen centers in Harris County are participating in Project CHOICES Plus, Maternal drug and alcohol abuse during pregnancy can have an intervention that focuses on smoking and other health devastating effects on infant health. Infants develop all of their behaviors in addition to alcohol consumption.87 organs before birth and do not have the capacity to protect themselves from toxins that pass directly from the mother to Teens, as a group, are more likely to engage in behaviors the infant prenatally. Babies who were prenatally exposed to that put their infants at risk. For example, 22% of pregnant alcohol, tobacco, or illicit drugs are also more likely than other teens report having used illicit drugs in the past month, infants to have low birthweight and other complications.75 compared to only 7% of pregnant women, aged 18-25, and 3%, aged 26-44.88 Teens are also less likely to seek timely Alcohol use in particular can lead to a combination of probprenatal care, breastfeed, and practice safe-sleeping practices lems with organ development called fetal alcohol syndrome that reduce the rate of SIDS.89 Babies of teen mothers are or a broader diagnosis of a fetal alcohol spectrum disorder more likely to be born at low birthweight for a variety of (FASD). Children and adults with FASD may have cognireasons, from teens’ immature reproductive systems to their tive disabilities, abnormal facial features, vision or hearing comparatively high levels of poverty and substance abuse.90 problems, problems with heart, kidneys, or bones, poor Texas taxpayers also pay a price for the high number of teen concentration, and hyperactive behavior.76 Each year, about pregnancies in the state; researchers estimate the annual 3,700 infants are born in Texas with fetal alcohol spectrum cost to the state of teen births is $1 billion.91 In addition disorders. Lifetime costs to society attributable to fetal to poorer health outcomes, children of teen parents also alcohol syndrome in one individual are estimated to be up to experience worse social and academic outcomes, compared $2 million.77 Early in pregnancy, when many women do not to the children of older mothers.92 yet know of their condition, represents an especially dangerous time for a developing embryo: according to the Centers More than half of Texans ages 15-19 have had sexual interfor Disease Control, 60% of women at the fourth week of course, and among those who are sexually active, 44% report gestation remain unaware of their pregnancy.78 In Texas, 41% they did not use a condom the last time they had sex.93 Texas of women of child-bearing age say they consume alcohol requires sex education to be an element of all health curregularly (defined as at least once in the past 30 days) and ricula; however, according to a Texas State University study 11% report engaging in binge drinking;79 this is particularly of the sex education curricula in 990 Texas school districts’ problematic combined with Texas’s high rate of unintended (96% of the total districts), 2% of districts report that they pregnancies. In addition, although most women give up skip sex education entirely and an astonishing 94% use alcohol use upon learning of their pregnancy, nearly 9% of curricula that have not been proven effective in preventing pregnant Texas women report drinking even in the third pregnancy and the spread of sexually transmitted diseases.94 A trimester, with 2% of Texas pregnant women reporting binge CDC Task Force determined in 2009 there is little evidence drinking.80 of the effectiveness of abstinence-only sex education proChild and Maternal Health

Smoking is believed to be the leading risk factor for low birthweight, and it increases the risk of miscarriages, premature births,81 pregnancy complications, stillbirths, and sudden infant death syndrome (SIDS).82 While illegal drug use during pregnancy is also believed to be harmful, researchers often are challenged to isolate the effect of particular illicit drugs, since they are often used by mothers who also drink or smoke.83

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grams,95 but a study by the University of Pennsylvania that post-dates the CDC study found one abstinence-only sex education program for urban middle-schoolers that is effective in reducing the number of children having sex and their number of partners. One-third fewer children reported sexual intercourse following participation in the program compared to a control group.96 This is the first randomized, controlled study that has found an abstinence-only program to be effective in reducing sexual intercourse among adolescents over a substantial period of time (in this case, two years). One thing is certain: the current system of sex education in Texas is failing our teens. Texas has the third-highest teenage pregnancy rate in the country.97 Texas also has the highest repeat teen birth rate in the nation, at 24%.98 Most school districts with high teen birth rates are not using evidence-based curricula: nearly all Texas counties with teen birth rates over 16% in 2006 still used non-evidence-based sex education curricula in their school districts in 2008. Whether Texas school districts choose to teach sex education through an abstinence-only or an abstinence-plus curriculum, curricula should be proven to reduce rates of sexual activity, pregnancy, and sexually transmitted diseases among teens. Because conditions encountered even before a child is born can have lifelong effects on wellbeing and development, these strategies aimed at ensuring healthier pregnancies are key to positive health outcomes. What Texas Can Do: • Expand access to evidence-based prenatal care models. • Use evidence-based practices to reduce maternal substance use. • Require that all schools that teach sex education use curriculum that are shown to reduce teen pregnancy and risky sexual behaviors. What You Can Do: • Let your local school health advisory council know you support health programs that have been shown effective at reducing teen pregnancy and risky sexual behaviors.

countries.99 Still, the nation as a whole has seen its infant mortality rate decline over the last decade—a trend that, unfortunately, has not occurred in Texas, where more babies are losing their lives. Prenatal challenges and complications of prematurity, such as low birthweight, cause the largest share of infant deaths, and babies who survive often develop cognitive challenges, learning problems, and disabilities.100 Premature birth is a primary contributor to low birthweight,101 and disparities in rates of prematurity correspond with disparities in infant mortality. If the United States had the same rate of full-term births as some other countries, the U.S. infant mortality rate would be one-third lower.102 In Texas, low birthweight increased by 20% between 1990 and 2000, outpacing the national rate of increase.103 In 2006, Texas saw 54,000 babies born before the 37th week of pregnancy and 33,000 babies arrived at a low birthweight (below 5.5 pounds).104 Maternal health problems and abnormalities, carrying twins or multiples, and maternal substance abuse (including smoking) are among the known contributors to babies being born with a low birthweight.105 The annual costs associated with preterm births in the U.S.—medical care, early intervention services, special education services, lost household productivity—is $51,600 per child born prematurely. In the first year alone, medical costs for a preterm infant are $32,325 compared to $3,325 for an infant born full-term.106 One of the first events that impacts the health of a baby is the delivery itself. Medically indicated Caesarian sections and inductions are at times necessary for the mother’s health or the infant’s. However, not all Caesarian sections and inductions are medically warranted.107 Compared with vaginal deliveries, Caesarian sections pose special threats; they are associated with higher maternal mortality rates, more infant injuries and health problems, greater numbers of hospital readmissions, longer hospital stays and healthcare costs, and increased problems in future pregnancies. Research indicates that the dramatic rise in the use of Caesarian delivery and early induction in the U.S. are drivers for the increased proportion of infants born preterm, especially late preterm, despite that the American College of Obstetricians and Gynecologosts (ACOG) cautions against delivery before 39 weeks of pregnancy without evidence of fetal maturity.108 In Texas, the percent of deliveries performed by Caesarian section increased from 24% in 1996 to 33% in 2005.109 Medical professionals too frequently schedule deliveries that pose unnecessary risks to the mother and baby. After birth, one of the most cost-effective ways to promote infant health is to support breastfeeding. Breast milk contains antibodies that boost immunity to diseases, reducing rates of ear infections, stomach viruses, diarrhea, respiratory infections, dermatitis, asthma, obesity, Type I and II diabetes, childhood leukemia, SIDS, and gastrointestinal disease. Breastfeeding is especially important for premature and low birthweight babies due to their multiple health concerns. In

Giving babies the right start in life
The tiniest Texans are also some of our state’s most vulnerable. Not only are they more sensitive to environmental pollutants and more susceptible to injury, but they have distinctive health needs, requiring special attention and care. Adopting practices shown to foster infant health can have a lasting impact on improving the lives of Texas babies. The infant mortality rate in developed countries worldwide has declined due to advances in medicine, but the United States ranks behind 21 other developed nations in infant mortality. For every 1,000 births, 6.8 deaths occur within the first year of life in the U.S., compared to just 2.8 per 1,000 births in Japan and fewer than 5 per 1,000 in most European 38

Hospital policies, including mothers, breastfeeding is also regarding the promotion of associated with lower rates of Too frequently, hospitals allow the infant formula, can affect scheduling of deliveries and inductions that Type II diabetes, breast cancer, whether women breastfeed. are not medically warranted but instead ovarian cancer, and postparThe Texas Department of 110 pose risks for mothers and their babies. tum depression for mothers. State Health Services creThe Surgeon General recomated a “Texas Ten Step” mends breastfeeding an infant designation for hospitals reaching 85% compliance with exclusively for the first six months, and breast milk in addition to other nutrition through the first year.111 Accord- breastfeeding support practices based on the World Health Organization-United Nations Children’s Fund Ten Steps to ing to the United States Department of Agriculture, the Successful Breastfeeding. Hospitals can use the designation U.S. would save $3.6 billion dollars annually related to ear to attract mothers-to-be choosing a hospital for delivery. infections and digestive tract complications alone if 75% of The designation is voluntary and based on self-reporting mothers breastfed in early post-partum and 50% breastfed by hospitals and, once achieved, does not expire.118 The for six months.112 “Ten Steps” include creating a hospital policy making breastfeeding the preferred method of newborn nutrition In Texas in 2007, about 76% of mothers initiated breastunless medically indicated, requiring breastfeeding training feeding, but only 44% were still breastfeeding when their for all employees who work with new mothers, encouragbabies were six months old, and 22% at 12 months. Rates ing breastfeeding within 30 minutes of birth, and showing of exclusive breastfeeding are even lower, with only about mothers how to breastfeed and to maintain lactation when 28% of mothers exclusively breastfeeding at three months they are separated from their infant.119 and only 11% exclusively breastfeeding at six months.113 Lactation consultants can help women who encounter problems initiating breastfeeding,114 and milk banks can connect infants who initially cannot be breastfed by their biological mother with human donor milk.115 Texas does not currently regulate the lactation consultant profession, and many insurance companies do not reimburse their services.116 Furthermore, there are only two milk banks in Texas, and, while the processing fees hospitals must pay to use human donor milk are reimbursed through insurance, the extra administrative steps this process creates cause some hospitals to shy away from human milk in favor of formula.117 For infants older than one month and younger than a year old, SIDS, when babies suddenly stop breathing, is the leading cause of death. Causes of SIDS are not fully understood, but effective public health campaigns—warning caregivers to place babies on their backs, remove hazards like loose blankets and pillows, and prevent overheating or second-hand smoke exposure—help reduce its incidence. SIDS occurs slightly more frequently in Texas than in other parts of the country. In 2006, SIDS caused 1 out of 10 infant deaths in Texas. Only about half of Texas mothers report placing their infants on their backs to sleep.120 Other caregivers also may put infants at risk
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of SIDS. One study found that up to 28% of child care centers have staff who place infants on their stomachs to sleep, despite that placing an infant in this position when the baby is not accustomed to it can increase the incidence of SIDS eighteen-fold. About 1 out of every 5 SIDS deaths occurs when a non-parental caregiver put the infant to bed.121 By promoting health in the early years of life, Texas can make substantial gains in not only infant health outcomes, but the overall health of Texans. What Texas Can Do: • Require hospitals to report the number of non-medically-indicated Caesarian Sections and labor inductions they perform, prior to the 39th week of gestation. • Make breastfeeding the default option at all hospitals. What You Can Do: • Join with existing groups to raise public awareness about the importance of breastfeeding and placing babies on their backs to sleep. • If you are an employer, make your workplace friendly to breastfeeding mothers.

inconvenient or unsafe—obesity is a growing problem. The evidence suggests that many Texas children are growing up in places with barriers to good health. A study by the University of Texas School of Public Health in Houston found among Texas fourth-graders, 42% are overweight,123 and so are nearly as many eighth- and eleventh-graders (39% and 36%, respectively). Research published in 2010 found that Texas also has one of the nation’s highest rates of adolescent obesity—excess weight that brings the most health risks—and that no state has a higher rate than Texas of obesity among 10- to 17-year-old girls.124 Even the youngest children face obesity risks: 16% of low-income Texan preschoolers (ages 2-5) are either overweight or obese.125 Many doctors believe that addressing childhood obesity is key to reversing obesity trends in the population at large— and, economists say, states and businesses need such a reversal to avoid dire costs. Because so many overweight children grow up to be overweight or obese adults, if no action is taken, 43% of working-age Texans will be obese within three decades.126 The Texas Comptroller of Public Accounts says this increase will cost Texas businesses $30 billion by 2025 (up from $9.5 billion today).127 Type II Diabetes, an obesity-related illness, today accounts for about 9% of all spending by Texas Medicaid, the largest single health and human services budget item, but that spending could more than double by the year 2030, reaching $1.5 billion per year.128 Obesity is linked to many other chronic diseases that shorten the life span, from high blood pressure to heart disease to cancer, and demographers now forecast that, should obesity remain on its current trajectory, today’s children will be the first generation in centuries to live shorter lives than their parents.129 Texas and other places have proven that changing the public environment can directly improve children’s health. For example: • Some communities lack sufficient places to shop for healthy foods like fresh produce. Policies can help promote business development for those who would sell produce in underserved neighborhoods. The mere presence of supermarkets and grocers, in turn, can increase fruit and vegetable consumption by up to 32%.130 The Pennsylvania Fresh Food Financing Initiative is one successful example of a public-private collaboration that has helped more than 80 grocery stores open, serving rural and isolated communities that previously lacked options for purchasing fresh fruits and vegetables. The Institute of Medicine and National Institute of Health recognize it as a model for obesity prevention.131 Houston is one of a handful of communities the nonprofit Food Trust is exploring for an expansion of the initiative. • Places where teens feel safe walking, biking, or getting outside experience significantly lower rates of youth

Supporting fit and healthy kids
To a great extent, our health as we enter adulthood is determined by the environment around us during childhood. Doctors and researchers say every state, neighborhood, and school has features that either support or inhibit physical fitness and healthy eating. In environments conducive to adequate nutrition and fitness, children tend not only to be healthier but also to see improved test scores, better classroom attendance, reduced dropout rates, fewer discipline problems, and better health outcomes overall. These sorts of gains benefit whole schools and communities.122 Yet in the places without them—where access to healthy food and beverages is limited, and where options for exercise remain

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prevention. The American Academy of Pediatrics (AAP) recommends that children limit “screen time,” activities such as watching television and playing computer games.138 However, researchers recently found that, unbeknownst to parents, many children in child care watch hours of television each day.139 Toddlers and preschoolers in the study were found to watch about five hours of TV daily, the equivalent of almost half their waking hours.140 The Institute of Medicine and the Surgeon General call for limits on screen time in child care settings, as well as greater participation in existing federal, state, and local nutrition and feeding programs. More training for child care providers in how to provide healthy environments is also recommended.141, 142 Texas is currently reviewing its child care licensing standards, and the Early Childhood Health and Nutrition Interagency Council created by the 81st Legislature has made recommendations as well. For older children, a growing number of Texas schools are going without supports needed to implement obesity prevention initiatives. Texas has been at the forefront among southern states in creating policies that encourage healthy school environments. However, without dedicated resources, some of these accomplishments are at risk. Coordinated school health, an approach recommended by the U.S. Centers for Prevention and Disease Control, is required in Texas elementary and middle schools, but districts struggle with implementation—both because funding is absent, and because training and technical assistance from the Texas School Health Network, which likewise is underfunded, is out of reach.

obesity, even when other factors, like income, are taken into account.132 Programs like Safe Routes to School, which helps ensure there are sidewalks and other safe passageways, have significantly increased weekly physical activity levels among children, according to a 2005 California study.133 Complete streets—roads designed for safety for all users, including pedestrians and bicyclists— Additionally, too many disalso promote health. The tricts are eliminating physical National Institutes of Although Texas now has the nation’s education, health courses, Medicine recommends 7th-highest child obesity rate, roughly 12% and recess. Curricular changes legislation that promotes of school districts have done away with health passed by the Texas Legislature sidewalks, bikeways, and education requirements in the past year. in 2009 and decisions by the other features of complete State Board of Education have streets as a strategy to fight 134 put once mandated health child obesity. offerings at risk. Between the 2009 and 2010 school year, Just as access to fruits, vegetables, and recreational opportu145 school districts statewide—or 12% of districts with high nities can help children maintain a healthy weight, retail of schools—did away with their health education graduation junk food and sugary beverages near children worsens oberequirement.143 Changes such as these undermine student sity. A 2009 study found that having a fast food restaurant health and academic success. Numerous studies, including within 500 feet of a school leads to a 5% hike in students’ research on students in Texas specifically, have found that obesity rates.135 A study in California found the presence in children who are healthy and physically fit perform better elementary and middle schools of “competitive foods” and and have higher scores on achievement tests.144 drinks, like those found in most vending machines, contributed to rising obesity in children.136 Texas took action in With public health officials and doctors in agreement that 2004 to create a Public School Nutrition Policy that limits the environment plays a vital role in preventing obesity, Texas the portion sizes of high-fat, high-sugar items at schools. The must keep up efforts to ensure our state is a place where policy has led to a decrease in soft drink, candy, and dessert children have the nutrition and fitness they need to grow consumption on middle school campuses.137 up strong. Children spend a great deal of their time in school or child care, so these places matter to the state’s success in obesity
Child and Maternal Health

41

What Texas Can Do: • Implement national standards to improve the quality of physical education. • Make health education a requirement for high school graduation. • Require that annual school health advisory council reports to school boards include information on how campuses have incorporated coordinated school health into their campus improvement plans. • Support physical activity in the community environment through “complete streets” policies. • Improve nutrition and physical activity in early childhood programs, including support for following current Dietary Guidelines for Americans in child care settings. • Improve access to farmers’ markets and other retailers offering fresh fruits and vegetables, and strengthen farm-to-school linkages. • Fund existing obesity prevention initiatives, including coordinated school health and the Texas School Health Network. What You Can Do: • Get involved with your local School Health Advisory Council and your school PTA to help influence decisions about campus health. • Encourage bicycling or walking to school by starting a “walking school bus” in your neighborhood. • Visit www.letsmove.org for more resources, including family toolkits for healthy living, data on your community’s child obesity challenges, and more.

Helping children in Texas drink well
Eating right and exercising are vital for children’s health, but reducing childhood obesity also requires paying more attention to a major contributor to weight gain that too often goes overlooked: sugary drinks. Americans’ consumption of sugary drinks like soda has more than doubled in the past four decades,145 in direct relationship to the dramatic rise in obesity rates. The national child and adolescent obesity rate has increased from an average of 5% in the 1970s, to nearly 17% today.146 In Texas, one-third of all 10- to 17-year-olds are overweight or obese.147 Multiple studies have found a direct link between consumption of sugary drinks and weight gain and overweight status in children and adults,148 with children the age group disproportionately most likely to have a sugary drink every day.149 Low-fat milk, juice, and even bottled water frequently cost more and are less accessible to children than soda and other sugary drinks. Until recently, there was little to prevent children being served sugary drinks multiple times a day in child care settings. Also, while some schools have reduced the number of vending machines, school remains a place where many Texas children drink high-calorie, sugary drinks. At the same time, there remain barriers for too many children to healthy drinks in public school cafeterias at lunchtime: even free tap water may be, in practice, inaccessible in some lunchrooms. The obesity epidemic has become so stark, and the scientific research has built such a clear link between obesity and sugary-drink consumption that now the Institutes of Medicine,150 the U.S. Conference of Mayors,151 the Brookings Institution,152 and numerous major public health associations all recommend that state and local governments enact a tax on sugary drinks. The United States Department of Agriculture has found that a tax on sweet-

42

ened beverages could result in the average adult losing an estimated 3.8 pounds a year and the average child losing 4.5 pounds a year, which would begin to reduce rates of obesity and overweight for both children and adults.153 Public health experts attribute 43% of the rise in children and adults’ caloric intake over the last thirty years to increased consumption of sweetened beverages alone.154 No single category of food accounts for more calories in the average child’s diet than sugary drinks.155 Research indicates that daily consumption of even one 12-ounce sugary beverage can result in annual weight gain of up to 15 pounds.156 According to a recent survey of over 15,000 Texas children in middle and high schools, 83% of boys and 78% of girls consumed at least one sugar-sweetened beverage per day; 35% of boys and 22% of girls consumed three or more sugar-sweetened beverages per day. Many of the children drinking these products believed, likely because of marketing’s influence, that what they were consuming was healthy.157 Unlike sweet solid foods that might be energydense but contribute to a feeling of fullness or offer some nutritional value, sugary drinks in fact meet no critical dietary needs and do not contribute to a sense of fullness. Decreasing soda consumption could prove key in reversing the obesity trend, just as reducing smoking has reversed lung cancer trends nationwide. Consumer demand for specific food and drink products is sensitive to increases in prices, and this holds especially true for children and teens. Taxation can be an effective way of reducing soft drink consumption, and, ultimately, obesity, with the level of demand reduction depending on the level of the tax.158 In terms of the effectiveness of taxation compared to other ways of reducing consumption, there are many parallels with smoking. Research into anti-smoking campaigns shows that taxation has been the single most effective mechanism at reducing the behavior.159 Today, Texas has a 6.25% general sales tax that applies to most goods, including all prepared foods, candy, and sugar-sweetened beverages.160 Unprepared food is exempt from the Texas sales tax, and the state has no tax specific to sodas or junk food.161 Approximately 40 U.S. states take a similar approach, taxing soft drinks and junk foods through the state general sales tax, which are usually broadly applied and thus have no effect on consumption of a particular item.162 A targeted tax on soda has two public interest goals: curbing consumption of an unhealthy product in order to reduce obesity and overweight prevalence, and raising revenue for obesity prevention initiatives.163 Some proponents of the sugary drink tax, including the Rudd Center for Food Policy and Obesity at Yale University, have done extensive research and public education on ways in which the marketing of unhealthy foods and beverages exploits vulnerabilities in consumers’ judgment. When people do not have complete information about health consequences and other considerations, they
kcal per day

National Trends in Childhood obesity

20% 15% 10% 5% 0%

1963- 1966- 1971- 1976- 19881965 1970 1974 1980 1994 2-5 Years of Age

1999- 2001- 2003- 20052000 2002 2004 2006 12-19 Years of Age

6-11 Years of Age

400 300 200 100 0

National Trends in Drink Consumption among Children
Milk Sugar-sweetened beverages Juices

1965

1977

1989

2002

2006

Source: The Rudd Center for Food Policy and Obesity

make decisions in the short-term that act against their own expressed long-term interests.164 Many economists note that public policies can counter imbalances in information, so that consumers’ choices better reflect these long-term preferences. Sodas and other sugar-sweetened beverages are marketed extensively to children,165 who are especially susceptible to prioritizing short-term preferences over longerterm wellbeing. The food and beverage industry spends more marketing sweetened beverages to consumers aged 2-17 than they do for any other category of products.166 People who become obese also impose increased healthcare costs on others. The public shoulders cost for obesityrelated increases in healthcare expenditures through higher premiums for private health insurance and taxation to pay for mounting public health insurance program costs.167 Average healthcare costs for a child treated for obesity are three times the cost of an average child, both for privately insured children and those insured by public programs like Medicaid.168 Further, the number of hospitalizations and associated costs for obese children nearly doubled in just six years from 1999 to 2005.169 The CDC reports that the average annual medical costs for an obese adult are $1,429 more than those for an adult with a healthy
Child and Maternal Health

43

weight.170 Obesity, while a product of various factors, can be controlled in many, though not all, cases. The rationale for levying a tax on sodas is parallel to the justification for levying taxes on cigarettes—these taxes balance the negative impact on the rest of society. Since demand for most goods is price-sensitive, the higher the tax, the less consumers drink rather than paying the higher price. When consumers decrease their demand greatly in response to a price increase, their demand is said to be relatively elastic; when they pay the higher price without reducing demand much, their demand is said to be relatively inelastic. Based on research from the Rudd Center for Food Policy and Obesity at Yale University171, the soda industry itself,172 and the Center for Science in the Public Interest (CSPI), 173 the elasticity of demand for sodas falls somewhere between -.6 and 1, with the -.8 estimate by the Rudd Center in the middle of that range and the most commonly cited in publications. This means that, for a 10% increase in price, there is an 8% decrease in consumption. Research shows that children and teenagers are more sensitive to price than adults since they often have less disposable income.174 For comparison purposes, the elasticity of demand for cigarettes is somewhere between -.3 and -.5.175 In other words, the elasticity of demand for sodas is nearly twice that of cigarettes. For a 10% increase in cost, the decrease of demand for sodas would fall by twice as much as cigarettes. The relatively high elasticity of demand for sodas compared to cigarettes implies that price changes would be an even more effective way to reduce demand for sodas than it is for cigarettes. There is every reason to believe that a sugar-sweetened beverage tax would have the intended outcome of reducing consumption that leads to obesity. The Rudd Center and CSPI both have online calculators that allow policymakers to estimate revenues generated by a sugary drink tax structured as an excise tax, where the tax is levied per ounce at the distribution level rather than

a sales tax taken at the register. An excise tax is visible to consumers in the price of a product, making it more likely that it will affect demand, and is relatively easy to enforce.176 The CSPI calculator uses the most conservative estimate of demand elasticity, -.6, and estimates that, a penny-per-ounce tax would raise $1.3 billion per year for Texas. As an alternate estimate, using regional consumption data from the Beverage Marketing Corporation, the Rudd Center finds that the same level of tax would bring Texas $1 billion annually.177 By contrast, the total annual medical cost directly attributable to obesity, just for adults, in Texas today is $6.8 billion per year.178 It is expected that as the tax continues to impact price, demand for sugary beverages will fall. This decrease in consumption will have a positive impact on the health of Texas children, and although decreased consumption also means less revenue, healthier Texans means lower costs related to obesity. What Texas Can Do: • Enact a penny-per-ounce tax on sugary drinks to help curb obesity and offset the costs of the epidemic. • Use revenue from the tax to invest in obesity prevention. • Ensure Texas students have access to water at lunch time. • Keep daycares from serving sugary drinks with each snack and meal. What You Can Do: • Provide the children in your life healthy drinks—like water, low-fat milk, and real fruit juice—most of the time, so that sugary drinks can return to what they have been for most of their history: occasional treats, instead of every-day or every-meal staples. • Sign on with the project to improve beverage options for Texas children at www.txchildren.org/DrinkWell.

44

Child and Maternal Health

45

cONNEcTINg cHILdREN TO HEALTH ANd MENTAL HEALTH cARE
Texas taxpayers. Numerous studies by Texas economists have From the first well baby check-ups to adolescent treatments found that communities spend more when children remain for health or mental health concerns, the care children get uninsured, compared to the cost of simply covering children from qualified professionals matters for their future success. In in programs like Children’s Medicaid or CHIP.185 Uninsured childhood, such care represents an incredible bargain, perhaps the most cost-effective coverage on the market. As a result, children tend to get and stay sicker and to receive care not in few issues garner more public doctors’ offices but in much support in polls than ensurcostlier emergency rooms at a Studies by Texas economists have found ing that children have access high cost to their communithat it is more costly to let children remain to health insurance. In poll ties. Hospitals recoup the cost uninsured than it is to simply cover children after poll, as many as 9 voters of emergency room care for the in 10 say they favor policies uninsured by passing on higher in programs like CHIP or Medicaid. that allow children to see a tax burdens through local health doctor in a doctor’s office.179 districts and increased prices The popularity of the idea has sparked activity in communities for service to people with private coverage. As the uninsured drive up premium prices, the average Texas family with private across the country, answering a national “Connecting Kids to insurance pays up to $2,700 in their annual premiums just to Coverage” challenge.180 From the governor’s office in Ohio to compensate for the cost of the uninsured.186 state agency offices in Louisiana, governments are implementing promising strategies to reduce bureaucracy and make the The state also loses hundreds of millions in federal funding promise of health care for children a reality. from its failure to invest in covering children. An analysis by Although Texas has trailed the other 49 states in children’s Texas economist Ray Perryman, examining several factors health coverage, it, too, has seen improvements when leaders in the cost of allowing children to remain uninsured, found set their minds to addressing children’s needs. For example, that for every dollar the state cuts in funding for Medicaid following action by the 80th Texas Legislature to reduce red or CHIP, Texans spend $3.67 in higher local taxes, private premiums, and out-of-pocket costs.187 The analysis does not tape in the Children’s Health Insurance Program (CHIP), hundreds of thousands more Texas children received covertake into account savings from preventing childhood illnesses, age. As a result, even as more families were losing their private mental health concerns, or injuries from becoming life-long health insurance due to climbing premiums and a faltering problems, but factoring in these considerations would further economy, overall coverage rates for children improved, resultcompound total savings. Children with no health coverage ing in the biggest single-year gain in children’s health coverage also miss more school due to illness, which, in turn, causes in a decade.181 In 1996, Texas was sued in a class action lawsuit their parents to miss work188 and their schools to lose funding. over allegations the state was not providing children covered by Lacking a doctor’s advice, these children also are more prone to Medicaid with services they were entitled to under federal law, spreading disease. partly due to a lack of providers resulting from inadequate rePrivate coverage accounts for the largest share of health insurimbursement rates. In response to the corrective action agreeance for Texas children, and about half of families secure ment arising from the Frew vs. Hawkins lawsuit (Frew), in 182 2007 the Texas Legislature increased Medicaid rates. As a re- health care for their children through benefits linked to an employer. Unfortunately, with unemployment’s sharp climb sult, Texas became one of very few populous states to increase since 2007, more children are losing private coverage. A 2010 the number of children in Medicaid receiving recommended screenings in 2009.183 However, the economic recession has led study found 1 in 3 children whose parents lost a job also lost their health insurance.189 In Texas, the fastest-growing group of to new cuts in state rates, with further erosion possible in light uninsured children is children in middle-class families earning of looming budget shortfalls in the years ahead. more than the income limit for CHIP.190 Despite past improvements, Texas remains home to the highest number and rate of children without health insurance.184 Leav- CHIP and Children’s Medicaid offer comprehensive coverage for children, which scientists say helps foster healthy developing more than 1.3 million children uninsured means not only ment and growth. Along with pediatric services, Medicaid that 1 in every 5 children goes without preventive and basic and CHIP cover mental health, vision, and dental services for physical and mental health care; it also means higher costs for

46

children who need them. About half of Texas’s uninsured children and youth are already eligible for CHIP or Medicaid.191 In some instances, the children’s families simply do not know they qualify. One factor in their awareness is the state’s limited budget for outreach, along with reduced funds for community-based organizations who partner in getting out the word to families of uninsured children. Promising models for outreach do exist and should be replicated to bring the successes some communities have seen in increasing application rates among eligible families to other parts of Texas. The families of many eligible, uninsured children in Texas have submitted applications for Medicaid or CHIP coverage— only to come up against red tape in the state’s overburdened and under-funded eligibility system. Operating with what a state auditor identified as outdated technology and inefficient processes,192 Texas’s Health and Human Services eligibility and enrollment system takes much longer to process applications193 than do neighboring states.194 Texas’s system is also historically far more prone to errors.195 Despite clear evidence of capacity challenges in processing applications, Texas continues to require the poorest families eligible for the Medicaid program to submit applications not annually but every six months, adding further red tape in the system. Some recent federal policy changes, including the passage of health reform, will give more children access to coverage. For example, the Patient Protection and Affordable Care Act instituted a ban that went into effect in 2010 on plans that barred coverage of preexisting conditions in children. Beginning in 2014, more children will be covered by Medicaid, as the program’s eligibility will be expanded to cover all children and adults under age 65 with incomes up to 133% of the federal poverty level. For those earning between 133% and 400% of the federal poverty level, subsidies will be available to help pay for private insurance premiums. When the law is fully implemented in 2014, 95% of children and youth nationwide196 will have health insurance, including mental health and substance abuse benefits.197 However, questions remain about how Texas’s overburdened enrollment system will cope with the influx of newly eligible beneficiaries. Additionally, federal regulations to determine which mental health services will be covered are yet to be written. Texas may have some discretion in establishing minimum benefits for mental health, and families who struggle today with incomplete coverage for their children’s mental health and special needs may continue to face hurdles if effective interventions remain out of their reach.

Having coverage does not guarantee a child will be able to see a doctor or mental health provider, which is what is truly necessary for taxpayers to avoid high costs. Health and mental health workforce shortages exist in Texas,198 affecting many patients who need care. Especially vulnerable are the Texans—most of them children—covered by Medicaid. While the state increased Medicaid reimbursement rates in 2007, it reduced them slightly (1%) in 2010 and may cut them even further in response to budget shortfalls. A March 2010 survey by the Texas Medical Association found, among doctors who currently take patients on Medicaid, 45% said the cuts would cause them to impose new limits on how many Medicaid patients they serve, and one quarter said it would cause them to cease accepting patients on Medicaid altogether.199 Additionally, for the more than 2 million Texas children covered by Medicaid, only about 600 psychiatrists and psychologists statewide treated children enrolled in Medicaid in 2008.200 Texas needs to develop its health and mental health workforce and ensure its reimbursements to providers allow children to get the care they need. Since providing children with health coverage also makes such good economic sense, insuring more children is a win for taxpayers as well as families. Other states have made remarkable progress, and Texas can as well.

What Texas Can Do: • Protect Texas’ critical public health and mental health safety net and infrastructure, including communitybased mental health services, coverage for children with special health care needs, and preventive health services for pregnant women and children. • Maintain a viable Medicaid and CHIP delivery system by maintaining provider payments and covered benefits, and investing in efforts to expand and improve Texas’ health and mental health care workforce. What You Can Do: • Contact your elected representatives at the state and local levels, and urge them to accept the “Connecting Kids to Coverage” Challenge. • Help sign eligible children up for Medicaid or CHIP by hosting an enrollment drive in your community.

To access detailed source information for this section of the report, visit txchildren.org/Report/Health
Child and Maternal Health

47

Children’s mental and emotional development and behavioral health are intertwined with their overall wellbeing, yet, the benefits of mental wellbeing reach far beyond individual children and families.1 Society reaps rewards from supporting the mental health of children, because it reduces costs in the health, education, and criminal justice systems and increases stability, productivity, and safety communitywide.2

Are we making smart investments?
When it comes to children’s mental wellbeing, Texas is not investing enough, nor is it investing wisely. Our state incurs significant losses when it fails to address the mental health concerns of Texans. Severe mental health challenges and substance abuse cost Texas businesses billions of dollars in lost productivity each year and more than 1.6 million permanent jobs. Spending and lost tax dollars related to mental illness and substance abuse cost the state about $13 billion annually.3 By investing in prevention and early intervention strategies and identifying and treating youth when concerns arise, Texas has the opportunity to avoid the high costs associated with untreated mental illness and reap the benefits of a healthy, productive workforce. Unfortunately, it remains a largely unrealized opportunity. Public investments in Texas children’s education and development4 are lowest in the earliest years, when return on investment tends to be the greatest.

CHILD MeNTAL WeLLBeING
Childhood represents a time of critical development in the mind, in part because it is when a significant amount of our lifetime brain development occurs. More than 85% of total growth in the human brain occurs right at the beginning of life. Science has found that early experiences have the power to forge positive or negative changes in the structure of the brain, affecting the neurological architecture in ways that can determine later learning success, health outcomes, and social and emotional behavior. By promoting healthy mental development and providing appropriate and timely interventions to children with mental health or behavioral challenges, Texas can help ensure more children have the ability to reach their potential.

Texas per Child Investment by Age

8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0

Federal State and Local

Infants and Toddlers (0-2)

Pre-schoolers (3-5)

School-age Children (6-18)

College-age Youth (19-23)

Source: Voices for America’s Children, The Child and Family Policy Center, and Texans Care for Children. (2005) Early Learning Left Out: Investments by Child Age on Education and Development.

Over the past decade, Texas has ranked at or near the bottom amongst the states in spending on public mental health services for all age groups, and it spends only about 15% of this funding on children.5 Spending on children’s public mental health in Texas in recent years has consistently decreased.6 Access to community mental health services is not an entitle-

48

Spending on Children’s Public Mental Health Services in Texas
Per Capita Expenditure

25 23 21 19 17 15
2003 $23.38 $20.92 $19.28 $18.80

In Texas, 10 state agencies and various local entities, including various health and human service agencies, the education system, and the juvenile justice system, each provide some type of mental health services or supports to children and youth. For many children, schools serve as the main provider for mental health services and supports,15 and primary care physicians provide the majority of prescriptions to children for psychotropic medication.16 However, there is no entity to coordinate these activities with authority, or to provide leadership in setting overarching priorities in children’s mental health policy. Despite a largely fragmented system to support the mental health of children and youth, and severe lack of investment in prevention, early interventions, and treatment, Texas has taken some encouraging steps in recent years and boasts some pockets of innovation. Prior to 2009, Texas did not have a formal infrastructure to facilitate communication, coordination, or collaboration across the various state agencies that provide services to children and families. That year, the Texas Legislature established two bodies to address this void: the Council on Children and Families, which addresses issues impacting all children and families in the state, and the Task Force for Children with Special Needs, which focuses on children with chronic illnesses, intellectual or other developmental disabilities, or serious mental illness. Improving high-level interagency coordination is an important element of improving outcomes for children and families across the state. The Legislature also made investments to bring homevisiting programs into some communities across the state, and with increased federal funding becoming available, more communities may benefit from this evidence-based practice that produces positive outcomes in many areas of child wellbeing. The state also increased funding for crisis services and to bring down waitlists for child and adolescent community mental health services. State grants have been provided to local probation departments to help divert youth from the Texas Youth Commission, and some communities have chosen to provide youth with mental health services as part of their effort. The Texas Integrated Funding Initiative (TIFI) assists some communities in building an infrastructure known as systems of care to serve youth with serious emotional disturbance and has helped five Texas communities to secure federal grants to support their ongoing systems-of-care efforts, bringing in millions of federal dollars to the state. Unfortunately, recent gains in investments stand to be erased as the state addresses significant budget shortfalls projected for the coming years. In 2010, state agencies were directed by the Governor and Legislative Budget Board to identify a schedule of planned budget cuts amounting to up to a 15% reduction of agency funding levels as passed in 2009.17 If the Legislature chooses to implement these cuts, about 2,600 children and youth stand to lose community mental health services in Texas.18
Children’s Mental Wellbeing

2004

2005

2006

Source: National Association of State Mental Health, Health Program Directors Research Institute, Inc. (NRI Inc.)

Children Waiting for Public Mental Health Services Due to Lack of resources
Data reflects waitlist for August of Fiscal Year

600 400 200 0
2005 2006 2007 2008 2009 Source: Department of State Health Services, Division of Mental Health and Substance Abuse Division

ment and is instead tied to available resources.7 As of August 2009, 512 children and youth with serious disorders were waiting for services because of a lack of resources, a 147% increase from 2005.8 More than half of the individuals with a mental or behavioral disorder in their lifetime report that problems started in childhood or adolescence.9 About one in five youth have a diagnosable mental disorder.10 Intervening early is more effective than waiting until problems become more severe and can prevent some disorders from worsening.11 Treating issues early is also more cost effective.12 While state law calls for an emphasis on community-based early intervention services for children at risk of developing severe mental health problems,13 the trend in Texas is to provide services only after serious issues arise—when a crisis occurs, when a child is arrested, or when an overwhelmed family gives up custody of a child. Often, there are earlier warning signs prior to these events, such as family distress, difficulties in child care or school, or unidentified mental disorders. Instead of investing in promotion, prevention, and early intervention services, the state has focused on crisis services.14

49

What Texas Can Do: • Adequately fund community mental health centers so that they can provide evidence-based, developmentally appropriate interventions. • Require greater coordination across state and local agencies providing mental health services and supports to children. What You Can Do: • Contact your legislators and let them know promoting young peoples’ social and emotional health is as critical as providing them with services when problems arise. • Raise awareness about the need for effective mental health services and supports in your community by inviting a representative of your local National Alliance on Mental Illness (NAMI) chapter to speak to your community group. • Participate in Children’s Mental Health Awareness Day each May to help raise awareness and reduce stigma.

mental health services in low-income communities are often more limited in terms of both quantity and quality, which makes it difficult for some families to get the help their children need.27 A child living in a higher income household in Texas stands a greater chance of receiving mental health treatment than does a Texas child living in poverty.28 Health Insurance Status Having health insurance is not a guarantee that children can receive mental health care, but it improves their access to services. Unfortunately, an estimated 24% of Texas children in 2010 were uninsured.29 Passage of federal health care reform will provide many of these children with access to coverage. Reform calls for both public and private insurance plans to provide minimum benefit packages, which are to include mental health services. Until federal regulations are written, however, it is unclear what services will be covered. Thanks to federal parity requirements, mental health benefits must be provided at the same level as physical health coverage. Prior to parity legislation, families frequently encountered more restrictive service limits, higher co-pays, and lower spending caps on mental health services as compared to other health services. Even with health care reform, there will remain uninsured children in Texas. It is not yet clear the impact reform will have on the public mental health system in Texas,30 but it is critical that the public mental health system continue to serve children who lack health insurance. Race/Ethnicity

Are we supporting mental wellbeing for all children?
In 2007, Texas ranked last among states in the rate of children with emotional, developmental, or behavioral problems who received mental health treatment. While many children throughout the United States go without needed mental health services, in Texas the rate trails nearly 20 percentage points behind the national average.19 Depending on many factors, including where they live, their families’ income, their health insurance status, and the demographic they are identified with, many Texas children face additional barriers to receiving care.

Non-white children make up about 60% of Texas’s child population.31 People of color are diagnosed with mental disorders at rates similar to whites, but the impact of mental illness is different,32 as they are less likely to receive care and the care they do receive tends to be of poorer quality.33 Rural Children A Texas child has less of a chance of These disparities are also found Children and families living in childhood. Children of receiving mental health care than any in rural areas in Texas face color are less likely than white other child in the country. a lack of services and must children to have their mental often travel long distances to health needs met.34 While address children’s mental health needs.20 While most regions Latino children are more likely to experience some menin Texas have a shortage of mental health professionals, tal health disorders compared to their white peers, 35 they the need is especially acute in rural areas.21 In all of Texas’ are the least likely to receive treatment for mental health 177 rural counties, there are only five child psychiatrists.22 concerns.36 Within the child welfare system, black children Mental health providers in rural areas face the challenges are less likely to receive counseling services than their white peers.37 of attracting, training, and keeping professionals, especially those with child and adolescent expertise, who are willing When children of color do receive treatment, it often does to work in relative isolation from other professionals and not meet their needs.38 Schools, social agencies, and the with limited continuing education and technical assistance legal system are more likely to refer minority children than available to help them stay abreast of advances in research white children to restrictive placements, such as residential 23 and practice. treatment, foster care, or detention, rather than community-based interventions.39 Doctors have been shown to spend Family Income more time with white patients than they do with patients One in four children in Texas lives in poverty.24 Children who are not white; this time translates to providing white living in poverty are at greater risk for mental health chalpatients with more information and allowing them more 25, 26 lenges that can last into adulthood. Unfortunately, input into their treatment options.40 50

Language Finding providers, services, programs, and resources in languages appropriate for people with limited English proficiency can be challenging. Children from families where English is not the primary language are less likely to access medical care, and when they do seek treatment, their caregivers report health care providers spend limited time with the child and do not adequately explain things to the family.41 Texas has initiatives to address health disparities and border health issues, but they largely do not address mental health. The Office for the Elimination of Health Disparities within the Health and Human Service Commission and the Office of Border Health within the Department of State Health Services track youth suicide rates and mental health workforce trends respectively, but have a primary focus on physical health. In 2005, Texas received a federal multiyear grant to undertake the ambitious goal of transforming its mental health service system into one that “promotes wellness, resilience, and recovery.”42 Many of the goals of the Texas Mental Health Transformation Project aim to improve access to quality services for children in the state;43 however, aside from the local activities of a few community collaboratives funded through the project, no statewide mental health transformation strategies specifically address issues of disparities. In addressing disparities in mental health services for children, Texas has the potential to improve services for all children. What Texas Can Do • Require training programs for mental health professionals to include strategies that are effective in identifying and treating mental health concerns in the various populations that access services in Texas. • Provide financial incentives, such as training stipends, tuition assistance, and loan repayment programs, to mental health professionals working in underserved areas. What You Can Do • Reach out to a parent of a child with mental health concerns and share your experience or let them know about supports that are available in the community. • Start or join a support group for families encountering mental health challenges • Volunteer in a program that promotes healthy child development, like an afterschool or mentoring program. • If someone in your community is having challenges in finding appropriate services, let your elected officials know. • If you are a mental health provider, involve family members in a child’s treatment, recognizing the primary role parents play in their children’s wellbeing, and provide services and materials to families in the language they speak.

Fostering healthy social and emotional development early in life
In the first years of life, children acquire skills, behaviors, and beliefs that stay with them into adulthood. It is a unique window of opportunity to promote children’s healthy social and emotional development, a cornerstone that supports their successful functioning in family, school, and community throughout life. While many children come out of early childhood prepared to do well in school and life, others do not. The interaction of a child’s genes, early experiences, and first relationships lead a considerable number of young children to develop— or be at risk of developing—social, emotional, or behavioral problems that significantly interfere with their lives. Some children are at higher risk, including those living in lowincome neighborhoods and children whose parents have a mental illness.44, 45 Overall, an estimated 10-14% of children under the age of 6 have difficulties that impact their functioning, development, and school-readiness.46 These early challenges can start small, but if left unaddressed, can lead to troubling consequences. In a 2007 survey of Texas child care programs, 66% said they had children in care with a suspected or diagnosed behavioral or emotional difficulty, and 60% admitted asking a parent to remove a child from their program.47 Young children are removed from public school classrooms at alarming rates, with pre-kindergarten students in Texas expelled at twice the rate of older students, in grades K-12.48 Between 2000 and 2006, 103 school districts in Texas removed approximately 500 pre-kindergarten and kindergarten students.49 Problems continue in the early grades, with about 2,700 first graders in Texas having been removed from their classrooms between 2000 and 2006 and placed in Disciplinary Alternative Education Programs.50 This is especially troubling, since a history of disciplinary referrals at school is the single greatest predictor of future incarceration.51 When problems arise in early childhood, early identification and interventions are crucial. Not only is it more effective to address issues before they become more serious, it is less costly. Intervening early increases the chance of preventing further social and academic difficulties.52 Early interventions also promote school retention, help schools be more productive, strengthen social attachments, and reduce crime, teenage pregnancy, and welfare dependency.53 For children with challenging behaviors or social and emotional difficulties that go unaddressed, however, the outlook is not good.54 Children who have behavior problems during early childhood often continue to have problems when they enter school, not just with their behavior, but also with their academic performance and with being accepted by their fellow students.55 Young children with behavior problems often require significantly more services through special education, remedial education, mental health, and
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juvenile justice systems.56 They are at greater risk of school A large number of children are removed from early care and education programs because the programs are ill-equipped failure, dropping out of school, delinquency, and adult 57 to address challenging behavior. Providing child caregivers incarceration. In addition to the significant toll these with access to behavioral health consultations is the leading outcomes take on children and families, they also come at best practice to prevent expulsions from child care seta great cost to victims of delinquent crime and taxpayers. tings.70 At least 29 states offer Supporting the social and consultations to caregivers to emotional development from young children are removed from public school address behavior problems the earliest years and interclassrooms for behavioral reasons at alarming and promote child social and vening early when problems rates. Pre-kindergarteners in Texas are emotional development,71 but arise is a win-win situation expelled at twice the rate of K-12 students. Texas is not one of them. for families and society. High-quality screening tools are available to help professionals identify children at risk for social, emotional, and behavior concerns.58 The American Academy of Pediatrics recommends children receive periodic developmental screening during well-child visits.59 However, many young children do not receive them.60 A recent federal study examining state’s screening rates for children enrolled in Medicaid, in which Texas was included, revealed that 76% of children failed to receive all the screens they should have, and 41% did not receive any of the required screenings.61 Children from birth to age six enrolled in Medicaid in Texas are required to receive standardized developmental screenings. However, not all approved screening tools are designed to address social, emotional, or behavioral concerns.62 Researchers have found physicians identify fewer than half of children with serious emotional and behavioral disturbances when relying solely on their clinical judgment.63 Research suggests that interventions targeting parenting skills can cut in half the harmful impact of poverty on children’s development.64 Research-based home-visiting programs are widely recognized as positively impacting children’s development. Such programs improve parent-child relationships and promote healthy child development. They also provide early detection of developmental delays and help prevent child maltreatment.65 Other parent education programs have been shown to substantially reduce antisocial behavior in children.66 However, the majority of families in Texas do not have access to home-visiting and parent education services. Early child care settings also play a key role in a young child’s social and emotional development. Quality early education programs provide long-term social benefits to children, including better peer relations, less truancy, and less antisocial behavior.67 These programs are especially costeffective for low-income children.68 Child care staff should have a sound understanding of child development and skills needed to appropriately address children’s individual needs. Unfortunately, the quality of child care programs in Texas is generally low, with training requirements, group sizes, and staff ratios typically falling well below nationally recognized standards.69 Through implementation of these effective early intervention strategies Texas can promote early academic and social success, while also fostering healthy development that will serve Texas children over their entire lifespan. What Texas Can Do: • Require the use of standardized developmental screenings that detect social, emotional, and behavioral concerns in primary care settings. • Ensure early childhood caregivers and teachers have appropriate training to support the social and emotional development of children and are able to identify potential concerns and refer families to resources. • Provide professional caregivers with access to early childhood behavioral consultations to avoid removal of children from child care programs. What You Can Do: • Seek out opportunities to learn about child development, so you can help foster healthy social and emotional growth in children in your life as they progress through different ages and stages. • Invite an elected official to visit your child’s day care program, and let him or her know the importance of good child care.

Schools on the frontlines for children’s behavioral health
Mental health plays an important role in a student’s ability to achieve academic success. Schools recognize this, and most have some programs and policies in place to support mental and behavioral health. The American Academy of Pediatrics has identified schools as being “the primary providers for mental health programs and services for many children.”72 In fact, a national study found that 20% of students had received some mental health service during the school year.73 The study did not determine the nature of these services, their effectiveness, or the level of unmet need for students who access services—and those who do not. As the environment in which most children spend most of

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their days, schools are in a prime position to help identify and provide or link students to mental health services.74 Currently, schools are not doing an adequate job of addressing the mental and behavioral health concerns that can prevent some students from learning.75

gests the implementation of a Positive Behavioral Interventions and Support (PBIS) approach.84 PBIS is a process that links students to graduated, evidenced-based interventions aimed at improving their learning and behavior.85 All students benefit from implementation of campus-wide PBIS interventions, such as clear Texas estimates 11% of its rules and expectations and havchildren between the ages of ing all school staff model and 1 in 3 special education teachers feel they lack 9 and 17 have a diagnosable reinforce positive behaviors. the training, support, or supervision mental illness.76 Many more For students who require more to handle students’ behavioral health. students are confronted with targeted interventions, such as social, family, or behavioral those with mental or behavioral challenges that get in the way health concerns, these interventions are applied either in of learning. When problems go unaddressed, many bright a group setting or through an individualized plan based students struggle academically. Others get into trouble, on students’ needs. PBIS is the recommended intervenfinding themselves pushed out of classrooms and towards tion for dealing with challenging behavior in children with the juvenile and criminal justice systems. Some students disabilities.86 Schools that implement PBIS school-wide move through school without causing trouble and getting have been shown to see improved academic performance, fine grades, but struggle later; because their early mental fewer disciplinary problems, and a greater sense of safety on and behavioral issues were left unidentified or untreated, campus.87 Some schools have seen up to a 60% reduction in these children may become young adults who have diffidisciplinary incidents following school-wide implementaculty finding or keeping stable employment, housing, and tion of PBIS.88 relationships. Early identification of and support for issues that arise can prevent bigger challenges that require more Texas already has several resources to assist school districts intensive interventions. in implementing these best practices. School districts can receive technical assistance on RtI through regional EducaUnder the federal Individuals with Disabilities Education tional Service Centers (ESCs), TEA, and through some uniAct (IDEA), schools are mandated to provide students versities, including the Building Capacity for Response to eligible for special education with services to ensure they reIntervention Implementation project within the Meadows ceive appropriate education. Some students with emotional Center for Preventing Educational Risk at The University disturbances are eligible for special education, but they tend of Texas at Austin. The Texas Behavior Support Initiative to be under-identified.77 The Texas Department of State (TBSI) assists local school districts in implementing PBIS Health Services estimates there to be more than 167,000 and the Texas Collaborative for Emotional Development in children between the ages of 9 and 17 in Texas with a menSchools (TxCEDS) provides school districts with guidance tal illness serious enough to interfere with their functioning on how to integrate behavioral health into RtI and PBIS at home or school.78 Yet in 2009, just over 30,000 students models. Texas schools have access to these resources, but between the ages of 6 and 21 received special education they are not required to use them, nor are they required to services in Texas due to emotional disturbance.79 Those who use RtI or PBIS. Despite TEA’s encouragement of school do qualify for special education services can receive counseldistricts’ use of RtI, as of 2008, “a significant number” of ing, behavioral plans, and positive behavioral interventions schools “across the state (had) yet to adequately prepare for and supports as part of their Individualized Education full implementation of an RtI process.”89 As of 2009, there Plan (IEP).80 Even with these additional supports, 50% of were more than 800 campuses actively participating in the students with serious emotional disturbances drop out of TEA sponsored Texas Behavior Support Initiative (TBSI) school nationwide.81 project.90 Other schools in Texas are implementing PBIS, however it is not known how many, nor how closely they Response to Intervention (RtI) is a framework used in the follow best practices. general education setting to help identify students struggling in school before they fall too far behind. It provides Most schools offer some range of services to support stuthem with a range of evidence-based interventions and dent mental and behavioral health, but these strategies are closely monitors their progress to help them catch up.82 often fragmented and limited in scope. Texas schools cite While RtI usually focuses on academics, it can also be used counseling as the most successful strategy to support stuto reduce behavior problems.83 By expanding the use of RtI dents’ mental health,91 yet many counselors find themselves to address behavioral concerns, schools can help students increasingly saddled with responsibilities unrelated to coundo better academically, while also helping to address their seling, most notably responsibilities related to administering mental health needs. academic performance tests.92 In 2004, Texas elementary school counselors spent less than a third of their time on In its guidance to school districts using RtI to address bebehavioral health counseling; high school counselors spent havioral concerns, the Texas Education Agency (TEA) sugonly 12% of time on it (despite that risk for mental illness
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and suicide spike in adolescence).93 High ratios may also be a concern. Districts are required to have one guidance counselor for every 500 elementary school students in its district.94 The TEA-recommended ratio is at least one counselor for every 350 students.95 High caseloads can prevent students with serious behavioral health concerns from receiving the more intensive attention they may need, and it can lead to other students with less obvious concerns falling through the cracks. School nurses and health centers see many students whose concerns are related to social, interpersonal, or family issues.96 In a recent survey of Texas schools, 14% of behavioral services to students were provided by school nurses.97 The integration of health and behavioral health is a key strategy to increase children’s access to services, but school health providers may not have training related to children’s behavioral health. About 1 in 4 school health services staff report a lack of training or support needed to address their students’ behavioral health effectively.98 General classroom teachers report similar rates, and nearly 1 in 3 special education teachers feel they do not have the training, support, or supervision necessary to “handle students’ behavioral health issues.” It is not surprising that more than half of Texas teachers and school health staff express an interest in training across a broad range of behavioral health topics.99 Schools can also provide various services including assessment of emotional problems or disorders, consultations to teachers to address student behavior management, crisis intervention, individual or group counseling, substance abuse counseling, or referral to community-based programs.100 While more than half of schools in Texas report having a student assistance program, in which a multidisciplinary team works to link students to needed resources within the school or community, many teachers and school health staff do not appear to be aware of them, and less than 20% of the programs had staff from community-based agencies serving on the team.101 To effectively address the multiple and often interrelated needs of students, various school programs and services and community-based resources must coordinate efforts and collaborate. Such partnerships can prove elusive. Many schools in Texas report a lack of community resources, and even schools where resources are available report trouble communicating with community partners. Schools also report that families often have difficulty getting to or paying for services.102 Each school district in Texas is required to have a School Health Advisory Council (SHAC), which is comprised of appointed parents, school personnel, and community members who make recommendations to the district on issues related to health education and the coordination of school health programs.103 While SHACs are required by state law to address the prevention of obesity, cardiovascular disease and Type 2 diabetes, they are encouraged to develop plans 54

for a broader coordinated school health program, including a healthy school environment, school counseling, and increasing school linkages to community-based resources.104 The levels of effectiveness and engagement of SHACs vary statewide, but each one has the potential to address the behavioral health needs of students and to improve the coordination of services within the school and community. By connecting programs and services, schools can provide students with a seamless system of prevention, early intervention, and intensive intervention as needed to promote the success of all students.105 This requires active collaboration between various departments within a school, and also with public and private agencies outside the school. What Texas Can Do: • Require schools to implement campus-wide Positive Behavioral Interventions and Supports. • Encourage school districts’ use of Response to Intervention to better address students’ behavioral concerns, which impact learning. • Limit the amount of time school counselors spend on activities not related to supporting students’ mental health. • Require that local School Health Advisory Councils address behavioral health. What You Can Do: • Contact your school district to learn more about its School Health Advisory Council and ways you can get involved. • Start a parent support network at your child’s school. • Join the PTA at your child’s school, and raise awareness about the impact of social and emotional health on children’s learning. • Attend school board meetings, and speak out for school programs supporting students’ behavioral health.

Creating a workforce that supports children’s mental health
Many mental health promotion, prevention, and treatment strategies not only improve the lives of children and families but also result in great savings to the taxpayer. Having a workforce with the skills and capacity to implement these strategies is critical. Unfortunately, Texas struggles to appropriately serve children with mental health concerns due to a scarcity of specialists in children’s mental health and a broad workforce that lacks the skills, knowledge, and training to handle children’s mental health challenges. An estimated 735,000 children and youth in Texas have a mental illness,106 yet, in 2007, only 192 child psychiatrists practiced in the state—approximately one for every 3,800 children with mental health service needs.107 Few psychiatrists serve children or specialize in children’s

mental health, in part because practicing pediatric psychiaare written by pediatricians and family physicians, and not try requires additional years of training but attracts low by child and adolescent psychiatrists. The latter have trainrates of reimbursement from health insurers.108 Both public ing in the appropriate use of these drugs119 and can provide and private insurers frequently offer reimbursement rates far medications under a course of treatment that includes more below what providers charge traditional therapy. Medicafor their services.109 Many tions can play a role in treatpsychiatrists forego accepting ing some mental disorders in Half of rural community mental health both public and private insurchildren when other options centers in Texas do not have a full-time ance and see only families who have been exhausted, however professional whose focus is children. pay directly. This makes access the convenience to providers to mental health treatment out of using medications as an of reach for the many families without the funds to pay for intervention makes children vulnerable to being prescribed the full cost of services for their children.110 medications even when they may be more appropriately treated in other ways. A recent study found that children Some families have access to community mental health covered by Medicaid are prescribed antipsychotic drugs services through the public mental health system, but few four times more frequently than children covered by private professionals in public community mental health centers insurance, and they are also more likely to be prescribed statewide are designated to provide children’s mental health medication for less severe concerns.120 services.111 Most of this workforce is located in urban areas. Almost half of the rural centers in Texas (46%) lack a fullDirect care staff in health, child care, education, child time mental health professional focused on children. 112 welfare, and juvenile justice settings play an integral role in serving children experiencing mental health difficulties, yet Psychologists, social workers, licensed counselors and most do not have training in identifying potential mental therapists, psychiatric nurses, and case managers also health concerns, making appropriate referrals as needed, provide mental health services and supports to children and supporting positive development. Without training and and families—with wide variance in skill level, preparatory without access to professionals who can provide consultaeducation, and methods of intervention. Child psychiatrists tions on specific cases, frontline service providers often do must complete an additional five years of training after they not know how to assist or manage children with mental receive their medical degree; psychologists have seven years health or behavioral challenges. of post-graduate training.113 Most clinical social workers have a master’s degree, but some practice with a bachelor’s While Texas has some bright spots of innovation in training degree.114 Across professions, not all clinicians are trained the broad workforce,121 by and large, a lack of training and 115 to provide care shown to be effective. With the variations technical assistance in Texas has led to a workforce unprebetween and within professions, it is difficult for families pared to use the latest breakthroughs in serving children to know which type of provider is best equipped to provide with mental health challenges.122 In reality, much of how 116 the safest, most effective care to their children. the broad mental health workforce is trained, how it practices, and what it is paid to do by insurers does not match With limited access to professionals specializing in chilwhat research tells us works.123 dren’s mental health, many families look to their pediatricians and primary care physicians to address their What Texas Can Do: children’s behavioral health. Integrating behavioral health • Provide funding to support child psychiatric into primary health care has been shown to be effective residency programs. in providing quality care, improving access, and reducing • Make financial incentive programs, such as training costs.117 Approaches to integrating behavioral health into stipends, tuition assistance, and loan repayment primary care include consultation programs, co-location of programs, available to more mental health professionals. services within pediatric practice settings, and collaborative care models.118 However, a certain level of training for the • Expand the use of higher education-state agency primary provider is needed for integrated care to be done partnerships to create on-the-job training within public effectively, and the provider should have access to mental child-serving agencies. health expertise when needed for consultation. Without • Provide those who work directly with children in health, access to these supports, many primary care providers find child care, education, child welfare, and juvenile justice themselves ill-equipped to address often complex children’s facilities access to experts in child development and mental health issues. The Frew Settlement (see page 46) mental health for case-based consultations, and training has funded projects to increase health provider access to and technical assistance on evidence-based practices. consultations with child psychiatrists, but the long-term vi• Ensure that Medicaid and CHIP reimbursement policies ability of these projects is uncertain and not all primary care support integrated care practices. physicians have access to them. —continued on next page— Most prescriptions for psychotropic medication for children
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REvERsINg THE TRENd TOWARd PuNIsHINg cHILdREN IN NEEd Of TREATMENT
—continued from previous page— • Investigate expanding tele-health and telecommunication services to provide mental health services and supports to children and youth. What You Can Do: • If you work with children in any capacity, attend a training on how to recognize potential behavioral concerns and what resources are available to assist families. • If you are a mental health professional, make your expertise available to others who work with children. • Ask candidates what they will do to make sure those who work with children have the knowledge and skills needed to promote their social and emotional development. Young people who struggle with mental health concerns are at greater risk of entering the juvenile justice system. National studies estimate that about 70% of youth in the juvenile justice system have a diagnosable mental health disorder, though not all are identified.124 The Texas Juvenile Probation Commission (TJPC) reports that in 2006, 41% of its youth had mental health problems, and 46% were chemically dependent. The Texas Youth Commission (TYC) reports that in 2008, 32% of committed youth had serious mental health problems, and 36% were chemically dependent. Both agencies acknowledge substantial gaps between identified mental health needs and services provided and have made progress in reforming the way they serve youth. Still, too often, the juvenile justice system acts as de facto provider of mental health services for children, despite that it was never created for this purpose and has not proven effective in preventing further delinquent behavior in youth with mental impairment. A well established alternative improves outcomes and saves the public money: early recognition and treatment of mental health disorders in a community setting.128 The average cost to commit a youth to the Texas Youth Commission is $99,000.129 In contrast, providing a child with community-based mental health services costs less than 56 $1,000 on average.130 By properly identifying children and youth with mental health concerns and providing them access to effective treatments and community supports, Texas can help these youth successfully remain in their families and communities and prevent them becoming involved in the juvenile justice system. Right now, Local Mental Health Authorities provide services to only about 18% of youth estimated to be eligible for services due to serious emotional disturbances and other mental health needs.131 Of the children and youth who do receive services, 80% are served at the lowest service level,132 which may be adequate for some but not all in addressing needs. More than a quarter of children who fail to receive the level of treatment clinically recommended for them do so due to a lack of community resources.133 In a national survey of families who had a child with a serious mental disorder, 36% of respondents said their child was in the juvenile justice system because of the unavailability of mental health services outside of the system.134 To help youth with serious mental health concerns remain in their homes and out of the juvenile justice system and other state systems, Texas began implementation of the Youth Empowerment Services (YES) Medicaid waiver pilot program in 2009, which provides intensive community-based services for children and adolescents with severe emotional disturbances. If the current pilot sites in Bexar and Travis Counties prove successful, Tarrant and Harris Counties will join the pilot project as additional test sites. Typically, the most effective services for youth with serious emotional disturbances are home- and community-based interventions, as opposed to interventions provided in more restrictive settings, such as detention centers or prisons.135 For youth at-risk of entering the juvenile justice system, evidence-based approaches that work with parents, guardians, and youth at home to improve youth behavior include multisystemic therapy,136 functional family therapy,137 multidimensional treatment foster care,138 and coordination of services through a wraparound approach,139 a key component in a systems of care approach.

Texas can reduce the number of youth who needlessly enter the juvenile justice system by better identifying and addressing mental health challenges before youth act out, providing them with interventions and supports shown to address mental health needs and preventing delinquent behavior. However, a greater number of children could be diverted from the juvenile justice and other costly systems and services if Texas would better align its policies with practices shown to promote the mental health and social and emotional development of all Texas children.

What Texas Can Do: • Require school districts to train school teachers and staff to recognize potential unmet developmental needs and to make appropriate referrals before issues of delinquency arise. • Help families with children with behavioral concerns navigate the various systems available to assist them by expanding the use of family liaisons and peer educators. • Adequately fund community mental health centers to eliminate waitlists for children and youth. • Increase reimbursement rates paid to health and mental health providers who see children and youth covered by CHIP or Medicaid to shore up the workforce serving children in low-income families. • Allow local service providers flexibility in policies and in funding to expand the system of care approach into more communities across Texas. What You Can Do: • Provide respite to a parent of a child with mental health concerns. • If you work or volunteer with youth, encourage your organization to adopt a positive youth development approach.140

Texas youth on probation

50% 40% 30% 20% 10% 0%

Incarcerated Texas youth

Percent with a diagnosed mental disorder

Percent with diagnosed chemical dependency

Sources: Texas Juvenile Probation Commission, 2006; Texas Youth Commission, 2008

To access detailed source information for this section of the report, visit txchildren.org/Report/Mental-Health
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Are we making smart investments?
Effective policies and programs make the most of limited resources. The further a child is enmeshed in the juvenile justice system, the more costly that journey becomes. Ineffective school discipline practices and failure to intervene early have expensive consequences. As of 2008, it cost the state $98,729 per year to imprison a child in a Texas Youth Commission (TYC) facility, not including what the state spends on assessment and orientation programs, contract facilities, halfway houses, and parole supervision.1 Based on the cost of incarcerating a single youth in TYC for one year, if the state were to invest in early intervention and prevention programs to keep children out of the juvenile justice system, the state could save over $91 million for every 1,000 children diverted from a year of incarceration. Almost all people will have difficult experiences in life. One of the more affordable ways to divert youth from crime is to help them respond well to hardship, and go on to lead a healthy life. Instead, many children struggle after an adverse experience, sometimes never landing on their feet again. What makes the difference? Social scientists call it resilience. Rather than reducing the negative elements in a youth’s environment and behavior, resilience-based approaches to youth development seek to capitalize on a youth’s strengths by providing caring relationships, high expectations, and opportunities for positive engagement. Research shows that the presence of these supports is more closely associated with positive outcomes in adulthood than the absence of risk factors such as poverty or drug use.2 Like resilience-based approaches, Positive Youth Development (PYD) emphasizes personal traits, like the ability to solve problems, a sense of self, and relationship skills, along with community protective factors, such as providing meaningful outlets for skills and expectations of success, that shape a young person’s growth. Just as in a traditional, tight-knit community, youth are most successful when the adults and organizations around them—parents and family, teachers and schools, faith communities, afterschool programs, neighbors, and community members— work together to guide a young person into adulthood.3 More youth service professionals are turning to PYD as growing evidence shows its ability to promote positive outcomes for youth, including keeping kids out of the juvenile justice system. In school settings, for example, an increasing number of districts are adopting Positive Behavioral Interventions and Supports, a process that utilizes evidence-based interventions to improve learning

JUVeNILe JUSTICe
When children fall through the cracks, failed by school, family, or community support structures, they risk landing in the juvenile justice system. These children are some of Texas’ most vulnerable. Many come from troubled homes and neighborhoods, some battle mental health and substance abuse issues, and others will face diminished educational and employment opportunities as a result of their involvement in the juvenile justice system. While the state’s juvenile justice system continues to enact and need further reforms, Texas also needs programs and practices designed to keep children from entering the system in the first place. Preventive strategies should be a part of every system children encounter, from schools to community supports to family life, so the behavioral problems children and youth display are addressed by the adults in their lives—family members, teachers, coaches, mentors, school administrators—in a way that keeps discipline challenges from worsening. Emphasizing a young person’s strengths through positive youth development, building caring networks for them in the community, and fostering resiliency among children and youth can reduce involvement in juvenile justice systems. 58

and behavioral issues. The return on investment for Promoting Alternative Thinking Strategies (PATHS) implementing PBIS comes in the form of reduced teacher, The PATHS curriculum helps students in kindergarten student, and administrator time spent managing and through 6th grade practice interpersonal problem-solving, 4 processing disciplinary referrals. In one state, 12 schools self control, and coping with found they had gained feelings.12 Students are given a combined 233 days of tools to help them manage If Texas were to invest in early administrators’ time and 700 their emotions and behavior.13 intervention and prevention programs days of instruction time for After one year, PATHS students after implementing that keep 1,000 youth from entering TyC, participants continued to show PBIS.5 A study by the Social the state would save over $91 million a year. significantly increased use Development Research of positive problem-solving Group at the University of solutions, better planning, and Washington identified 25 lower aggression compared effective PYD programs in community, school, and family to non-participants. After two years, PATHS participants settings. These programs reduced problem behaviors or had fewer reported conduct problems and improved school increased positive behaviors, including improved anger functioning.14 management, communication and social skills, problem Community Youth Development solving, decision-making, empathy, and personal health 6 knowledge and maintenance. Community Youth Development (CYD) recognizes the importance of highly involved, positive adults in a young Some positive youth development programs shown to be person’s life. This approach to delinquency prevention effective in reducing the risk of delinquent behavior in emphasizes collaboration and cooperation among youth7 Texas include the following: serving agencies, community groups, schools, and families to “build a youth’s assets.” CYD is based on the belief that Services to At-Risk Youth (STAR) involving youth in meaningful ways in every institution STAR offers support to youth and their families in that touches their lives is the best way to strengthen youth, order to prevent delinquency, truancy, and abuse. STAR their families, and their communities.15 CYD programs focus on mentoring, youth leadership development, and includes crisis intervention, emergency residential facilities, youth decision-making through the establishment of a counseling, and coping-skills education. A follow-up study Youth Advisory Committee. CYD incorporates other serof STAR recipients has found that 83% of youth who had vices to meet specific community needs in areas like career previous contact with the juvenile justice system had no development, conflict resolution, sports programs, and further contact a year after receiving services and 95% of academic and family support. 16 CYD programs have operyouth who had been delinquent had no further reports of ated in Texas since 1995, today targeting 15 zip codes with delinquency 90 days following STAR participation. STAR high juvenile justice system involvement.17 The Department costs approximately $620 per youth served, a significant of Family and Protective Services oversees CYD, and local return on investment compared to the cost for each youth youth-serving organizations are selected to administer the served by TYC and nearly $70,000 for each youth who programs in their communities; residents, businesses, and goes on to enter the Texas Department of Criminal Justice.8 other groups participate in developing, monitoring, and evaluating CYD programs.18 Big Brothers, Big Sisters Big Brothers, Big Sisters pairs an adult volunteer with an atrisk child or youth in a long-term mentoring relationship. The program uses positive role models to foster healthy social development and success.9 One study found participation in Big Brothers, Big Sisters decreased drug use by 45%, the number of times the youth skipped school by 52%, and the number of times he or she lied to a parent by 37% compared with non-participants. Additionally, these children showed increased trust in their parents and were 71% more likely to believe in their ability to complete school work.10 The Washington State Institute for Public Policy found that the benefits of Big Brothers, Big Sisters outweighed the costs by $48 per child, as determined by reductions in crime and improved educational attainment.11 Because early behavior problems serve as meaningful predictors of later difficulties in school and life, early childhood intervention is also a recommended strategy for improving overall academic, social and community success.19 If the state invests in early education and intervention programs, research indicates that those programs can prevent behavior problems from becoming more severe.20 Economic research proves that the return on public investment in high quality childhood education is substantial.21 In Washington State, the net benefit for investing in preschool for lowincome 3- and 4-year-olds was calculated to be $9,901 per child.22 Similarly, the HighScope Perry Preschool Program in Michigan, a development program that targets young at-risk children, found that the public gained $12.90 for every dollar spent on the program—an 80 percent return
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on investment.23 It has been predicted that if the nation launched a program that invested in early childhood development, by 2030 the budget benefits would exceed costs by $31 billion, increasing to $61 billion by 2050.24 What Texas Can Do: • Increase funding for programs proven to promote resiliency and prevent delinquency. • Invest in quality early education for Texas children. What You Can Do: • Become a mentor for a young person. • Talk to school district and other elected officials about implementing positive youth development programs in every school.

racial and ethnic groups. Some research has found that DMC in juvenile prisons is due to racial differences in the types of crimes committed, with youth of color being more likely to be arrested for crimes that lead to imprisonment.30 However, other research shows that black youth are five times as likely and Latino youth are twice as likely as Anglo youth to be arrested for drug offenses, even though all three groups have similar rates of self-reported drug use. Black youth are also twice as likely as Anglo youth to be arrested for weapons possession despite that Anglo youth report carrying weapons at a higher rate.31 To understand DMC, we have to look at structural differences leading to varying rates at which youth of different racial and ethnic groups are referred to the juvenile justice system and how they are handled once in the system. For example, DMC can occur when police departments disproportionately patrol and make arrests in neighborhoods with concentrated populations of color. Greater levels of discretion in police departments and courts for the types of crimes that warrant arrest and the sentences that follow can also contribute to racial imbalances. “Victimless” crimes such as drug-related offenses and “public order” crimes are especially open to discretion.32 What the Texas research currently shows is that, for black children, the disparities lie primarily in the rates of disciplinary referrals from school, while Latino children are more affected by biases within the system itself.33 In the school setting, students of color are disproportionately represented in Disciplinary Alternative Education Programs (DAEPs), programs that place a student outside a regular referrals to Juvenile Probation Fy 2001 to Fy 2008

Are we ensuring justice for all children?
There is much evidence that Texas has a long way to go before it closes the gaps between outcomes for different groups of children who face disciplinary action. Practices and programs within the juvenile justice system also may not be effective at steering all children away from the juvenile justice system and toward greater success. Race/Ethnicity When race or ethnicity predicts the likelihood that a child or adolescent will be involved in the juvenile justice system, this is called disproportionate minority contact (DMC). The U.S. Department of Justice’s Office of Juvenile Justice and Delinquency Prevention (OJJDP) defines DMC as any instance where the proportion of a minority group’s contact with the juvenile justice system exceeds that group’s representation in the general population.25 In Texas: • African-American and Latino youth are more often referred to the juvenile justice system than are their white counterparts;26 • African-American youth are disproportionately represented in every stage of the system;27 and • Latino youth are disproportionately represented at every point in the system except probation placement an confinement.28 A study of DMC in Texas looked at the racial makeup of arrests, detentions, and youth sent to the Texas Youth Commission (TYC), Texas’ youth prisons. For African Americans, the top five counties that had the highest combined levels of involvement were Travis, Montgomery, Lubbock, Tarrant, and Denton. For Hispanics, they were Fort Bend, Lubbock, Denton, Travis, and Tarrant. AfricanAmerican overrepresentation was magnified with each decision point that deepened system involvement.29 Research regarding DMC indicates that it cannot be attributed merely to different crime rates among the various 60

120,000 100,000 80,000 60,000 40,000 20,000
46,356 39,724

108,171 113,047

106,495

108,867 103,068 104,166

103,991 99,566

45,700 36,453

47,698 33,700

49,374

47,151

46,707

48,583

47,235

32,768

30,175

29,540

28,522

26,470 24,741 1,120 FY 2008

25,818

25,052 966

24,025 1,072

25,528 1,197

24,726 1,016

26,887 25,816 1,032 1,070

1,149 FY 2001

FY 2002 FY 2003 FY 2004 FY 2005 Total African American Caucasian Hispanic Other

FY 2006 FY 2007

Source: Texas Juvenile Probation Commission and Texas Youth Commission. (2009) Coordinated Strategic Plan, Fiscal Year 2010.

classroom separate from other students.34 A 2009 report by the Intercultural Development Research Association found that, of the more than 750,000 Texas students in DAEPs in the past decade, half were Hispanic and one in four were African American—nearly twice African Americans’ proportion in the general student population.35 In over a third of all Texas school districts, African-American students were overrepresented in discretionary referrals to out-of-school suspension, and Hispanic students were overrepresented in DAEP referrals in forty districts.36 In addition to having more disciplinary referrals in school, children of color—especially black children—are also more likely to be moved further into the juvenile justice system. A 2010 Texas Juvenile Probation Commission (TJPC) report, found that 25% of the juveniles referred to a juvenile probation department in 2008 were African Americans, even though African Americans make up only 13% of the total juvenile population. Latinos make up 40% of the juvenile population and 43% of those entering the juvenile justice system.37” Differences in the types of sentences children of color receive can be attributed to structural qualities of the juvenile justice system. A lack of norms, standards, and accountability across different police departments, court rooms, and local juvenile justice systems increases the amount of discretion available to decision-makers. 38 For example, juvenile court judges have a great deal of leeway when it comes to handling delinquent behavior. They can choose to place a juvenile in a residential placement, put the youth on probation, assign community service, or simply send them home—all for the same offense.39 The more choices and fewer standards there are at each decision-making point, the greater the likelihood that different children will face different consequences for the same offense. There is also disparate treatment in the percentage of children who are certified as adults and processed in the adult criminal justice system. A study by the University of Texas at Austin laments “the extreme arbitrariness, unpredictability, and racial disparities in determinations about when and whether a young child will be treated as an adult.” The study found that half of the young children nationwide sent to adult court for crimes against others were black, nearly four times their proportion in the general population.40 Prior involvement in the juvenile justice system increases the likelihood of an adult certification, but even among juveniles with similar ages, histories of offense, and records of prior system involvement, African-Americans and, to a lesser extent, Latinos were more likely to be certified as an adult than Anglo youth. A major study of juveniles who had been convicted of violent crimes with a history of system involvement found that 27% of eligible African-American juveniles were certified as adults, compared to 17% of eligible Latinos and 15% of eligible Anglo juveniles.41

Gender The juvenile justice system is disproportionately comprised of males. Even though males commit 72% of all juvenile offenses,42 they make up 91% of the population in TYC43 and 91% of all transfers to the adult system.44 Due to their small numbers, young women in the juvenile justice system have a greater difficulty accessing specialized programming in both TYC and, for juveniles certified as adults, in the Youthful Offenders Program operated by the Texas Department of Criminal Justice (TDCJ). While there is now a Youthful Offender Program unit at a separate location especially for girls, it lacks therapeutic programming and staff specially trained to work with female youthful offenders.45 TYC has recognized that girls in its charge have little access to the rehabilitative services they need and has begun taking steps to enhance services for girls. It has extended substance abuse treatment, sex offender programs, and its Capital and Violent Offender Program to girls.46 It is also enhancing individualized, gender-specific case planning and multidisciplinary team meetings and is training staff who work with females with the Girls Circle support group model, Gender Responsive Training, and Trauma-Focused Cognitive Behavioral Therapy.47

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Geography and Economic Conditions In neighborhoods with adequate resources and supports, behavior problems are more often handled informally, while resource-poor neighborhoods have few options beyond law enforcement.48 School suspensions and DAEP referrals are also more closely tied to the specific school a child attends, rather than the type of behavior problem displayed,49 and 66% of all probation referrals and TYC commitments in 2009 came from only 23 juvenile court jurisdictions.50 Special Needs Special education students are at higher risk of being funneled into school discipline and juvenile justice systems than are other students. Across the state, special education students are referred to DAEPs, in-school suspension, and out-of-school suspension at higher rates than students without special needs.51 Special education students represent 22% of annual DAEP referrals, despite making up only 11% of the Texas public school population.52 Texas Appleseed reported that 317 Texas school districts disproportionately suspended special education students every year between 2001 and 2006.53 Nearly 40% of youth in the Texas juvenile justice system received special education services prior to coming into contact with the system.54 Age Very young Texas students are suspended and expelled from school at a higher rate than are older students. Though the Texas Education Code prohibits a child under age 6 from being sent to alternative school unless the child brings a firearm to school,55 in practice over 3,000 pre-Kindergarten through first-grade students were referred to DAEPs in Texas school districts between 2001 and 2006.56 In Texas, preschoolers were expelled at a rate of 6 per 1,000 children in the 2003-2004 school year—more than twice the rate for students in grades K-12.57 When the factors that contribute to gaps in juvenile justice outcomes are rooted in the policies and norms of disciplinary bodies, systemic change is needed, including the analysis of existing policies to identify those that negatively impact certain groups of juveniles.58 This analysis has begun, with the federal and state governments having recognized the gaps that exist between the characteristics of students who end up in disciplinary systems and those in the broader population. The Juvenile Justice and Delinquency Prevention Act of 2002 requires states to monitor and develop a three-year plan to reduce DMC in order to receive federal funds.59 In Texas, HB 1118, passed in 2007, took a first step towards addressing DMC in the juvenile justice system by requiring that it be studied.60 In jurisdictions that have successfully begun reducing disproportionate treatment for youth of color, a primary strategy has been collaboration.61 Having local law enforcement, judges, community leaders, education officials, and juvenile justice personnel work together to identify the points at 62

which gaps in treatment occur and to collaboratively craft solutions has gotten results. Additionally, focus needs to be given to data collection, transparency, and analysis. Collecting data on race and ethnicity as juveniles move through school and legal disciplinary systems is a major barrier in many states. Texas is unique in that we have good statewide data through the Texas Juvenile Probation Commission that allows for DMC analysis at many points of contact. However, school discipline data is problematic in Texas. The Texas Education Agency (TEA) collects data on referrals to DAEPS, suspension, and expulsion, though this data is not easily available to the public or to researchers. It does not collect data on the issuing of criminal citations to children at school or on arrests at school. Since school discipline practices are the largest contributor to entry into the juvenile justice system for all children, and disproportionately for children of color, it is critical that TEA begin collecting data on the practice of school ticketing at the local school district level. Increases in transparency and public availability of data currently collected by TEA are also needed. In identifying and addressing the structural causes of system over-involvement for some children, Texas can better address improving the system for all children. What Texas Can Do: • Require TEA to collect data on school ticketing and arrests and to make school disciplinary data publicly available. • Require school districts that disproportionately refer students of color or special education students to DAEPs to implement a remediation plan. • Remove discretion in categories of behavior that can result in expulsion and referral to juvenile court. What You Can Do: • Attend a school board meeting in your district and ask about discipline referral policies. • Organize a community meeting to discuss the demographic information available from your local probation department.

Addressing the school-to-prison pipeline

The movement toward increasingly severe punishment for misbehavior at school dates back to 1994, when the U.S. Congress passed the Gun-Free Schools Act in response to several school with district discretion in criminalizing some shootings and required a While some disciplinary Texas kids for offenses that, elsewhere, “zero tolerance” approach to consequences are determined weapons on school campuses.72 would get met with a teacher’s reprimand. by Texas law, many are The Texas Legislature adopted not. For example, the zero tolerance the following Texas Education Code regulates the use of restraints, year.73 Zero tolerance policies require automatic, severe sets standards for alternative education programs, and punishment, such as suspension or expulsion, for school mandates situations in which a teacher must remove a discipline code infractions, regardless of age, developmental student from the classroom.64 The Education Code governs stage, or whether the child intends to do harm.74 There is no statewide practices that promote safe environments in evidence, however, that zero tolerance improves children’s public schools while allowing school districts to write behavior or makes schools safer.75 On the contrary, students and enforce discipline policies based on the Education who are placed in out-of-school suspension are 32 times Code.65 However, these legally mandated referrals make more likely to commit an offense compared to students who up only a small minority of all discipline cases in Texas. are in school.76 Similarly, research indicates that students School districts also have the discretion to discipline and placed in DAEPs have five times the school dropout rate of remove children from class for other reasons, and these students in regular classrooms.77 In all, nearly $200 billion discretionary referrals make up the majority of placements a year in economic loss could be recovered if more funds in disciplinary alternative education programs (DAEP), were invested in improving the quality of school discipline in-school suspension, and out-of-school suspension.66 The and lowering dropout rates.78 Dropouts also have a higher number of students taken out of school and put in one of level of criminal justice involvement: 80% of adult Texas these programs has grown steadily since the mid 1990s. prisoners are school dropouts.79 In the 2005-06 school year, Texas schools made 62,981 Texas has made some recent changes to its school discipline discretionary referrals to DAEPs (compared to 27,093 policies in order to mitigate the negative effects of zero legally mandated referrals).67 Many youth who commit tolerance. For example, in 2007, the Texas Education minor violations are also referred to county juvenile Agency (TEA) enacted standards at the Legislature’s probation departments monitored by the Texas Juvenile direction for DAEPs,80 such as requiring DAEPs to Probation Commission (TJPC).68 Two-thirds of first-time administer an intake and exit exam for students placed referrals to juvenile probation were youth who had at least there for 90 days or more.81 Although the standards are one school disciplinary referral in the year prior.69 positive steps to ensuring that DAEPs are run effectively, If a school seeks a more serious punishment for a student there is currently no state oversight to ensure that standards offense, expulsion is another option. Students can be are enforced. In 2009, the state legislature mandated expelled with no placement—they stay home or go that schools in situations involving possible suspensions, elsewhere during school hours—or they can be expelled to removals, or expulsions consider mitigating factors that a juvenile justice alternative education program (JJAEP) contribute to a child’s behavior, including self-defense, if the district is large enough to have one. A JJAEP is a intent or lack of intent at the time the student engaged separate educational setting that allows expelled students in the conduct, the student’s disciplinary history, and any to continue receiving classroom instruction on grade level. disability that substantially impairs the student’s capacity to Only the 26 counties with populations over 125,000 are appreciate the wrongfulness of the conduct.82 required to operate a JJAEP.70 Despite these efforts, Texas students continue to be sent to DAEPs and JJAEPs, suspended, expelled, ticketed,
Juvenile Justice

The public education system is the gateway by which many of the 150,000 Texas juveniles arrested each year first come into contact with the criminal justice system.62 Schools are increasingly likely to use disciplinary measures that take children out of the classroom for even minor offenses and enter them into the correctional system, a trend advocates term the “school-to-prison pipeline.” In fact, according to a report by the Texas A&M Public Policy Some school districts in Texas expel students Research Institute, “the single and issue criminal tickets much more often greatest predictor of future than others. Parents have no way of incarceration is a history knowing how their own district compares— of disciplinary referrals at meaning a lack of transparency combines schools.”63

A third option for school discipline is ticketing—issuing a criminal citation. Issuing tickets for all types of school disciplinary violations is becoming increasingly common and more school districts now house their own police departments. Children as young as six have received such tickets, which come with fines ranging from $250 to $500. Judges determine whether failure to pay the fines will result in community service or jail time.71

63

and referred to local juvenile probation departments for violations of school conduct codes at alarming rates. In 2008, the Texas Juvenile Probation Commission (TJPC) reported 99,276 total juvenile referrals. Of these, 5,829 came directly from schools, and many of the 77,287 referrals that came from law enforcement, plus those from municipal courts, were also for offenses at school. Schoolrelated offenses also contributed to the 56,737 juvenile arrests handled by local judges and courts in 2008.83 About 3% of youth referred to probation departments are later committed to the Texas Youth Commission, the state’s juvenile corrections agency.84 In Texas, school districts’ disciplinary practices vary widely. For example, disrupting a classroom (which can include things such as swearing or chewing gum) could be handled in the classroom by a teacher in some districts and could result in expulsion or a criminal ticket in another district. Some districts expel students or issue criminal tickets many times more often than other districts. Further, neither districts themselves nor parents have access to basic information about how districts compare in discipline responses. This combination of discretion and lack of transparency results in significant gaps between outcomes for various groups of students. School police officers have the responsibility of keeping schools safe from violence. For many, however, their time is spent primarily on violations of school discipline policies, not violent crime. Further, when a school police officer issues a criminal ticket to a child or youth, the city courts that handle the tickets do not use a normal court process involving a defense attorney, prosecuting attorney, judge, or jury. They can, but in practice, they do not. This means that Texas children and youth do not in practice have basic due process to resolve criminal charges they are subject to based on school discipline practices. An additional concern is the inherent incentive to ticket children. Though not all school districts report what is done with revenue from tickets issued to students, in at least some districts, a portion of the revenue from tickets funds the school police departments that issue the citations. To avoid conflict of interest, funds from tickets should not perpetuate a school police presence.85 An alternative to criminalizing behaviors is to implement school-wide Positive Behavioral Interventions and Support (PBIS), an evidence-based framework effective at reducing disciplinary incidents, increasing school safety, and improving academic outcomes.86 Texas needs a school discipline environment that does not make criminals out of youth, but rather redirects problem behavior. Our valuable criminal justice resources should be redirected into things that protect the public from violent crime, while our teachers and principals need sufficient resources and training to manage students in need of behavioral interventions.

What Texas Can Do: • Require schools to train school police officers, teachers, and staff on how to discipline students in a positive way. • Limit ticketing at school as much as possible, redirecting revenue from remaining tickets away from police departments and towards youth programs. What You Can Do: • If you are a parent, read the Student Code of Conduct handbook for your child’s school and talk it over with your child. Also, inquire regularly about your child’s conduct at school. If there are problems, work with your child’s teacher to develop alternatives to disciplinary referrals for him or her. • Attend school board meetings and contact your superintendent to change any disciplinary practices in your district that funnel children ino the justice system.

Choosing strategies that divert youth from crime
A fundamental step in keeping youth out of the juvenile justice system is providing them with opportunities for experiences that promote healthy, positive choices—in other words, preventing delinquency. By empowering parents, caregivers, teachers, and other adults who work with youth with skills and strategies to support healthy development, Texas can help young people succeed. Prevention strategies at each stage of child development support healthy growth into adulthood. Parenting education programs have been shown to reduce antisocial behavior in children.87 Young children who attend quality early childhood programs are less likely to be truant or engage in delinquent behavior when they are older.88 Schools that implement a positive behavior support approach have fewer disciplinary problems.89 After-school programs, mentoring programs, youth-engagement programs, and recreational activities provide youth with opportunities to have a sense of belonging, develop relationships, build skills, and experience success in ways that help prevent negative behaviors.90 Connecting youth and families to services when needed also helps prevent children from coming into contact with the juvenile justice system.91 These prevention strategies support healthy child development and also help the state avoid substantial costs related to juvenile crime. When youth do make poor choices, the best approaches prevent future delinquent behavior, promote youth success, and keep the community safe. Research indicates that providing youth with interventions in the community, close to their families, is the most effective way to prevent delinquent behavior from continuing.92 Interventions applied in more restrictive settings, such as confinement, are not only much more expensive, but have generally proven ineffective at producing long-term changes in behavior.93

64

Families are an integral part of preventing youth from Delinquency often arises among a myriad of problems, including difficulties in school, mental health challenges, entering—or becoming more involved in—the juvenile and a history of abuse and neglect.94 These are compounded justice system. Multisystemic therapy and functional family by a lack of services. The Texas Juvenile Probation therapy, both evidence-based practices, work with parents, Commission has reported many youth entering the guardians, and youth at home to improve the youth’s juvenile justice system have not had their basic treatment behavior, as well as the communication and problemand service needs met.95 The solving skills of parents and complex needs presented by siblings. Many of Texas’s Two-thirds of youth with mental health youth and their families often child- and youth-serving disorders in juvenile probation programs do require collaboration among agencies have begun to employ various entities. Each Texas parents or young adults who not receive mental health services. county has a Community have themselves navigated the Resource Coordination Group state’s systems for health and (CRCG) that coordinates human services or juvenile resources and services for youth and families with the most justice. In staff positions, they, in turn, help other families complex needs. More than 70% of referrals to CRCGs navigate the systems to access services and support their stem from behavioral health issues.96 Varying levels of children’s treatment. participation among local partners and a dearth of flexible Several actions taken by the state legislature in 2009 are funding to meet individualized needs prevent CRCGs from expected to prevent youth involvement with the juvenile addressing the needs of all youth with complex needs who justice system. For example, in an effort to reduce the are in the community.97 number of youth who are committed to the Texas Youth For all youth who come into contact with the juvenile Commission, the Legislature established the Commitment justice system, screenings and assessments should be Reduction Program Grant, or “Grant C” program. This administered at the earliest point possible to allow voluntary program provides local juvenile probation probation departments and juvenile courts to better departments with funding to expand their communityidentify interventions that will most appropriately meet based diversion programs and services. the youth’s and community’s needs. Screening instruments Local juvenile probation departments are now required that have been validated should be used to detect mental to use a validated risk and needs assessment instrument, health issues, including substance abuse and traumatic in addition to the mental health screening they have stress disorders. Local probation departments in Texas are been using. TJPC is also developing a series of assessment required to do an initial mental health screening and a risk instruments for identification of a juvenile’s risk of reand needs assessment when youth are admitted to detention 98 offense based on criminal history and needs.103 The or enter the probation system. However, screenings Legislature also funded a pilot project in Bexar County and assessments do not guarantee treatment. Specialized to divert youth at risk of being incarcerated or otherwise treatment services are often in short supply or are too 99 placed outside of home into an integrated system of care. expensive for local communities. The majority of youth with mental health disorders served by local probation There are other promising diversion practices underway departments in Texas do not receive treatment. In 2004, in Texas. Dallas and Harris counties are participating 67% of youth served by juvenile probation departments in a project funded by the Annie E. Casey Foundation, who needed services did not receive them.100 the Juvenile Detention Alternatives Initiative, which helps communities devise systems to help minimize the number Courts play an important role in making sure delinquent of youth who are detained while awaiting trial.104 The youth are linked with appropriate interventions and have Front-End Diversion Initiative is an intake-based diversion adequate legal defense focused on securing appropriate 101 effort that provides motivational interviewing, family community-based services. Mental health and drug engagement, crisis intervention, and mental health training courts are emerging as promising alternatives to address to specialized juvenile probation officers to help them juvenile offenders’ mental health and substance use issues, 102 better identify and work with youth with mental health while also addressing public safety. Mental health courts challenges.105 The Special Needs Diversionary Program pairs a link offenders who would ordinarily be prison-bound local mental health professional with a specialized probation to long-term community-based treatment. Drug courts officer to coordinate a range of community-based services provide court-supervised treatment as an alternative to for youth and their family, including skills training, anger traditional criminal sanctions. Specialized court programs management, and medication maintenance.106 are unavailable to the majority of juveniles in Texas, but some communities are implementing this promising All of these measures acknowledge that incarcerating practice. youth is not an inevitability, but rather an avoidable policy decision. The right thing to do for Texas youth at risk of
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criminal justice involvement is also what is most costeffective in the short- and long-term: supporting youths’ positive development. What Texas Can Do: • Maintain community corrections funding and increase the impact of this investment by requiring that communities use strategies proven to be effective. • Use multidisciplinary teams as standard practice for assessment and service delivery. • Provide flexible funding for Community Resource Coordination Groups and Texas Integrated Funding Initiative sites to provide more children with complex needs access to supports and services using a systems of care approach. • Require probation-based diversion strategies in all counties. • Increase use of mental health and drug courts, and move all juvenile courts towards treatment-based models. What You Can Do: • Volunteer at a community program that supports positive youth development.

to youth and allow more youth to learn coping skills that lead to improved decision-making.111 In any rehabilitation program, all facility staff should use a youth-focused and strength-based approach, involve the youths’ families where possible, and have adequate training to work with youth, including training in strategies to defuse escalating situations.112 Additionally, co-occurring mental health and substance abuse disorders need addressing. Youth with emotional and behavioral problems are almost four times as likely to be dependent on alcohol or drugs.113 A Texas Youth Commission (TYC) study found that youth who received mental health treatment while incarcerated were significantly less likely to be rearrested or reincarcerated within a year of release.114 Maintaining small secure juvenile justice facilities, close to a youth’s community and with low youth-to-staff ratios, also improves outcomes.115 This is sometimes referred to as the “Missouri Model” after the state that pioneered the effective practice.116 Other effective models for engaging and treating juvenile offenders likewise bring a high return on investment. For example, the Washington State Institute for Public Policy notes Dialectical Behavior Therapy for youth with complex mental health needs returns $38.05 in benefits per $1 cost, saving $31,243 per youth,117 while Multi-Systemic Therapy, a short-term intervention that works with a youth’s family to address causes of delinquency, returns $2.64 in benefits per dollar of cost, saving $9,316 per youth.118 As agency data and recent media reports demonstrate, the TYC requires substantial continued reform. At the same time, the best option for Texas continues to be a juvenile justice system separate from the adult correctional system and a commitment to making ongoing improvements to that system. There are some innovations within our juvenile justice system that are promising. For example, TYC has begun using a promising rehabilitation approach, called ConNEXTions, that incorporates various therapeutic techniques and tools to help youth within facilities.119 ConNEXTions uses an evidence-based assessment with all youth, and assessment results form the basis for individual treatment plans. In addition to general programming, youth may receive mental health support, alcohol and drug education, anger management, or psychosexual development support, all within group settings. Additionally, TYC operates the Capital Offenders program at its Giddings facility and the Ron Jackson unit for girls.120 This program is guided by research and based largely on cognitive, psycho-social techniques that promote self-regulation and empathy and has been proven to be successful at reducing overall recidivism by 55%.121 Finally, TYC uses Aggression Replacement Training (ART), a 10-week group intervention designed to help youth control impulsive, violent behavior by practicing positive behaviors.122 ART has proven effective in decreasing the

ensuring kids in the system get the care they need
The quality of services and supports youth receive in the juvenile justice system, as well as the conditions they face there, help determine later success. Incarceration alone is not typically effective in changing youths’ behavior after release,107 but providing specialized mental health and substance abuse treatments, community-based services, and youth-centered treatments during incarceration can prevent a youth from reoffending and bring about real, positive change. This benefits taxpayers, as well. According to the Washington State Institute for Public Policy, “There is credible evidence that certain well-implemented programs can achieve significantly more benefits than costs… Investments in effective programs for juvenile offenders have the highest net benefit. Such programs yield from $1,900 to $31,200 per youth.”108 For spending on juvenile justice to be efficient, dollars ought to be directed toward the areas that produce the most beneficial outcomes for the state. A thoughtful system that addresses the root causes of delinquency and system involvement, such as unaddressed mental health challenges, would offer appropriate screening and assessment, so when youth have special treatment needs the juvenile justice system can respond.109 Also, having qualified professionals with appropriate training provide individualized and specialized services110 and limiting the use of medication except when it is medically warranted (versus as a chemical restraint) would help prevent serious health and safety risks 66

frequency and intensity of aggression and increasing moral reasoning,123 while saving taxpayers money. Texas reaps $20.56 in benefits for each dollar spent on the program, a savings of $14,846 per youth.124

Although youth are mostly kept separate from adults in adult correctional facilities, they are subject to the same disciplinary code, and when they violate any part of it, the disciplinary protocol is the same as for an adult.133 The Texas Department of Criminal Justice (TDCJ) offers a These programs are largely out of reach for Texas children youthful offender program called COURAGE, but youth who are in the adult criminal system. According to the are only allowed to receive programming until age 18 and U.S. Department of Justice, there were 156 youth under not all youth younger than 18 are in the program.134 Some age 18 in Texas state prisons youth may attend school; in mid-2009; 98% of them however, in 2006 less than half were males.125 Of youth Many children are placed in the adult of youthful offenders in the certified as adults, most system for minor, nonviolent offenses— adult correctional system were are 16 or 17 years old, but enrolled in school,135 leaving over half are certified as adults for children as young as 14 can many youth ill-prepared to property or drug-related crimes. be sent to adult prison.126 function successfully in the Adult certifications in Texas community once released. increased approximately No research exists with 40% in 2005 alone; despite fluctuation in the years that regard to the outcomes for youth after they receive TDCJ followed, the number of youth certified as adults nearly programming. Such research is difficult to obtain since quadrupled four years later (from 60 to 225). According to youth often continue into adult-system programming the most recent comprehensive report on adult certification instead of being released into the community.136 of juveniles in Texas, most youth eligible for certification as adults do stay in the juvenile system, but among those who Because of their unique circumstances and needs, children are certified as adults, 6 in 10 wind up in prison (versus should be kept physically and programmatically separate 4% in jails and 27% under community supervision, like from adults in the criminal justice system.137 Children’s 127 probation and deferred adjudication). Many children are brains are still developing; their culpability in a crime placed in the adult system for minor, nonviolent offenses— and odds of finding success in rehabilitation differ from over half are certified as adults for property or drug-related adults’. Placing a youth in a juvenile justice system is crimes.128, 129 also more cost-effective, saving, by one estimate $3 in later correctional costs for every $1 spent on juvenile The adult system ill equips a youth for reentry into remediation.138 the community, so outcomes are far worse than for youth in a juvenile system. For example, the Center There are several ways to reduce the number of juveniles in for Disease Control and Prevention has found that it is the adult system. Juveniles who are certified to stand trial “counterproductive” to place youth in an adult system; as an adult could be held before and after trial in juvenile rather than serving as a deterrent, it leads youth to higher facilities rather than adult facilities. For juveniles convicted recidivism and more serious crime.130 Juveniles transferred as adults, judges could have judicial review when the youth to the adult system also experience higher risk of physical turns 19 to determine the best next step. TYC could be and psychological victimization and suicide than adults.131 allowed to request judicial permission to extend the TYC These transfers also expose a youth to longer sentences program for a youth turning 19 who would benefit from without potential for review once the youth reaches the age staying with TYC to complete specific services rather of maturity.132 than be transferred. The number of children certified as

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adults would also be greatly reduced by reserving adult certification only for those who commit the most serious offenses. Extending probation for youth until age 19 would make the probation system parallel to TYC and eliminate the pressure some judges feel to send a youth to TYC in order to keep the youth in the juvenile justice system one year longer. Meeting youth’s mental and physical health needs, keeping youth connected to their communities, and ensuring they are receiving an education and protected from violence are essential to making our juvenile justice system an effective route to rehabilitation, rather than the start of continued criminal involvement and poor outcomes. What Texas Can Do: • Identify youth needs early by conducting comprehensive assessments on all juvenile offenders and creating individualized treatment plans that plan for the youth’s release. • Limit seclusion and restraint to times when there is an imminent risk of danger to the youth or others and no other safe intervention is possible. • Facilitate community and family involvement by serving youth in small, regionalized facilities, partnering with community-based organizations, and bringing families into decision-making roles. • Promote professionalism among juvenile justice staff by increasing training and field experience requirements, paying a living wage, and rewarding staff who work effectively with youth. • Amend policies regarding youth certified to stand trial as an adult by housing them in juvenile facilities and making adult certification offenses and opportunities for judicial review consistent with those of determinate sentenced youth. What You Can Do: • Call or write your elected officials asking them to help improve treatment options and supports for youthful offenders. • Start an online support group for parents of children in the juvenile justice system. • Volunteer with a program that visits incarcerated youth.

issues.139 While some will go back to supportive families and communities with access to resources, many more are likely to return to homes, neighborhoods, and peers struggling with poverty, violence, low-performing schools, and a lack of community supports.140 Helping youth prepare for these challenges is a critical piece in keeping youth from reentering the juvenile justice system or graduating into the adult criminal justice system. In order for the juvenile justice system to be effective in preventing continued delinquency, the youth’s time in the system should be focused on preparation for an eventual successful transition back into the community. This requires a thorough assessment of a youth’s needs and individualized transition planning that begins soon after the youth is first confined. This planning should address: mental, behavioral, and physical health needs; housing upon release; whether the youth will return to school or enter the workforce; and what social supports he or she will have with family, friends, and adults in the community.141 Throughout the process, supportive family members who will help ensure successful reentry into the community should be engaged to minimize risk of a youth reoffending.142 There are certain characteristics of transitional programs that research has shown work best to prevent reoffending. Successful programs provide a combination of supervision and treatment, use assessments to identify the individual needs of each youth, focus on youth who are most likely to reoffend, use individual case-planning instead of a one-sizefits-all approach, and link youth to appropriate community services.143 They also use treatments that target the specific behaviors or factors which are known to increase a youth’s risk of reoffending.144 Finally, effective programs implement interventions the way they were designed to be used by a workforce that has been trained to do so.145 The systems, agencies, and communities that support returning youth offenders also face challenges. Many communities lack the programs and providers to offer the range of services needed. Where programs and providers do exist, coordination among agencies maximizes resources and helps prevent youth from facing gaps in services. Such coordination does not always come easily, though, and the flexible funding to support successful collaborations is difficult to obtain. Effective collaboration also requires certain competencies and skills not traditionally taught in the training of the workforce serving youth.146 During its 2009 session, the Texas Legislature made several policy changes to assist juvenile offenders in successfully transitioning back into their homes and communities. TYC is now required to develop a comprehensive plan to help youth reenter their communities upon discharge and to prevent them from committing further crimes. TYC must also develop a reentry and reintegration plan for each youth in its facilities and a report on the youth’s progress for the court that sentenced the youth or the county or state to which the youth is being released.

Creating effective transitions for youth leaving the juvenile justice system
As youth leave juvenile justice confinement they face barriers to successfully transitioning back to their homes and communities. The majority of youth in the Texas Youth Commission (TYC) are behind their peers in reading and math skills and come from low-income homes and chaotic environments; many have a history of abuse and neglect, gang involvement, and mental health and substance use 68

Youth eligible for public health benefits now have better access to health and behavioral health care services upon release, as state agencies work together to determine a youth’s eligibility for public health benefits as part of the discharge-planning process. Youth with serious mental health concerns have access to additional supports and services now that juvenile justice, human services, and education agencies are required to provide a coordinated continuum of care to juvenile offenders with serious mental health concerns to address their physical, mental, educational, and rehabilitation needs from the time they enter the juvenile justice system until they are released from supervision into their communities. The Legislature also closed a gap in state policy to provide access to ongoing mental health treatment and supports to youth who have been discharged from TYC due to a mental impairment. Prior to this change, these high-need youth were unable to access certain services because they were not placed on parole. Unfortunately, the Legislature did not provide funding that would have enabled local Community Resource and Coordination Groups to help youth released from juvenile justice facilities successfully reintegrate back into their families and communities. Other proposals for improvements in coordination were successful. To better address the needs of youth who are committed to the juvenile justice system and foster care system, the Legislature has directed TYC and the Department of Family and Protective Services to better coordinate their services. Also, TYC and TJPC have recently partnered with community groups in San Antonio to launch the Children's After-care Reentry Experience (CARE) Project that will provide youth coming out of the juvenile justice system with access to a transition center that provides healthcare, housing, education, employment, and relational needs assistance all in one place.147 Texas must ensure effective implementation of these policy improvements and increase local capacity for assisting youth in transitioning to the community. Successful community transitions promote youth success and keep Texas communities safer. What Texas Can Do: • Engage a child’s network of support in preparing for the child’s reentry into the community. • Ensure eligible youth are enrolled in Medicaid or CHIP and begin receiving covered services immediately upon release, the point in time when they are most vulnerable to reoffend. • Provide grants to community-based organizations that assist youth in enrolling in school or training; securing employment and safe, stable housing; accessing mental health services; and resolving substance abuse problems to decrease the likelihood of reoffending.

• Explore opportunities for statewide use of transition centers, such as those serving youth leaving the child welfare system, to assist youth leaving the juvenile justice system. What You Can Do: • Donate to or volunteer at an organization that provides services to youth returning to their community. • Ask your local elected officials to support programs that provide youth with skills and opportunities to succeed. • Hire a youth who is a former offender.

Moving toward a judicial system that understands what kids need
The judicial system recognizes that children and youth are different from adults by having a juvenile justice system distinct from the adult criminal justice system. The courts further recognize that adolescents are fundamentally different from adults in their maturity and culpability.148 Without adequate education about the neurobiological, psychological, social, and moral development of children,149 though, judicial decision-makers—judges, prosecutors, and defense attorneys—can overlook this distinction, making decisions that have a detrimental impact on a young person’s future without ever achieving the twin goals of youth rehabilitation and public safety. Many Texas youth who appear in juvenile court come from chaotic homes or neighborhoods and have had significant interaction with adults who respond in threatening, inconsistent, or unfair ways.150 Judges have the opportunity to foster a positive experience of authority by providing youth with consistency, respectful treatment, and fair discipline in a developmentally appropriate way. It is important that judicial decision-makers understand this important opportunity so that they avoid acting in ways that further hinder a youth’s positive social development.151 The Texas Office of Court Administration (OCA), overseen by the Texas Supreme Court,152 funds 18 organizations153 that offer judicial education, and state law requires judicial education on some topics, such as child abuse and neglect, family violence, sexual assault, disability issues and more.154, 155 However, there is no mandated judicial education in Texas on child development or juvenile delinquency. There is also no oversight of the content that the 18 judicial education organizations offer in their courses.156 The judicial education organizations should be using promising practices based on accurate information and findings based on research, but currently there is no way to tell whether this is happening. An additional concern is that lack of oversight in training heightens differences in the quality of judicial decision-making across the state. Currently, there is also no mechanism for holding judges accountable for meeting judicial training requirements.
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There are three Texas entities that provide opportunities for judges and attorneys to develop expertise in adjudicating and representing juveniles involved in delinquency courts: • The Juvenile Law Section of the State Bar of Texas promotes competent and knowledgeable legal counsel. In February 2001, the Texas Supreme Court approved a Legal Specialization in Juvenile Law,157 overseen by the Juvenile Law Section of the Bar, which further enhances educational understanding of juvenile offenders for attorneys who specialize. • The Texas Municipal Courts Education Center158 provides seminars for newly appointed and elected municipal judges and attorneys. The Center’s 2009 seminars included sessions on understanding adolescent decisionmaking and juvenile reporting for court clerks.159 • The Texas College for Judicial Studies, organized by the Texas Center for the Judiciary, offers a multiyear program that expands judges’ knowledge in specialties such as family and juvenile law. The program helps judges better assess juvenile offenders.160 Several nationally recognized organizations also produce resources for judges and attorneys to improve juvenile court practices. These range from the American Bar Association’s Healthy Beginnings, Healthy Futures: A Judge’s Guide, which presents research on developmental factors like physical health, child development, attachment, infant mental health, and early care and education,161 to The National Child Traumatic Stress Network’s Helping Traumatized Children: Tips for Judges, which recognizes that a majority of children in the juvenile justice system have suffered trauma162 and gives judges information about trauma’s psychological, emotional, and behavioral consequences.163 For attorneys interviewing and assessing child clients, there is also The National Family Resiliency Center’s Attorneys Representing Children. 164 Like judicial decision-making, court practices should be based on a solid understanding of child and adolescent development. Mental health courts have proven effective in their potential to reduce recidivism among individuals with mental health disorders because of this focus on root causes of delinquency.165 Texas currently has mental health courts in six counties: Bexar, Dallas, Harris, Smith, Tarrant, and Travis. Harris County was the first to start a mental health court in 2006 with the hopes of reducing crowding in jails and state prisons while also improving public safety through lower rates of recidivism.166 The Travis County Juvenile Court is currently a participant in the Model Delinquency Court Project, established by the National Council of Juvenile and Family Court Judges, while the El Paso Juvenile Court is a former participant.167

Travis County also has a juvenile drug court that serves post-adjudicated youth, ages 13 to 17, with co-occurring mental health and substance abuse issues. The court utilizes a strength-based model that encourages accountability. This model includes weekly court reviews, intensive supervision, and efforts to address the linkages between substance abuse treatment and mental health services so juveniles can comply with probation conditions.168 The Tarrant County Juvenile Court Program utilizes a comprehensive service treatment model to meet the needs of youth beyond substance abuse treatment.169 The court addresses ways to improve a juvenile’s school performance, decision-making, self-esteem, job skills, physical health, social behaviors, and community participation through various opportunities. Tarrant County found that using this national model to assess youth comprehensively resulted in 83% of participants successfully completing the program. Among those who completed the program, 98% of them did not receive further referrals that resulted in adjudication or commitment to the TYC.170 When court officials are equipped with a good understanding of child and adolescent development, they can make decisions that both protect public safety and reduce a young person’s likelihood of reoffending. They can sanction based on the offender’s developmental stage in a way that is both proportional to the offense and shown to be effective. Sanctions of this nature can redirect a youth towards positive development and deter future delinquency, the desired public safety outcome. What Texas Can Do: • Require judges with jurisdiction over juvenile delinquency cases to complete training on child development. • Require judicial education organizations to use promising practices and provide training related to child development and juvenile delinquency. • Ensure mandated training requirements are met by requiring judges to report annually to their respective chief justices what trainings they attend. • Expand availability of juvenile mental health and drug courts. What You Can Do: • Let your legislators know you support increased judicial education for judges hearing delinquency cases.

To access detailed source information for this section of the report, visit txchildren/Report/Juvenile-Justice 70

Acknowledgements
Managing editor
Christine Sinatra Eileen Garcia Jodie Smith

Chief executive officer and editor Project Director Authors
Child Protection Christen Miller Family Financial Security Christen Miller Child and Maternal Health Christen Miller Christine Sinatra Jodie Smith Children’s Mental Wellbeing Josette Saxton Juvenile Justice Christen Miller Josette Saxton Jodie Smith

Made possible in part by Methodist Healthcare Ministries, the Eleanor Butt Crook Foundation, and the Shield-Ayres Foundation.

Special thanks:
• Amanda Broden, Taylor Coffey, Sherri Hammack, and Michelle Long, Texas Health and Human Services Commission • Jim Conditt, Kelly Gorham, and Mark Mason, Texas Department of State Health Services • Nancy Arrigona, Linda Brooke, Erin Espinosa, and John Posey, Texas Juvenile Probation Commission • Liz Kromrei, Michael Martinez, Katie Renner Olse, Beverly Ross, Anne Strauser, and Gaye Vopat, Texas Department of Family and Protective Services • Don Baylor, Anne Dunkelberg, and Celia Hagert, Center for Public Policy Priorities • Anne Olson and Stephen Reeves, Christian Life Commission of the Baptist General Convention of Texas • Clynita J. Grafenreed, Region 4 Education Service Center • Carrie Kroll, Texas Pediatric Society • Molly Lopez, University of Texas at Austin • Bee Moorhead, Texas Impact • Steve Murdock, Rice University • Marissa L. Rathbone, Texas Education Agency • Arloc Sherman, Center on Budget and Policy Priorities • Joanna Shoffner Scott, Voices for America’s Children • Kelly Wilson, Texas State University • Coalition and board of directors members of Texans Care for Children, as well as the members of the Texas CHIP Coalition, the Infant Health Alliance, the Children’s Mental Health Forum, Texas Juvenile Justice Roundtable, Partnership for a Healthy Texas, Partners in Child Protection Reform, and the Poverty and Economic Security Roundtable • Allison Daskam, Ellen Balthazar, Elaine Shen, and the families and children of Any Baby Can Austin for making possible many of the photographs of Texas children that appear in this publication • The late Phil Strickland, whose vision has led to the many efforts and successes of Texans Care for Children

Project Coordinator
Nicole Trinh

research Support
Lauren Dimitry Lauren Rose

Graphic Design

Tribe Creative Agency

Acknowledgements

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To get detailed source information and access to online research referenced in this report, go to www.txchildren.org/Report

Texans Care for Children is a 501(c)(3) nonprofit organization and the leader in policy advances for Texas children. Texans Care works to promote the wellbeing of children in Texas in the areas of child and maternal health, child protection, family financial security, children’s mental health, and juvenile justice. With members statewide, the organization is a nonpartisan voice for children, a source on children, and a network for people who put kids first. Texans Care for Children gratefully acknowledges Methodist Healthcare Ministries of South Texas, Inc., for their financial support of this publication. The opinions expressed in this document are those of Texans Care and do not necessarily reflect the views of MHM.

Methodist Healthcare Ministries (MHM) is a faith-based 501(c)(3), not-for-profit organization whose mission is “Serving Humanity to Honor God” by improving the physical, mental and spiritual health of those least served throughout the Southwest Conference area of the United Methodist Church. MHM partners with other organizations that are also fulfilling the needs of the underserved in local communities. It supports policy advocacy and programs that promote wholeness of body, mind and spirit. MHM is one-half owner of the Methodist Healthcare System—the largest healthcare system in South Texas.

THE LEADER IN POLICy ADvANCES FOR TEXAS CHILDREN
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