Psychotropic Medications pp. 1–3

NICWA Testimony to ACF pp. 4–5

Keeping Families Whole p. 6

Cotter Q & A p. 7

Medicaid as Payer Source pp. 8–10

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For many years, social service providers, clinicians, and courts have struggled with the issue of whether to use psychotropic medications in the treatment of trauma and other psychiatric disorders. Mental health disorders and the subsequent treatment of them often involve Native American foster children. These child care situations can be volatile because the children are often fostered out to non-Native individuals and are separated from their Native communities and relatives. In addition, many of these same children are experiencing the impacts of abuse—emotional, physical, sexual, and psychological. Tribal people have known for years that separating a Native child from her or his community is a significant issue. Yet, tragically, often the first response to this issue is the administering psychotropic medications to countless Native children.

Dr. Art Martinez (Chumash), a member of the National Advisory Council for the National Resource Center for Tribes (NRC4Tribes) explains, “These foster

by Barbara Sorensen

experiences are compounded by issues of historical trauma and cultural intolerance. The relatively unsupervised medication of children is being addressed by the joint efforts of NRC4Tribes and the Children’s Bureau.”

Under the leadership of Kathy Deserly and Martinez, groups of experts, including Indian child welfare providers, are convening to discuss the best way to educate government entities about the importance of addressing the over-medication of Native foster children. Martinez believes that by working together, these organizations can assist tribes in developing procedures, protocols, and processes which will allow time for thoughtful consideration before the indiscriminate dispensation of psychotropic medications to tribal children can

Mitigating the Use of Psychotropic Medications for Native children in Foster Care

Dr. Art Martinez

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Fall 2013

Pathways Practice Digest is published by theNational Indian Child Welfare Association, Inc. Terry L. CrossNICWA Executive Director

Nicole AdamsEditor Barbara Sorensen, Contributor

National Indian Child Welfare Association, Inc.5100 SW Macadam Avenue, Suite 300Portland, OR 97239Nonprofit rates are paid at Portland, OR.Published quarterly. Submissions and Back IssuesSubmissions are accepted. As long as back issues are available, they may be ordered for $4 each, plus S/H. Quantities of 10 or more are $2 each, plus S/H. To make submissions or order reprints, contact Nicole Adams, editor, at (503) 222-4044 x133, or at nicole@nicwa.org.

PolicyInformation in the articles and opinions expressed do not necessarily reflect the policy or opinions of NICWA.

Continued on next page

of instructing tribal governments and communities how to seek out and gather resources. “Tribal governments need to be committed and consistent in developing a process whereby tribal courts, tribal child welfare systems, and tribal social services are working in tandem to enforce meaningful input whenever there is consideration about administering medication to tribal children,” Martinez emphasizes.

Far too often, recommendations to medicate children are made without proper resources, training, and allowance of time. Furthermore, the court system itself is not educated on the complexity of issues surrounding different medications, which invariably leads to inept decision-making. “This is a national problem recognized at many levels,” says Martinez, “and NRC4Tribes has stepped forward to assist in developing the infrastructure of training and technical assistance available to county and state workers through the state system. Yet, all of this education needs to be made available to tribal services and courts.”

NRC4Tribes is creating a platform for empowering tribes to assert

their authority in court decisions that advocate psychotropic medication of children. The platform’s focus is to develop a cohort comprised of family, elders, and community care experts who could address the courts to advocate for deliberate and careful medication management considerations when a decision involves tribal children in placement. Martinez explains that, “NRC4Tribes envisions doing this work in a tribally and culturally specific manner, using the best resources available to the tribe, mentoring the processes of the local of tribal child care providers, and eliciting the wisdom of our of tribal traditions.

“While medications at times are necessary,” says Martinez, “we find that children are placed on psychotropic medications without a clear plan for how [the trauma they have experienced] will be addressed or treated and even if a culturally based healing process would be allowed.” It has been Martinez’s experience that the courts generally react to the symptoms of childhood trauma by medicating rather than re-mediating. The use of psychotropic medications is highly controversial even among medical

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be executed. The new model of restraint would affect children within the jurisdiction of state and tribal courts.

Martinez notes that, “The importance of this work is clear in our Native communities. Far too many times psychotropic medications are administered in an effort to mask symptoms that are psychological cries for help from our children. Many times the issues of both mental health and familial care are lost in an effort to subdue the symptoms that the child is experiencing. However, we were taught by our ancestors that it is more important to give thoughtful consideration, care, and treatment to the long-term effects of traumatic experiences.”

In other words, medications really only offer a quick-fix, or “band aid” to an otherwise complex situation. Committed to renewing their cultural values, NRC4Tribes has begun the monumental work

“Far too many times psychotropic medications are administered in an effort to mask symptoms that are psychological cries for help from our children...However, we were taught by our ancestors that it is more important to give thoughtful consideration, care and treatment to the long-term effects of traumatic experiences.”

—Dr. Art Martinez

The platform’s focus is to develop a cohort comprised of family, elders, and community care experts who could address the courts to advocate for deliberate and careful medication management considerations when a decision involves tribal children in placement.

PATHWAYS FALL 2013P A G E 3

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personnel. Martinez believes that, “Some people who are prescribed medications in a crisis end up being burdened with negative long-term or lifetime side effects of these medications.”

NRC4Tribes is committed to training and informing tribal jurisdictions and communities about best practice and culturally-based resources for bringing about healing in the heart of the child. “This would answer the hopes and prayers of our families and elders for treatment which could lead to the elimination of the need for medications,” says Martinez.

To this end, NRC4Tribes has identified four components necessary to achieving this goal: • Competent case management

and social services,

• Support and involvement of the tribal court when necessary,

• Treatment of the family system, and

• Therapy for the child

Therapy for the child and his or her family therapy involves important areas of cultural participation and healing. Martinez is adamant when he says, “NRC4Tribes is here primarily to inform tribes and offer

resources to tribes about training and community development which will allow us to focus upon the needs of our children rather than the distancing efforts of judicial policies and procedures. [By addressing the four identified areas of concern], we hope to bring meaning to the concerns of our elders, to protect our children and the hope of a strong tribal future.”

Why Join?NICWA is dedicated to providing its members with access to information, people, and resources to facilitate their work in the field and build a national network of Indian child welfare advocates.

NICWA MEMBERSHIP

You should become a member if:

• You are an Indian child welfare professional or a tribe, organization, or agency serving AI/AN children and families

• You believe culturally-competent, community-based services should be standard practice

• NICWA is voicing the challenges facing your Indian child welfare program and championing your interests through national advocacy

• Your personal ethics align with NICWA’s dedication to the well-being of AI/AN children and families

• You want to play a role in how NICWA evolves as an organization and works to meet its mission

For more information or to join oniline, please visitwww.nicwa.org/membership

PATHWAYS FALL 2013 P A G E 4

“ACF can ensure that AI/AN children and families receive the most culturally appropriate and effective services, thus ensuring bet-ter outcomes for children by supporting and empower-ing tribes and tribal govern-ments directly.”

—From NICWA’s Testimony to the Administration for

Children and FamiliesJuly 2013

At the Administration for Child and Families’ tribal consultation that was held in early July, the National Indian Child Welfare Association provided testimony and recommendations that specifically addressed policy and budgetary con-cerns that affect American Indian and Alaska Native families. Excerpts are below. The full testimony, which provides much greater explanation, can be found at www.nicwa.org/government/.

One of the most fundamental rights and responsibilities of a sovereign is to protect and serve citizen children and families, so the issues addressed by ACF programs are critical to tribal governments’ ability to ensure the well-being of their communities.

Unfortunately, when it comes to tribal governments’ social service provision, most tribal governments have to do more with less. This is because the historic treatment of tribes and American Indian and Alaska Native (AI/AN)people has left tribal communities with social problems at rates beyond that seen in other American communities and because federal programs, like those overseen by ACF, are not authorized to provide funding at rates that match the need of communities and the federal government’s trust responsibility. While there has been progress in the last 20 years in increasing the overall access for tribes to ACF programs there is still more to do to ensure that tribal governments have the same access to funding that is more closely aligned to the actual need, thus fulfilling the federal trust relationship.

Although funding is the largest barrier to service provision in tribal communities, the ability of agencies and de-partments to work effectively with tribal governments can also be a challenge for tribal service provision. When tribal governments are supported and able to participate in federal programs in a meaningful way, the results can be very positive, sometimes surpassing those achieved by states. These achievements pay big dividends for the communities’ well-being and reduce the need for future outlays of federal and tribal funds in more crisis-oriented and expensive interventions.

Self-determination recognizes that tribes are best equipped to identify, understand, and effectively respond to the needs of their members. ACF can ensure that AI/AN children and families receive the most culturally appro-priate and effective services, thus ensuring better outcomes for children by supporting and empowering tribes and tribal governments directly. Where tribes have been allowed to operate programs directly, both states and tribes have benefited—in terms of improved outcomes for tribal children and improved tribal-state relations.

In accordance with these comments, please find below the National Indian Child Welfare Association’s recommendations for ACF at this tribal consultation.

Policy Recommendations

ICWA Implementation1. We recommend that when ACF becomes aware of ICWA non-compliance, it should provide clear action steps in conjunction with formal performance improvement plans to assist states. ACF should work with tribal governments and national Indian organi-zations with ICWA and tribal child welfare expertise to enhance technical assistance and training to states.

2. Efforts should be made to enhance data collection by ACF on issues pertaining to ICWA compliance. ACF should work with tribes to improve program instructions and internal administrative procedures regarding state ICWA compliance.

NICWA Offers Recommendations in Testimony to Administration for Children and Families

PATHWAYS FALL 2013P A G E 5

At the Administration for Child and Families’ tribal consultation that was held in early July, the National Indian Child Welfare Association provided testimony and recommendations that specifically addressed policy and budgetary con-cerns that affect American Indian and Alaska Native families. Excerpts are below. The full testimony, which provides much greater explanation, can be found at www.nicwa.org/government/.

NICWA Offers Recommendations in Testimony to Administration for Children and Families

3. As ACF begins their analysis of the recent U.S. Supreme Court decision in Adoptive Couple v. Baby Girl they should work closely with legal experts from Indian Country to help supplement their analysis and response.

Tribal Liaison and Political Appointment 1. We recommend that ACF reestablish a political appointment to the position of associate commissioner over-seeing the Children’s Bureau, and ensure that this appointment will possess experience with tribal child welfare services and programs.

2. We recommend that ACF establish tribal liaison positions within each ACF agency and be housed in both the central and regional offices. We recommend that ACF use an Indian hiring preference to ensure people with experience in the provision targeted program in tribal communities are hired for these positions. These tribal liaison positions should be given the authority necessary to meaningfully influence program and policy develop-ment.

Tribal-State Collaboration EffortsSeveral statutes under the Social Security Act contain requirements for states to collaborate, consult ,or pro-vide good faith efforts to tribes regarding state implementation of federal child welfare programs. ACF should enhance their efforts to monitor and facilitate state efforts to improve collaboration between tribes and states to ensure equitable participation in federal programs.

102-477 ProgramWe recommend that ACF ensure that the original intent of PL 102-477 is fulfilled by acknowledging the excep-tions to reporting allowed under the statute, finalize the reporting documents with the tribal representative rec-ommendations, and begin accepting applications of new tribes and tribal plans into the 477 Program.

Commission to Eliminate Child Abuse FatalitiesWe recommend that ACF work with DHHS leadership to identify two tribal representatives to recommend to the Whitehouse for appointment as part of the six appointees the Administration will choose for this commission.

Budgetary Recommendations

Title IV-B, Subpart 2, Promoting Safe and Stable FamiliesWe recommend that ACF request an increase in funding from the current amount of $63 million to $75 million under the discretionary portion of this program.

Community Services Block GrantWe recommend that ACF oppose the proposed cuts to the program and request the program be enacted at full FY 2013 levels, leaving the funding structure as a block, non-competitive grant.

Head StartWe recommend that ACF support the Administration’s request for FY 2014 (FY 2013 $225.3 million—FY 2014 request $229.4 million).

President’s Foster Care Reform InitiativeConsult with tribal governments to discuss how the Administration’s proposal might impact tribal communities, families, and children and recommendations on how to address tribal needs within the Administration’s proposal.

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In order to better assist Tlingit and Haida families in Alaska to create and sustain safe environments for their children, a unique, col-laborative grant was drafted and implemented. The grant acts as a bridge between each tribal child welfare program and temporary as-sistance for needy families (TANF) programs.

The focus of the grant is on a prevention and early intervention services model which is currently being used by the Central Council Tlingit and Haida Indian Tribes of Alaska (CCTHITA). Using a collab-orative, cross-referencing system, families are screened when they apply for TANF benefits. The fami-lies that demonstrate the greatest risk of child abuse/neglect are of-fered short-term, intensive preven-tion services.

When needy families come in to be screened for TANF eligibility, they are screened for either a low, moderate, high, or very high risk likelihood of parental negligence. If the assessment indicates the possibility of child abuse or ne-glect, the families are then referred to the Preserving Native Families Program (PNF). This program was implemented to ensure that a proactive intervention approach is taken. The program includes an in-home management method of intervention.

Rather than a “one-size-fits-all” ap-proach, the PNF case worker who would be assigned to a particular high-risk family works directly and closely with the family and indi-vidualizes their prevention services

case plan. The indi-vidualized plan ad-dresses each family’s strength as well as their weaknesses to focus on discovering the underlying familial difficulties.

The plan takes place over a 90-day period of time, after which time a reassess-ment is conducted. This reassessment is conducted by a TANF case man-ager and engages both the family members and the PNF worker. The reassessment does not dwell on the negative aspects of the 90-day period, but rather focuses on the positive progress the family has made in accomplishing the goals to which they originally committed.

Brenda Chapman (Tlingit) and Pam Credo Hayes conduct the screening assessment and advise any referrals to PNF. TANF staff members are responsible for the reassessment that is done at that the conclusion of the 90-day pe-riod. Both of them recently spoke at the NICWA conference, along with Jennifer Cotter, who acts as

an independent outside contractor. Jennifer works with CCTHITA to assist with fulfilling the assessment model and to offer continual techni-cal expertise.

The intention of this collaborative effort is to be able to identify and intervene in a positive manner before families are hurt or split apart. The outcomes are invaluable and include empowerment to tribal people and recognition of what works best for the adults and chil-dren. Of equal importance is that the tribes are receiving the most trustworthy and up-to-date assess-ment methods.

Cotter adds, “The hope is that a cross-system approach to preven-tion, with services provided by the tribe, will better serve families and begin to impact the demographics of Alaska’s child protection sys-tem. The care and commitment of CCTHITA’s services providers tells me that their families will benefit from this collaboration.”

The intention of this collaborative effort is to be able to identify and intervene in a positive manner be-fore families are hurt or split apart.

by Barbara Sorensen

Keeping Families Whole: Alaska’s Preserving Native Families Program

PATHWAYS FALL 2013P A G E 7

“Prevention Is an Important Focus”: A Q & A with Jennifer CotterWhat is the connection between employment assistance and fam-ily services?

Although child maltreatment preven-tion and employment assistance are often thought of as separate concerns, evidence suggests that they are closely linked. Many of the barriers to successful parenting—for example, substance abuse, mental health issues, and domestic vio-lence—are also barriers to successful employment. More than half of all TANF clients experience multiple barriers to employment. The more barriers clients face, the less likely they are to be employed and meet TANF participation requirements. A program that successfully addresses these barriers may simultaneously improve multiple outcomes for parenting, participa-tion, and employment.

Why are we focusing on families at risk for child maltreatment?

Research shows that TANF applicants are involved in child protective services (CPS) more often than the average family. For example, a recent study showed that 38% of TANF applicants were investigated for child maltreatment in the three to four years after receiving assistance. Prevention is an important focus because child maltreatment can result in cognitive and psychological impairments that can become permanent. The costs of targeted prevention programs are less than the direct costs of medical care, social services to fami-lies, law enforcement, and court action associated with child maltreatment.

Prevention programs that use structured assessments to target at-risk families, identify family needs, and develop individualized service plans are more likely to be effective. This research forms the basis of the Family Prevention Services program.

Why do TANF case managers have to do so much for the Family Prevention Services program?

TANF case managers are crucial to the process because they screen participants, allowing agencies to quickly identify applicants who can benefit from Family Prevention Services. Screening occurs during the initial meet-ing between the TANF case manager and the family because much of the information needed to complete the assessment is already being gathered in order to determine the family’s eligibility for other services and ben-efits.

TANF case managers are often the clients’ first and primary contact with TANF, and the first impression they make influences clients’ expectations. A productive first meeting can help the rest of the services come togeth-er.

Every TANF-eligible family without current child protection activity should be engaged in the screening pro-cess. Although the primary goal of the program is to prevent child maltreatment, the services provided can also help families remove obstacles to successful employment and full TANF participation. High and very high risk families can benefit from prevention services in areas of their life beyond family functioning and are prioritized for prevention services.

Photo courtesy of the Central Council of Tligit and Haida Indian Tribes of Alaska

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“The right person engaged in the right activity”In order for services to be Medicaid-eligible and there-fore billable, they need to be medically necessary, performed by a billable provider, and appropriately documented. Dan Aune, who as president of Aune Associates Consulting, has worked with many tribal communities, elaborates, “The key feature is provid-ing services to kids who have some kind of diagnosis. Medicaid wants there to be a medical necessity to the activity, so there has to be a diagnosis and a treat-ment course for it.”

Additionally, tribal programs that have accessed Medicaid for cultural services share one common trait: each carefully built a team approach to service deliv-ery. For many, this team was comprised of a licensed therapist, a cultural expert, and someone familiar with the Medicaid billing process. Aune explains, “Medicaid, as a payer source, requires that you have the right person engaged in the right activity. Having the person who’s licensed doing the therapeutic piece is what makes it a billable event.”

Stacy Rasmus, PhD, an assistant research professor at the University of Alaska Fairbanks, built just such a team when working with a community in Alaska. She states, “There was an elder counselor, a behavioral health aide, and a family advocate that would collec-tively do wraparound with each client. The behavioral health aide was doing assessments, treatment plan-ning, and service delivery [the Medicaid-billable com-ponents]. The family advocate was doing the case management and social work. The elder counselor was providing the traditional and spiritual healing. We would all work with the client and family to identify the needs of the child.”

“I can conduct psychotherapy sitting on the ice”Tribes have also made innovative use of Medicaid’s flexibility. Rasmus says, “Reading the Medicaid regu-lations, it’s clear there’s flexibility regarding where healing, therapy, and therapeutic practices can take place.” Rasmus was able to have a clinic fish net set out on the ice. She and the behavioral health aide would conduct assessments on the walks to and from it with youth. “The fact is that I can conduct psycho-therapy sitting in a chair or sitting on the ice,” she states. “Therapy is so context-dependent. You could

very naturally run a psychotherapy session while go-ing to check fishing nets or picking berries.”

Rasmus points out that conducting therapy outside of an office setting while employing hands-on activities is similar to other therapeutic techniques such as art therapy, which have long been accepted.

For young Native men who were struggling through a community-wide suicide epidemic, this approach resonated. “Most of the time, they needed to con-nect more with the land and animals as part of putting together a stronger identity,” Rasmus explains. “In establishing an integrated approach, we were doing subsistent activities, but we also emphasized that it wasn’t just about catching a fish or setting a net or making a spear. We made these connections really explicit: how making a spear and catching a fish di-rectly addresses the issues this young man is dealing with in his own life and heart.”

Aune indicates that these types of events are billable as long as the person who is licensed and the cultural expert work together. In his work with the Blackfeet equine therapy program, equine therapy-trained staff-ers worked together with a licensed therapist “who would meet with the group of kids so that a psycho-therapeutic process was going on along with the

How Medicaid Can Serve as a Funding Mechanism for Cultural and Traditional Behavioral Health

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Because psychotherapy is so context-dependent, it can be conducted dur-ing tranditional subsistence activities.

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cultural activities.”

At Pascua Yaqui, incorporating cultural elements into behavioral health services extends beyond its equine therapy program. Dennis Noonan, project director of the Sewa Uusim program, elaborates, “When-ever possible, we do it in the mental health counsel-ing, group counseling, and family therapy available through the clinical direct services.”

“We don’t know enough about it, and so we can’t”Using a team-based approach that taps the cultural expertise of a Native community and embeds tradi-tional healing, subsistence, and other cultural activi-ties into children’s mental health treatment plans encourages the development of community-based, culturally appropriate wraparound systems. At the same time, one of the more pressing challenges in accessing Medicaid as a funding source is finding someone who is well-versed in Medicaid billing and can ensure a program meets eligibility requirements and complies with other regulations.

Navigating Medicaid’s billing system is complex due in very large part to the fact that each state operates Medicaid differently. At Pascua Yaqui, Noonan says, “We work with the state system. We put staff in place here that understand the state Medicaid system.”

Building capacity also extends to developing more

members of a tribal workforce who are licensed and trained in Medicaid systems over time. In the short term, Noonan suggests, “If you don’t have it within your tribal community, you have to get creative. Sometimes there are retired people who can help give you some ideas and expertise on how to move through the system.”

Indeed, the complexity of Medicaid’s billing system is not for the faint of heart. Often confusion regard-ing what is required to bill for traditional and cultural practices results in inaction. “It takes a really special knowledge of both worlds, and that is hard to find,” Rasmus explains. “You have hesitancy of tribal lead-ership, even those who are really knowledgeable of their own tribal-based healing approaches. Because they are less knowledgeable in state Medicaid regula-tions, they think they can’t bill for tribal healing ser-vices. Then on the other side, you have behavioral health directors, who are often not Native. They are very competent and knowledgeable of the Medicaid billing system but come with a more limited knowl-edge about tribal healing. They have no idea how to integrate the two. People think, ‘We don’t know enough about it, and so we can’t.’”

“It’s a huge win”And yet those who have embraced Medicaid as a payer source for cultural and traditional services over-whelmingly tout its potential to serve as a significant

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Tribes have successfully billed elements of equine therapy programs to Medicaid.

revenue stream for children’s behavioral health programming. According to Aune, “Medicaid is a completely untapped source of funding. This is part of my excitement for working with tribes to get them to develop their own systems. They’re going to get paid much better than at any state rate.”

In Noonan’s equine therapy program, “You do a lot of group work that can be structured to be group therapy. By billing Medicaid for group therapy, you can help offset some of the costs of individual therapy, which is also part of the program. Between this and leveraging tribal support, if we structure our program creatively, we can sustain our entire equine therapy program through billing. This is saying a lot. Equine therapy is much more expensive than other types of therapy.”

Furthermore, with increased numbers of AI/ANs becoming Medicaid-eligible in 2014, Aune sees great potential to increase behavioral health revenue and services in tribal communities. He explains, “A lot of tribal commu-nities depend on IHS services where there is one pot of money for behavioral health care in any given year. They almost always run out. If more eligible people get enrolled in Medicaid, IHS doesn’t have to use that pot of money because Medicaid is the ‘first payer,’ and the IHS dollars are the ‘second payer.’ You’ve added a whole lot more health care dollars into the community with Medicaid. It’s a huge win.”

“Why aren’t more Native tribes and corporations doing this?”Creating such community-based outreach models is exactly what many SOC communities intend to do. In the Alaska program where Rasmus worked, “We wanted to give tribes the ability to effectively treat their own people. By establishing more culturally based modalities for intervention, we were trying to figure out a way to make [Western and non-Western] worldviews comes together, for care to be truly integrated. It truly is a system of care when services are integrated. I thought this approach was really innovative. You wonder, ‘Why aren’t more Native tribes and corporations doing this?’”

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