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Support for this story came from the USC Annenberg Center for Health Journalism’s 2024 Data Fellowship and The Carter Center.

Reporting highlights

Locked up: West Virginia still sends kids with physical or emotional disabilities to group homes and treatment centers at a rate three times the national average, according to the most recent data available. 

Undiagnosed: After the federal government began investigating West Virginia’s treatment of foster kids with disabilities, the state started screening a much smaller percentage of kids for these conditions, data shows. 

Failed solutions: The state has touted new programs to help send fewer kids to these facilities, but those kids still aren’t getting sufficient mental health care.

By the time Sadie Kendall turned 18 and aged out of West Virginia’s foster care system, she had lived in more than two dozen places. There was her mother’s house in Mineral County, where she lived until the state took her away after discovering her mom’s substance abuse. There were foster homes, and a revolving door of parents who ultimately couldn’t or didn’t want to keep her. There was shelter after shelter, short-term spots where Sadie waited for something better. 

And there were the treatment centers, a series of in-patient hospitals the state started sending her to when she was only eight. The first one — Southwood in Pittsburgh — is fuzzy in her memory. She knows there were other kids, some of whom were scary to her. She remembers being restrained, and nurses giving her shots in the butt. And she can still taste the psychiatric medications. She was too young to swallow pills, so nurses fed them to her crushed up in peanut butter. They made her sleep all day. 

“I was sedated most of the time, pretty much,” Sadie, now 27, recalled.

It didn’t help. There were outbursts, tantrums and repeated attempts to run away. Sadie missed her mom and was confused about why they weren’t all together. Time and time again, West Virginia sent her to short-term homes where she struggled to get adequate mental health care and form permanent relationships. 

“I think I just had a lot of trauma in my life, and I just needed somebody to care for me how you’re supposed to care for a child,” she said. 

Listen to Sadie Kendall discuss her experience.
Photo by Duncan Slade/Mountain State Spotlight

By the time Sadie turned 18 and left the state’s care in 2015, the U.S. Department of Justice had concluded West Virginia was over-relying on these types of group facilities and treatment centers. This “systemic failure,” officials wrote in their findings, violated kids’ rights under the Americans with Disabilities Act and “places children with mental health conditions who currently live in the community at risk of unnecessary institutionalization.” In 2019, West Virginia and the DOJ agreed to a plan to fix the issues. But several months later, there hadn’t been enough action for the state to avoid a lawsuit over the issue. 

And even now, more than five years later, West Virginia is still failing to meet the mental health needs of kids like Sadie, a Mountain State Spotlight investigation has found.

Undoubtedly, there are some foster kids who need in-patient mental health care and benefit from short-term intensive treatment. But in a system where by definition almost every child in it has either experienced trauma or neglect, West Virginia officials have fallen short of helping kids get access to therapy while they live with families in communities. 

Despite early gains reducing the overall number of kids in group homes and institutions, kids with any kind of physical or mental disability were still institutionalized at a rate more than three times the national average as recently as 2022, according to an analysis of the data West Virginia submits to the federal government. The state’s Department of Human Services still doesn’t have an adequate number of social workers to investigate child abuse cases and help find homes for foster kids; this in turn means untenable case loads that leave kids in care and foster families without adequate mental health care and necessary supports. 

And though the state has trumpeted increased enrollment in a new program to help kids access mental health care in their communities, in practice it has fallen short of giving biological, adoptive and foster parents and kids the support they need to keep kids safe and healthy at home.

Over the last two months, Mountain State Spotlight has shared findings of our reporting with state human services officials. A spokesperson initially responded, referring us to previous agency press releases. We then sent the agency a long list of our questions, but received no response.

For kids like Sadie, hard to place because of behavioral issues, it may seem like there are few good options. But sending vulnerable children to residential facilities, including group homes, shelters and in-patient treatment centers, can end up doing more harm than good, according to warnings from years of research.

“Sending children to live together among other children who have behavior problems, we have good evidence, makes them worse,” said Mary Dozier, the Amy E. du Pont Chair in Child Development at the University of Delaware.

That’s what happened to Sadie, who spent her early adulthood struggling to piece together a life after her years in state custody. 

“It never got better,” Sadie said. “It was always just the same shit over and over again.” 

Kids Still Being Institutionalized 

The system’s problems are deep, entrenched, and intertwined. But there are two points that can’t be ignored: mental health care is hard to access for many West Virginians, and there is a dire need for quality care among foster kids.

Most kids enter the foster care system because they are either abused or neglected, both of which can cause lasting mental health problems. Nearly half of the West Virginia kids who spent time in foster care from 2012-2022, were there at least in part because of a parent’s substance use. One-third of all foster kids were neglected, nearly one-fifth were exhibiting some sort of behavioral problem and one in six were physically or sexually abused.

And of course, all of them had experienced the trauma of being taken away from their families. While the goal of the state’s foster care system is to reunify kids with their biological parents, that’s not always possible. In those cases, West Virginia is their guardian on paper, tasked with making sure their needs are met and that they’re able to eventually leave the system as productive adults.

But all this is happening in a state where access to mental health care is a struggle. Only six of West Virginia’s 55 counties exceed the very low target adopted by the World Health Organization of one psychiatrist per 10,000 people. Thirty-five counties have no psychiatrist or addiction medicine specialist. None of the state’s public school districts met the recommended ratio of one psychologist for every 500 kids during the 2023-24 school year.

The result has been the state sending many kids with mental health needs to in-patient hospitals and residential facilities. In 2014, the rate of kids living in these kinds of residential treatment facilities was so high, it kicked off the DOJ investigation that concluded West Virginia had built its entire child welfare mental health system around these segregated facilities. 

“The system is killing a lot of children who remain alive but who have just been so devastated by the circumstances that they encounter that they’re effectively destroyed.”

marcia lowry, executive director, a better childhood

It’s a system that Orion Flynn knows well. He was only 10 when he spent his first long-term stint in a psychiatric hospital. At that point, he had been through a lot in his short life — taken away from his parents as his mother struggled with substance use and his father repeatedly robbed the bank down the street. 

This led to behavioral issues. Orion says he “was a child who didn’t know what was going on, throwing a tantrum, yelling, slamming a door, that sort of thing,” he recalled. “And it would sometimes get me sent to actual in-patient psychiatric hospitals.” 

Orion Flynn has aged out of the state’s custody, but as a foster child, he spent time in several different in-patient treatment centers. Photo courtesy Orion Flynn.

That first hospitalization at Charleston’s Highland Hospital lasted a year. Orion is 19 now, and still remembers the types of restraints the hospital used on him. 

There was the four-point restraint, a system of wrist and ankle cuffs that held the ten-year-old child to the bed for up to four hours. Then, there was the papoose board, immobilizing Orion on the floor when he acted out.

A spokesperson for Highland Hospital noted that the facility has changed ownership since Orion was hospitalized there, but that it uses these kinds of interventions for patients’ safety and in accordance with “the latest least restrictive psychiatric intervention guidelines” and to “prioritize de-escalation.”

But for Orion, it was an experience that didn’t seem to help any of the mental health issues he was experiencing. “When I left, I think I was on 12, maybe 13 different medications, and I received mediocre therapy at best,” he said.

Listen to Orion Flynn discuss the year he spent in an in-patient psychiatric hospital as a child.

West Virginia officials have spent the last decade arguing that they’re making progress on fixing the issue. In 2015, in the wake of the DOJ investigation, then-Cabinet Secretary Karen Bowling wrote in a press release that she had already been working for two years to “turn these statistics around.”

But four years later, in 2019, disturbed by the ongoing high rates of kids in institutions, a group of foster kids sued the state, seeking more independent oversight of the system. 

“Basically what's happening is the system is killing a lot of children who remain alive but who have just been so devastated by the circumstances that they encounter that they’re effectively destroyed,” said Marcia Lowry. She is a lawyer and the executive director of A Better Childhood, a nonprofit advocacy group that is representing the foster children in the lawsuit against West Virginia. Her group has successfully sued other states over similar issues, forcing reforms to their foster care systems.

“They are just destroyed, and they continue to walk around, but when they get to be 18, there's no way that they can effectively contribute to society. Some of them survive, lots of them don't, but they're all damaged,” she said.

In response to the suit, agency officials once again argued they were in the process of making major improvements, and shrugged it off as the work of outside lawyers. 

“The issues they raise are generally those the Department has already publicly reported to the Legislature and is working to resolve with the input of the Department of Justice, our local stakeholders, the West Virginia Judicial Branch, and the West Virginia Legislature,” former Cabinet Secretary Bill Crouch said in a press release. “For an out-of-state group to sue the State of West Virginia to take over our child welfare system is offensive to the many federal, state, and community partners who have worked tirelessly to transform and improve our system.”

It’s true that since the DOJ first issued its findings, West Virginia has made some progress. 

In the years immediately following, West Virginia cut the overall percentage of kids going to group homes and institutions by half. There’s also been an effort to keep more kids closer to home, rather than sending them to out-of-state group homes and institutions, which a 2021 Mountain State Spotlight investigation found left some kids in unsafe situations. 

But while the state improved, the majority of those gains weren’t for the kids who needed it most.

Progress getting kids with disabilities out of group homes and institutions was much, much slower, according to a first-of-its-kind Mountain State Spotlight analysis of the data states submit to the federal government. In September 2022, West Virginia was still putting half of the kids with any sort of disability — physical or mental — in these types of places. That was three times the national average for similar kids with disabilities for that year.

The West Virginia Department of Human Services wouldn’t provide any more recent data about whether that has changed. But it does post monthly reports about where foster kids are living on a dedicated website. That separate state data doesn’t indicate disability status, but it does show that since the time period when the federal data ended, the state has sent even more foster kids — and a larger percentage of kids in care — to residential treatment facilities. 

Quality mental health treatment for a short period of time can help kids with some conditions. But the class action lawsuit alleges kids are being left to “languish” in these kinds of settings, where they experience additional trauma. And even in the best case scenarios, workers in these group centers, no matter how caring, are still coming and going. These situations rob kids of the key ability to form attachments, which can have life-long implications.

“If there's no primary persons who are pretty much reliably there, they're not able to form that kind of attachment, which will impact them throughout their lives,” said Carole Shauffer, the senior director of strategic initiatives at the Youth Law Center.

State’s Solutions to These Problems are Falling Short

As West Virginia grapples with trying to find appropriate homes for the increasing number of foster kids in its care, it’s under a mandate from an agreement with the federal government to offer more alternatives to in-patient psychiatric care. 

The goal is to give kids more options for mental health care in their communities, whether that’s living with their biological parents, with adoptive parents or in a foster family. 

It’s hard to say how many foster kids could benefit, because the data shows West Virginia hasn’t determined whether a large percentage of foster kids have a disability or not. 

Starting in 2016, there was a sharp jump among West Virginia foster kids who “had not yet” been diagnosed with any kind of mental or physical disability. In 2015, only 6% of kids had this undiagnosed status. The next year, as the DOJ continued to closely examine how West Virginia treated kids with diagnosed disabilities, 26% of kids were undiagnosed. Some remained that way for years, and West Virginia’s foster care agency didn’t respond to questions about why that might be.

But people familiar with the system weren’t surprised. 

“There’s a lot of things they’re supposed to do that don’t get done,” said Layne Diehl, a Martinsburg attorney who is frequently appointed to represent foster kids’ interests in court. She said often she’s had issues even tracking down kids’ basic medical records for their foster parents. 

“The way that that abuse and neglect system works, a lot of times I feel like the focus gets placed on putting resources around the parents and the kids oftentimes get left out,” she said. “You have parents who have to complete an improvement period and so they need to get a psychological evaluation, but the child’s not necessarily getting the services they need.”

And while kids entering foster care are required to be scheduled for an initial medical exam within the first several days, there’s no similar requirement for a mental health screening.

“There were times they needed a psychological that they didn't get it until they were court-ordered,” said former Child Protective Service worker Kathie Giboney, who worked for four years in the district that covers Pleasants, Doddridge and Ritchie counties.

“At some point, it breaks your heart when the system screws a child so badly you know they’re never going to be fixed.”

stacy jacques, adoptive and foster parent

Over the past 12 years, the state has rolled out program after program designed to help kids access mental health care in their communities. The list of programs has been a moving target as they change names and services over time; Safe at Home morphed into West Virginia Wraparound, for instance, and the state’s services now include a veritable alphabet soup of acronymic programs: ACT, CCBHCs, FSCs, CSED

The idea is simple: if you provide whatever mental health services a West Virginian might need in their own community, you may be able to avoid having to send them somewhere else for residential psychiatric treatment.  

For the last several years, the state has offered a special program for kids on Medicaid with serious mental health needs. It’s not just for foster kids or adoptive kids, but there is a large overlap between the two groups. 

Stacy Jacques’ son was one of the first kids to get into this program, back in 2020. Jacques adopted him from the foster care system and he had been struggling with significant mental health issues — so significant that they had posed a safety threat to Jacques and her other children and necessitated him living with another family for a while.

Jacques said this Medicaid program is the only solution the state has offered her son. “And it’s just not enough,” she said. 

Stacy Jacques with her son in 2007 on their first day together; she fostered him from infancy then eventually adopted him. Photo courtesy Stacy Jacques.

West Virginia has touted the program’s increased enrollment as a sign of its success. In a December press release, the Department of Human Services reported that nearly 4,000 children have enrolled in the program, and provider numbers have doubled since 2020 to meet the growing demand. 

But while the program has grown exponentially — between 2020 and 2023, the number of kids approved on the first try grew six-fold — the providers haven’t kept up. There are just 26 providers now, up from 22 in 2021.

The state’s own reports have highlighted the program’s shortcomings.

Since 2022, the expert hired by West Virginia to assess whether it’s complying with the state’s agreement with the DOJ has warned that the number of hours of therapy each kid is getting through the program is too low. Even when there were fewer kids enrolled in the program, the report found they were getting less than nine hours a month of services. In a recent report — from March 2024, which analyzed 2023 data — kids were only getting 10 hours a month, and half of that was staff time for administrative tasks. 

When Jacques signed her son up, she says the program promised 2-4 hours of in-home services a day. But that didn’t last for long.

“Now we’re lucky to get half an hour every week.”

She said they’ve had some amazing providers through the program, but there have been major gaps and inconsistencies. She’s been waiting four years to get access to family therapy through the program, but has been told there are no therapists available in Cabell, Kanawha or Putnam counties. Once, her son didn’t have a therapist for a year because of a lack of providers. Once, during a crisis on a Friday night, she tried to access the emergency support that’s supposed to be part of the program. The coordinator who answered the phone said she was at a party and would call back on Monday.  

“With other families that I’ve known, most have given up,” Jacques said of the program. 

Stacy Jacques and her son at “foster parent day” at the West Virginia Legislature in 2019, advocating for more adoption resources. Photo courtesy Stacy Jacques.

Now, after five years enrolled, she said assessments of her son still indicate he has severe needs, despite all that she’s done to keep him at home and improve his life.

“But the hand he was dealt before he even came to me has made it impossible to achieve those goals,” she said. “At some point it breaks your heart when the system screws a child so badly you know they’re never going to be fixed.”

Around the state, others have reported problems too. Giboney said while she saw kids get into the programs, they ended up being plagued by the same staffing shortages that are an issue among state CPS workers. “They had a worker that would come once in a while but then the worker had to either drop them, or they just didn’t have a worker because the worker quit,” she said. 

And in Martinsburg, Diehl said though the concepts behind many of the state’s programs are excellent, “the bureaucracy around it is absolutely maddening.”

She’s worked to get kids approved for the Medicaid program, but then their caseworker left the agency. Then, she has encountered the same sort of turnover among the mental health providers and the facilities. After months of calls trying to find someone else with a record of the approval, she’d reach someone only to learn the services were withdrawn because they weren’t used. 

“Right about the time you feel like you’ve got everybody on the same page, there’s a ball that’s dropped over in the corner somewhere. And everybody’s scrambling trying to find that,” she said. “It can be very, very frustrating.”

The Cycle

As West Virginia enters its second decade of trying to fix the problems in its foster care system, thousands of children have entered adulthood having spent time in group homes and institutions. In the cases of both Orion Flynn and Sadie Kendall, they were released from the state’s custody with lasting trauma, ill-prepared to thrive on their own. 

Carole Shauffer of the Youth Law Center says that moving kids from one abusive or neglectful home to another goes against the goals of the system. “I think once the state intervenes, it has an obligation to intervene in such a way as to provide you with high quality care that will enable you to thrive and become a healthy adult,” she said.

Sadie Kendall cooking dinner on a recent evening for her daughter. She loves to cook, and hopes to do it professionally someday. Photo by Duncan Slade/Mountain State Spotlight

It can be a vicious cycle, where it’s easy for former foster kids to see their own children taken away and put into the same system that defined their childhoods.

That’s what happened to Sadie. After she aged out of the system, she struggled to get back on track. She was sometimes homeless and worked low-wage jobs at Walmart and a local hotel. She moved in with her boyfriend to a house that she said was so bad, it should have been condemned. And she had two children.

“I didn’t have anything. I took care of my kids, I took care of them very well. But it wasn’t enough for the state,” she said.

After Sadie was arrested on a series of misdemeanor charges including disorderly conduct, obstructing, public intoxication, refusal to fingerprint and battery on an officer, the state intervened.

“They took them and that was it. That was it.”

To regain custody of her children, Sadie was told she could enroll in a series of parenting classes and report for regular drug tests. But she didn’t have reliable transportation to get there, and was trying to keep a job. The state had created a set of hurdles she just couldn’t clear.

“I kind of gave up,” she said sadly. 

At that point, it’s easy to see how for Sadie, the cycle might have continued. She signed away her parental rights, and her children were eventually adopted by a foster family. For many, that would be the end of the story. It wasn’t for Sadie.

She made more mistakes, trusting the wrong people and struggling with drug addiction. 

“At this point, what do I have left to lose?” she said.  

Then, she had another child. And she was determined not to repeat the mistakes she made with her older children.

Today, her daughter Zariyah is four years old. And despite Sadie’s best intentions, she’s continued to struggle to retain custody. Last year, she made a huge error in judgment when she gave an acquaintance a ride home. She got pulled over, and he had drugs on him. The state took Zariyah away. For a minute, it seemed the cycle would repeat itself again. 

But this time, Sadie knew what to do. She fought.

“They think it’s how it used to be and it’s not. I’m going to show them that I’m not just a statistic,’” she said. She hired a lawyer, she drove herself to the drug tests, she attended the classes. And several months later, she got Zariyah back. 

Now Sadie is trying again to be the mother she always wanted to be. She works part-time as a bartender; when she’s not at work, she describes her life as “Mommy mode 24/7.” She loves to cook and started culinary school this month in hopes of eventually doing it professionally. 

Sadie Kendall holds her daughter, Zariyah, who is four years old. Photo by Duncan Slade/Mountain State Spotlight

Though Sadie’s life has stabilized, she continues to bear the scars of her time in foster care. She struggles with deciding who to trust. She won’t touch prescription medication, even if she needs it. And she feels like West Virginia’s system repeatedly set her up for failure. 

“They were convinced I wasn’t going to make it,” she said. “I’m going to prove them wrong.”

Mountain State Spotlight is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering stories on mental health care access and inequities in the U.S. The partners on the collaborative include The Carter Center and newsrooms in select states across the country.

The data used in these stories, [Dataset 176, 187, 192, 200, 215, 225, 235, 239, 255 and 274, Adoption and Foster Care Analysis and Reporting System (AFCARS), Foster Care File 2012-2021], were obtained from the National Data Archive on Child Abuse and Neglect and have been used in accordance with its Terms of Use Agreement license. The Administration on Children, Youth and Families, the Children’s Bureau, the original dataset collection personnel or funding source, NDACAN, Duke University, Cornell University, and their agents or employees bear no responsibility for the analyses or interpretations presented here.

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