Response—The Demise of MED’s Child and Family Program



Here is another contribution to the discussion thread on support for Foreign Service children with special needs that began with the Speaking Out by Kathi Silva in March (“Families with Special Needs Kids Need Support”).

The May FSJ contained a response from Dr. Charles Rosenfarb, medical director of State’s Bureau of Medical Services (“Our Commitment to Foreign Service Families”). Letters in the April, May and July-August editions added to the conversation.

The Child and Family Program within the Bureau of Medical Services’ Mental Health program was constituted in 2013, when the full team was finally in place after years of planning. I was brought onto the team as one of two child psychologists. By March, we had on board a child psychiatrist director, two child psychologists and three clinical social workers who had experience in treating and managing the needs of children and adolescents.

I was on the ground floor of this program, and our mission was both exciting and challenging. This was the first extensive effort within the State Department to support the specific mental health and developmental needs of children, adolescents and their families living abroad.

We were to bring the various child welfare activities under one roof, allowing for a continuum of care for children and adolescents and their families. This meant that child mental health clearances, administration of the Special Needs Education Allowance (known as SNEA) and child medical evacuations for mental health reasons would be managed as a seamless activity. In addition, a new range of services was to be offered.

We were provided telemedicine units and were charged with developing a telemedicine program offering clinical support to the medical providers around the world in U.S. missions. Because the mental health needs of children and adolescents are a specialty that few of MED’s providers have, the CFP was to offer guidance and support to those working “on the ground” with State Department families.

We were also to develop a program of brief mental health consultation through the use of telemedicine. This type of support has been requested by families for years and is still very much needed. This program was not only to support families, but to try to reduce the medical evacuations of children and adolescents with behavioral health problems.

The typical medical evacuation of a child or adolescent for a behavioral health problem lasts about six weeks, with evaluations and treatment taking place in the United States. And it usually involves a child or youth who has not been “on the radar” through the clearance system. In other words, the typical behavioral health medical evacuation is of a child or teen who has not previously been known to be having problems because child and teen behavioral health needs are usually not chronic and crop up because of life circumstances or trauma.

Medical evacuations are extremely disruptive for families, often requiring family separation or entire families leaving post and temporarily relocating for evaluation and treatment of the child or teen and the family. It is also very disruptive to a mission, which often must do without an employee for an extended period of time.

Further, medical evacuations are extremely expensive, when accounting for the costs of relocating and housing a child and perhaps an entire family, the evaluation costs and the treatment costs. The cost savings would occur from improved triage and brief treatment for those with conditions that can be easily resolved or supported at post.

This program was not only to support families, but to try to reduce the medical evacuations of children and adolescents with behavioral health problems.

Examples of medical evacuations prevented by telemedicine consultation while we were piloting this program include a preschooler who had toileting problems and a school-aged child who had developed school phobia. I was involved in 10 consultations in our pilot program that were mild problems being considered for medical evacuation simply because there were no local treatment options. All the children and teens improved while maintaining the family at post.

The Child and Family Program was also charged with tightening procedures in the administration of the SNEA program. The SNEA program had been inconsistently administered, and policies and procedures for SNEA had drifted from State Department rules and regulations and from the spirit of the Individuals with Disabilities Education Improvement Act of 2004 law and other disability laws on which it was based.

Many parents were upset by changes in how SNEA was administered. The new CFP worked closely with the Office of Allowances to assure adherence to the policies and procedures governing SNEA and the Foreign Affairs Manual. We scrutinized services paid for by SNEA carefully and communicated more with financial management officers. Our goal was to include all stakeholders in the process, to be more transparent and to be more consistent in decision-making.

Our hope was that in five years, a more comprehensive and robust program of support for children and families would be in place, with clear policies and procedures, so that families would find ample support from MED in taking care of the behavioral health and developmental needs of their children.

We expected growing pains, and we expected there would be a need to educate employees about how to use the various programs being developed. We expected a lot of individual work with families to link them with needed services. We expected a need to request changes to SNEA and other processes that would need upper management direction.

What we did not expect was suspicion and animosity from our State Department colleagues and many in the MED leadership. We thought everyone was on board with this new program. But we found that many MED psychiatrists, some members of the Office of Overseas Schools and some within the Family Liaison Office were prepared to torpedo the CFP from the start. I never understood the opposition to the program by members of the Office of Overseas Schools and the Family Liaison Office.

We had been told when we began that the CFP was part of a strategic initiative developed by MED and upper State Department management that was intended to consolidate support services for Foreign Service children and their parents living abroad: the SNEA process, the child educational clearance and child mental health clearance process, and the medical evacuation process for children and teens.

By 2015, three of the psychiatrists who were opposed to the CFP functioning as a comprehensive support program ended up having leadership roles in MED. Dr. Stephen Young took over as the director of mental health. Dr. Kathy Gallardo took over as deputy director of mental health, and Dr. Aleen Grabow was brought in as a child psychiatric consultant. Together, they worked toward limiting the scope of the CFP, limiting the SNEA program and reducing the opportunities for families with disabled children through more restrictive use of child mental health clearances.

Within a year of their tenure in leadership, we lost our child psychiatrist director, the two child psychologists and one clinical social worker. I and the other providers left because Drs. Young and Gallardo changed the mission and scope of the CFP. It became an unpleasant place in which to work, with the emphasis being on clearances and restricting access to SNEA. Support for families was no longer the focus. Rather, support services were being cut and the clearance process was being used to restrict the opportunities of those with disabled children.

The program is now a skeleton of what it was previously, with only one social worker, one child psychologist and one retired Foreign Service psychiatrist. Telemedicine is forbidden. The program now basically performs an administrative function, processing clearances and SNEA requests.

This was a very sad, missed opportunity for the Department of State to support their employees with families abroad. I hope for the sake of State Department families that the idea of the Child and Family Program can be revived. But, if so, it will need fullthroated support from upper management so that it cannot be subverted by those with a different agenda.

James Brush, Ph.D., is a child and adolescent psychologist in private practice in Washington, D.C. He worked at the State Department as a child psychologist with the Child and Family Program division of MED Mental Health from January 2013 through March 2016. Prior to his work at State, he had a private practice in Cincinnati, Ohio, for 26 years. A past president of the Ohio Psychological Association, he continues to be involved as a committee chair.