“Each child is a vast reservoir of potential”- An Interview with Dr. Jacqueline McKnight on Foster Care in North Carolina

Health is greater than our medical needs. It happens where we live, work and play. That is why Blue Cross and Blue Shield of North Carolina (Blue Cross NC) invests so heavily in helping our members and communities address the socioeconomic, environmental and behavioral factors that play an outsized role in shaping our health and well-being.

This work doesn’t just affect adults. When parents face barriers to safe housing, transportation, access to healthy foods and other non-clinical drivers of health, children feel the impact, directly and indirectly. These risk factors can lead to allegations of neglect as parents struggle with poverty-related concerns. When local social services offices become involved, children and their families can find themselves thrust into oversight and support from the state’s child and family services system.

As a heath care organization, we are committed to serving populations with the highest needs and at the greatest risk.  For example, many of our efforts to address drivers of health challenges converge around foster care and children, from infants to 18-year-olds. For one, we advocate for a whole-person approach to health care, which is good for parents and helps keep families intact. And, when children do enter the state’s foster care system under a judicial order, they can face significant challenges. Inconsistent access to care and delayed responses to restorative treatment that addresses their trauma leave them at higher risk of experiencing long-term negative impacts on their well-being.

Blue Cross NC works to ensure that these children and their families have access to specialized care and support that meets their specific needs – at the right time, at the right place, and through an extensive network of culturally-appropriate and responsive care and treatment providers.

More than 30,000 children and youth in North Carolina are involved in North Carolina’s foster care system, including those who were adopted from foster care. Blue Cross NC is committed to helping them overcome barriers to good health so that they can lead fulfilling lives.

I recently asked Dr. Jacqueline McKnight to share her thoughts on the most pressing issues facing these children. Dr. McKnight is the social services deputy director in Mecklenburg County, NC, and she sits as a member of Blue Cross NC’s Healthy Blue Foster Care Advisory Council.

Here is our conversation.

Dr. McKnight, you once served as the executive deputy commissioner of children’s services in New York City, and now you serve as one of the leaders of the largest social services offices in the state. From your perspective, what do you see as the most significant challenges children and their families in the foster care system typically face?

I think it’s important to start by recognizing that a child or teen in foster care isn’t defined by the challenges they face. I’d like to see our communities and culture reframe the narrative so that we focus instead on each child as a vast reservoir of potential.

But it is true that children and teens in foster care face more hurdles on their path to success. Any time a child is separated from a parent following a substantiated allegation of abuse or neglect, that is a profoundly traumatic event, often preceded and followed by other traumas. This cycle will likely have a life-long impact in some form.

 A recent report from Think of Us and The Annie E. Casey Foundation reveals the degree to which adolescents in state custody who are placed in group homes and institutionalized-care settings face unique and especially complex challenges. In many cases, teenagers are placed long distances from their home and community, losing contact with siblings and friends.

Many of these youth find themselves in challenging circumstances. They often feel as if their living environments are competitive rather than nurturing. They face more significant barriers to academic success and risk falling behind in their education. Some group homes offer minimal or inadequate behavioral and emotional services to help children and adolescents heal from their documented trauma. In some institutionalized group care settings, they may also be subject to further maltreatment.

That’s eye-opening. From Blue Cross NC’s work on improving drivers of health, we know that data show a clear relationship between childhood trauma and mental and physical health problems. That’s why we support early intervention and preventative measures, early childhood education and efforts to ensure our health care infrastructure is better equipped to deal with children at risk. It sounds like children in group homes can face a higher risk of experiencing long-term effects on their well-being.

That’s right. A child who has six or more adverse childhood experiences (ACEs) can expect to lose 20 years off their life, on average, compared to their peers who have none, according to the CDC.

Adolescents placed temporarily in these congregate care settings face very real challenges that are often difficult to see on the surface. And yet these challenges of individualized trauma without the responsive capacity to address it can accumulate quickly and have consequences that stretch into adulthood.

How can we improve a child’s environment to support well-being?

As a long-time child welfare worker, what has stood out to me is that we often rely on removing children from their communities when there are better options available. 

Far too many families have their kids taken from them because they don’t have the financial means to provide adequate care. Families undergo difficult times, and face unemployment and housing instability, substance use and barriers to good mental health. The need to keep children safe is paramount. That said, any child and family services system should be working to find new ways to engage and support families before a tough decision needs to be made to remove the child from the home.

With greater access to vital resources and services, especially in trauma-responsive continuums of assessment and treatment and placement options, we – the collective ecosystem of stakeholders and responsible agencies – could do a better job proactively identifying families in need. Our goal should always be to step in and provide the resources families need before crises erupt.

Youth in foster care need love, support and opportunities to get the restorative help they need, not institutionalization.

The urgency of these investments seems especially acute right now, given how substance use is driving record numbers of children into North Carolina’s foster care system.

Absolutely. According to the North Carolina Department of Health and Human Services from 2016 to 2020, overdose emergency-room visits in North Carolina increased by 23%. Over the past year alone, the N.C. Alcohol and Drug Council provided nearly 9,200 people with information and referrals for substance use disorder treatment.

This crisis is impacting families in every region of the state. Look at the list of the five counties with the highest numbers of overdose-related emergency room visits: Burke, Randolph, Carteret, Craven, and Catawba. It’s clear that communities in the mountains, in the piedmont and the coastal plains are all dealing with this.

Unfortunately, as treatment providers get more overwhelmed, parents experiencing substance use disorder can find themselves waitlisted for treatment, or they might have trouble locating a high quality, evidence-based option for treatment. For example, in the midst of the pandemic, many counties have had to redirect resources away from the opioid crisis to address the immediate needs related to COVID-19. To make matters worse, the highly infectious coronavirus has forced people into isolation, creating even more barriers to opioid treatment. Now hospitalizations and overdoses are soaring.

Tragically, when parents can’t find the help they need, that’s when child and family services offices have little choice but to remove the child from the home. It’s a vicious cycle, really. That’s why it’s so important to intervene early and with a deep commitment to providing the resources families need to overcome challenges and to be whole and healthy once again.

Child safety should always be our first priority … but removing them from their family isn’t necessarily the best option – not when parents can get support and successfully engage in treatment programs, and not when removal means that, in worst case scenarios, children are sometimes sent out of state or placed in group-living situations.

Blue Cross NC has certainly invested in tools to help connect families with proven treatment options quickly. Our collaboration with Quartet is making it easier for physicians to identify patients with substance use disorder and connect them with the right care at the right time … in most cases within 72 hours. We have helped launch resources that make it easier for all North Carolinians to make more informed treatment choices. We are investing in community-based efforts, harnessing local expertise to address challenges and opportunities unique to each community.

What other strategies have you seen that are effective at keeping families together?

There’s a lot of important work taking place, not just in Mecklenburg County, but across the state.

Through partnerships with local service providers and community stakeholders, and our colleagues at Healthy Blue, we are working to intensify our recruiting efforts and wraparound case management supports for our kinship caregivers who keep children and their siblings together, within their communities and with caring adults who know and love them.

Kinship care means that we enlist their godparents, stepparents, members of their tribe or clan, or other adults with whom the child shares a family relationship to take on the role of providing full-time care and protection. The key is to harness the power of a pre-existing relationship that respects and sustains the family's cultural values and emotional ties. These aren’t informal, ad hoc arrangements. Kinship caregivers are chosen and serve following strict guidelines, especially in consideration that they will be caring for a young person who has experienced trauma and adverse childhood experiences. The children and youth in their care still receive careful attention from case workers. But when a child can maintain family and community ties, it promotes stability and safety. That’s a key to well-being.

Encouraging youth to engage in pro-social activities can also have a big impact. Participating in after-school activities and community events can help youth establish independence in their families. This too is a crucial form of support that can help prevent the family breakdown.

When you look at North Carolina’s foster care system, what gives you the greatest sense of hope?

We have made great strides here in Mecklenburg County toward meeting our goals of child and family safety. Yet, we need a committed group of partners and people, both inside and outside of the child and family services system, who share our conviction for the families in our community, and across our nation. What fills me with optimism? Knowing that, in North Carolina, there are so many who already do share my conviction … who are ready to do the hard work to make things better.

Consider the work unfolding at Blue Cross NC, for instance. I’m proud to be a part of the new advisory council you’ve formed to hear from subject matter experts from across the child and family services system to better understand what works, what doesn’t and how to address the gaps. You’ve actively supported organizations like Open Table, which helps youth and young adults in foster care transition out of the system to independent adulthood. And, you are investing in community-based organizations that are committed to strengthening families, using family-centered treatment approaches.

I see that level of commitment across the state. North Carolina has a diverse coalition of child- and family-centered policy makers. Just this year, legislators came together and unanimously passed House Bill 769, the Foster Parents’ Bill of Rights, which provides support to foster care parents. Child advocacy organizations like NC Child and Benchmarks have a strong voice and presence that reaches across the state. There are vibrant and trusted community partners, like North Carolina Association of County Directors of Social Services, that recognize the importance of this work.

What gives me the greatest sense of hope? The children and the families that we are all serving. After all, they embody everything that’s possible. When I look in their faces, I see a better, brighter present and future for North Carolina.

Dr. McKnight, we share your sense of dedication and hope. I too believe that if we all work together, we can ensure that every child in North Carolina has the resources and support they need to achieve their true potential and reach a brighter future ahead.