As a child in Missouri, Anoela Martin sometimes lived in another person's garage. At other times, home was under a bridge. Occasionally, it was in an unsafe home with a parent. She bounced back and forth between her mom’s care in Kansas City and her dad’s in St. Joseph.
“My dad was a raging alcoholic at that time, and my mom was a drug addict,” she said. “We didn’t really get to eat as much as we probably should have. He wasn’t home a lot. We kind of had to take care of ourselves.”
When Martin was 11, she entered Missouri’s foster care system. And at 14, she was adopted, but the relationship with her adopted mother soured.
“I was becoming a rebellious teenager; I didn’t have any freedom at home; I was locked in a bedroom at night,” she said. “So I started sneaking out of the house. After the third time of sneaking out and going to school the next day and the cops showing up at school to arrest me, my adopted mom decided to place me in Missouri Girls Town.”
Few alternatives
Missouri Girls Town is a residential home primarily for girls in the foster system with specialized needs. They may have behavioral problems stemming from PTSD or need treatment for bipolar disorder and other mental health conditions.
The 23-acre property was designed to accommodate up to 50 girls but only can take 12 because of staffing and funding challenges. The Kingdom City facility – about halfway between Kansas City and St. Louis – is one of about 10 centers in Missouri that provide beds solely for girls. Martin landed there in 2011.
In the Midwest, many states have space – or beds – for boys who need a spot in a foster residential home, but there are not as many beds for girls. In Missouri, Missouri Girls Town and other Qualified Residential Treatment Programs collectively have about 200 beds specifically designated for boys but only about 60 for girls.
QRTPs are designed to offer a higher degree of behavioral and mental health care than other facilities. In fact, there are nearly 2,400 beds for youth in Missouri residential facilities as of early July. But, most are for youth experiencing homelessness or are at centers without accreditation or where licensing isn’t required.
QRTP is a designation created by the federal 2018 Families First Prevention Services Act. It means the residence uses a trauma-informed treatment model, described by the Substance Abuse and Mental Health Administration as “a multi-pronged, multi-agency public health approach inclusive of public education and awareness, prevention and early identification, and effective trauma-specific assessment and treatment.”
A QRTP facility has a round-the-clock nurse on staff, families are included in the treatment when possible, and follow-up services are provided after the child is discharged.
Janee Harvey, Iowa’s director of Family Wellbeing and Protection, said a growing understanding about how trauma affects behavior in girls has led to greater demand for QRTP beds for them. According to a Stanford University study, girls and boys experience PTSD differently.
“It is important that people who work with traumatized youth consider the sex differences,” said Megan Klabunde, the study’s lead author and an instructor of psychiatry and behavioral sciences. “Our findings suggest it is possible that boys and girls could exhibit different trauma symptoms and that they might benefit from different approaches to treatment.”
Demand at QRTPs can swell because residential programs are sometimes used as the final safety net for foster girls with critical mental health or behavioral health needs. And the centers can act as transitional spaces for girls – between juvenile detention and life outside the criminal justice system, said Deanna Barger, the Missouri Girls Town director of development. The average age of girls at that center is about 14.
Occasionally, Missouri Girls Town receives a girl as an emergency placement who doesn’t really need residential care, Barger said.
“And that’s not fair to the child, is it?” Barger said.
If there is no space for a girl seeking a residential bed in the state or there isn’t a center that can provide the particular care that she needs, she may stay in a shelter without specialized care or be sent to an out-of-state provider that does have that service. In aggressive behavioral situations, or when the girl has committed a criminal act, she may end up in the juvenile justice system that may not have specialized care.
In any situation where a girl moves around in the child welfare or juvenile justice systems, she isn’t able to build relationships and trust with caretakers. That disruption of stability can lead to increased risks of emotional and behavioral issues and poorer educational outcomes, according to the Annie E. Casey Foundation, a children’s welfare organization.
Resources and reality
It’s hard to nail down the exact number of beds the Midwest needs to meet demand because the number of girls who seek space at a residential center is always in flux and each person may have a specific or complex treatment need. Some facilities have beds that aren’t gender specific but lack the specialized care that a bed designated for a girl requires.
Most girls stay at Missouri Girls Town from anywhere between six months and a year, Barger said. But, in both Missouri and Iowa, stays can be as short as a few days in emergency situations.
“We do not have enough female QRTP beds,” Harvey said. The state has two providers serving girls, Harvey said, one in the juvenile justice system and one in the child welfare system.
“Both are struggling significantly with workforce stabilizing and implementing the appropriate treatment plans,” Harvey said. The demand for girls' beds recently has appeared as a problem in part because there is a better recognition of the services needed for girls who have experienced trauma, often sexual trauma, according to Harvey.
Martin stayed at Missouri Girls Town for two years. In addition to receiving therapeutic services, she said she had a strict routine that many teenagers in families have. She took classes, ate lunch at a cafeteria and spent recreation time outdoors. There was often a group activity in the evening. One of the most valuable classes she said she learned from was money management.
“I don't think that I would have learned everything that I learned that got me to where I am today,” she said. “The only thing I would have known is to follow the same path (as my parents), I wouldn't have known any different.”
The goal of the federal law is to focus on preventative services to keep kids out of the foster care system and with their families. The number of children entering the foster system in the U.S. declined by nearly 77,000 from fiscal 2018 to 2022, according to a report from the federal government’s Children’s Bureau.
Some Midwestern states, including Iowa and Kansas, have seen a decrease in foster care numbers. Missouri’s numbers have dipped slightly, and Nebraska actually has increased its number of children in foster care.
Whatever the reason for a child entering foster care, each state’s responsible agency assesses the best course for the child. This might mean placement with relatives as a start. Other options include foster parents and then – as a last resort – a foster group residence.
The FFPSA prioritized this order because outcomes improved when children maintained consistency of care in the family, according to research by the Annie E. Casey Foundation, among others.
There are different types of residences, but often, the children who are placed at emergency shelters, group homes or licensed QRTPs have severe mental health and behavioral issues and trauma. The children may only number in the dozens in a state, but they need specialized care.
Iowa’s Department of Health and Human Services sees the QRTPs and shelters as necessary services for children with “extraordinary needs,” according to Matt Highland, a previous HHS director of strategic operations, who said so in a May 2022 meeting of the Department of Human Services Council.
And while the number of kids in these centers is trending downward and could be seen as a sign that the law is working, many Midwest centers have closed over the past few years, taking with them bed space for girls. That’s left the remaining centers struggling to meet demand.
“Treatment options that are available through QRTP placement are essential,” Highland said at the 2022 meeting. “They include substance abuse treatment, psychiatric and mental health treatment, sexual abuse and perpetrator treatment. And the permanent closure (of several homes) accounted for an unexpected loss of approximately 50 QRTP beds and 25 shelter beds.”
Missouri has also seen several facilities with female-specific programs close over the past few years, said Sara Smith, residential services director for the Missouri Department of Social Services.
“Missouri definitely needs more girl beds available. We almost have double the amount of beds for a male than we do for a female,” Smith said. “Over the last year, we’ve had about a 450 reduction in the number (of beds overall) we have available.”
Staffing woes
Keeping staff on board is a challenge many health care systems – like nursing homes and assisted-living facilities – deal with, especially since the COVID-19 pandemic. Even though Iowa and Missouri have both seen increased reimbursement rates for services through their legislatures, many service providers struggle to retain staff.
“Finding qualified individuals to be interested in this type of work has been difficult,” said Smith of Missouri’s Residential Services. Based on provider feedback, she said, “Often it costs more to provide these services than the rate that they are getting paid.”
Nearly all service providers, state employees and child advocacy groups interviewed for this story said reimbursement rates, or what the state pays a provider for a child’s care, while improving, still need to catch up with the physical and emotional demands of the positions at the residential homes. That responsibility lands on the shoulders of state lawmakers.
“Trying to be able to recruit a workforce, train a workforce, support a workforce, we’re going to have to be looking at those rates again,” said Kim Scorza, CEO of the Crittenton Center near Sioux City, Iowa.
Scorza was hired as CEO in 2021 after the emergency youth homeless shelter shut down because of the COVID-19 pandemic. The shelter reopened in January 2022 with 22 beds, a trauma-informed and mental health focus, and a mission to keep employees. Today, the shelter has 27 beds for boys or girls.
Scorza said it’s hard to compete with other hiring industries when residential staff are asked to take on a physically and emotionally demanding job caring for the girls.
“You can come to a facility where you’re dealing with kids with pretty significant mental health issues and behavioral disorders and risk potentially getting, you know, hit by a child or yelled at by a child. I mean, that takes a toll,” she said.
Scorza said the Crittenton Center has been fairly successful at retaining employees by recognizing that staff come in with their own lives, grief and traumas, and supporting them.
“That’s not a game-changer, right? I may not be able to give you $100,000 a year, but what I can give you is support, training, flexibility. I can give you a lot of these things and truly be there for you,” she said.
The organization YSS in Iowa provides statewide services in child welfare, mental health and substance use disorder treatment. It runs an emergency youth shelter in Mason City and another in Ames. Each has 10 beds for boys or girls. YSS also operates two residential substance use disorder addiction treatment programs for adolescents – one for boys and one for girls.
“I think we have a small waiting list right now,” President and CEO Andrew Allen said of the adolescent program. “That really fluctuates.”
The workforce is also one of the biggest challenges for YSS. Allen said a few years ago staff made $11.25 an hour. Now it’s $17 as reimbursement rates have improved.
“But the increase in our costs has not necessarily kept up with the reimbursement rates across the state and our different contracts,” he said. “The youth that we are seeing, the acuity has increased, which makes them just that much more difficult to manage from a behavior standpoint. It’s that much more work for staff, who are dedicated, who are passionate.”
“So the more passionate people that we have that want to make $17 an hour, four and a half weeks of vacation, and work for an organization that has the goal to create hope and opportunity, purpose-driven work, we need people in this field to do this important work.”
Allen said YSS is expanding this fall by opening the Ember Recovery Campus, a 70-bed center that will focus mostly on addiction treatment for adolescents and young adults from age 12 to 24. At least 24 beds will be for girls: 12 for adolescents and 12 for young adults.
“We see a balance of boys and girls that need access to shelter service,” Allen said. “And while addiction has similar prevalence for both males and females, boys and girls, in Iowa, we see fewer girls pursuing substance use disorder treatment than we do boys. And it’s a concern.”
Missouri Girls Town has frozen its admissions for the summer in order to train new hires so the home can take more girls in the fall. The organization relies on government programs for about 50% of its funding, with the rest coming from fundraising and donations, Barger said.
Specialized for girls
At Missouri Girls Town, the girls decorate their desks and dressers with pictures of famous celebrities, like Taylor Swift, cute boys and notes from friends.
In addition to the activities that Martin remembers, they have regular appointments with their caseworkers and therapists. Those who are young mothers may visit their babies. Some have physical and emotional scars.
“Trauma can really manifest in psychosomatic responses. So a lot of our kids can deal with chronic pain because they are constantly in this fight or flight mode,” Barger said.
The majority of the girls in residential centers have some form of PTSD, according to Barger. She said they’ve been in abusive and neglectful situations. Others have anxiety, depression and bipolar disorder. Some girls have been sexually assaulted. Others have eating disorders. Some self-harm by ingesting things or cutting themselves.
“Girls are different than boys. Just how they’ve responded to trauma is different; their needs are different,” said Kristie Oliver, executive director of the Coalition for Family and Children’s Services in Iowa. “And providers will tell you that it costs more to serve girls. Currently, our system does not have a specialized rate for girls.”
The limited number of staff with specialized training needed for treating girls in foster residential centers plays into the disparity between the number of beds for boys and the number for girls. And conditions found in boys have been more commonly treated.
Scorza said that often it’s been easier for people to say “boys will be boys” when they get into trouble, and then boys sometimes get a free pass. “But when a girl does that, it's viewed differently. And so we've got some girls that can really struggle and how they express that is through violence.”
Historically, that meant sending girls to juvenile detention or psychiatric facilities.
“Girls who end up going to group home-level of care, so QRTP, many of their behaviors require a lot more intensive staffing,” Harvey said. “So while the majority of the beds are occupied by the boys, when a girl is reaching that level up placement, what the providers will say is the acuity of those girls is incredibly heightened.”
Harvey also points to better recognition of the trauma that girls go through when sexually assaulted and the higher risk they face than boys.
One in nine girls under age 18 experiences sexual abuse or assault, according to the Rape, Abuse and Incest National Network. The Centers for Disease Control and Prevention estimates it’s more likely one in four girls experience sexual abuse. With that comes higher risks of drug abuse, PTSD and depression.
“This is more of a contemporary understanding of how trauma affects behavior,” Harvey said. “It’s a better understanding of some of the gender-based violence and exploitation that we see present in society.”
What’s being done?
At the end of 2022, Iowa’s Health and Human Resources Department vowed to overhaul the child welfare system in the wake of several child abuse cases. At the time, Harvey told Iowa Public Radio, “We have missed opportunities to connect families to concrete goods and economic support, or maybe community-based programs that can provide stability within their homes.”
Today, Scoza, Harvey and Oliver say there is at least a relationship between the providers and the state, with many people at the table figuring out how to advocate collectively for their needs going forward.
Scorza said a lot of progress has been made since 2022 and praised Director Kelly Garcia and her HHS team. “But she can only do so much, and her team can only do so much,” Scorza said. “They need the help of the governor’s office, and they need the help of the legislators to say these kids are important.”
In May, Iowa Gov. Kim Reynolds signed a behavioral health bill she championed into law. It unifies mental health, substance abuse and recovery services into the Behavioral Health Services System. The law created behavioral health districts and opened up federal funding opportunities for treatment centers, like Crittenton Center or Embed Recovery Center, that want to expand their mental health care for residents.
"We want to reduce the number of pillow changes the child is having and make sure they’re in the fewest placements possible."Sara Smith, residential services director for the Missouri Department of Social Services
Missouri partnered with Home State Health, a subsidiary of managed health care company Centene, to launch a statewide single-managed care plan called Show Me Healthy Kids for all its foster youth in 2022. The program assigns a case manager to a child to help identify what specific services should be in place for a child leaving a group home setting and returning to a foster home.
Missouri has also put together a ”multidisciplinary team” that includes representatives of the Department of Mental Health, Show Me Healthy Kids, Division of Youth Services, Children’s Division and juvenile courts. Each month, the group reviews three to five cases in which the placement of a child has been a struggle.
“I think we're on the right trajectory as a state, I mean, one thing that I've seen is really beneficial is that everybody's coming to the table,” Smith said. “Because we need more services to offer these youth.”
“In Missouri, we use the term ‘pillow changes.’ We want to reduce the number of pillow changes the child is having and make sure they’re in the fewest placements possible,” Smith said.
For Anoela Martin, Missouri Girls Town was the right place at the right time. She’s now 28 and has two kids.
“I think that girls going into their teenage years face a lot more emotional struggles, and therefore, rebellion and negative behaviors than maybe boys do from what I had seen and saw growing up,” she said. “And if there is nowhere for them to run, to learn how to be a better person, or how to grow up, you know, and put themselves in a better situation, they're just going to continue the same family cycle. They're not going to be as lucky as I was to be able to change my own future generations.”
“For me, one open bed changed the rest of my life.”
St. Louis Public Radio's Eric Lee contributed reporting and visuals to this report.
Corrections: A prior version of this story had the incorrect number of Qualified Residential Treatment Program beds allocated for boys in Missouri. The Missouri Department of Social Services counts about 200 boys' beds available.
This story comes from the Midwest Newsroom, an investigative journalism collaboration that includes Iowa Public Radio, KCUR, Nebraska Public Media, St. Louis Public Radio and NPR.
Do you have a tip or question for us? Email midwestnewsroom@kcur.org.
