The severity of youth mental health needs intensified after the COVID-19 pandemic, with more children exhibiting extreme behaviors.
Some parents turn to child welfare system to find mental health services
Hear from Nina Richtman as she shares her experience trying to find mental health services for her son but ultimately having to turn to child welfare services.
Nina Richtman was desperate.
Over the summer, the 43-year-old mother had exhausted every avenue to find her teenage son the mental health care he badly needed as his behavior spiraled to alarming and dangerous levels.
The breaking point came as he began starting fires in their Des Moines home, and Richtman couldn’t keep him from smuggling in more materials to burn.
Faced with impossible choices, Richtman said she chose “the best of bad options.”
She gave up custody of her son to the state.
“It was incredibly hard to admit to myself that I was at the end of the road, that I could not do any more as one parent trying to help him,” Richtman said. “I was just at that point where I could not do any more. There wasn’t anything else to do there; we just tried everything.”
Richtman is among a rising number of parents and guardians who have relinquished custody of their children to the state in recent years as a last-ditch way to seek out additional behavioral health services, according to top officials at the Iowa Department of Health and Human Services.
Like Richtman, those families feel they have little choice: Iowa’s disjointed and underfunded system lacks a clear pathway to obtaining care for many troubled children.
“I’ve seen this repeatedly throughout the years,” said Kim Scorza, executive director of the Crittenton Center in Sioux City. “Families reach a certain breaking point, and they just don’t know what else to do or where else to go.”
But as the mental health conditions among youth have become increasingly severe following the COVID-19 pandemic, more families are turning to desperate measures to find adequate care for their children.
Even before the pandemic, thousands of children across the country entered foster care mainly for behavioral or disability services, research found. Between February 2017 and February 2018, there were as many as 25,000 such cases of custody relinquishment nationwide, according to an analysis published in January by U.S. Department of Health and Human Services.
In Iowa, state officials are ramping up efforts to divert families from this drastic pathway, but given the severity of some of the mental health conditions, they say they are struggling to meet these children’s needs.
“We are hard pressed right now to find concrete, long-term solutions, and I don’t think a state has. I think we’re in a much better space than most states are, but as a nation, we are really struggling with this particular issue, especially with youth,” said Iowa HHS Director Kelly Garcia.
‘It was not a decision I took lightly’
Richtman adopted her son and his older brother from foster care when they were 2- and 3-years-old respectively. She requested any identifying information about them remain anonymous.
Her youngest, who was later diagnosed with reactive attachment disorder and an intellectual disability, first began stealing and exhibiting other impulsive behavior in the 3rd grade.
As those habits became more frequent, Richtman said she took him to every type of therapy, including mental health, speech and occupational therapies. He had special education support at school since age 3, and has had multiple stays at crisis stabilization programs.
“Really, anything and everything that I could get access to, we tried it,” Richtman said. “There are a fair number of services that just don’t really exist, practically speaking, so I can’t say we tried everything. But we tried everything that was available.”
His behaviors escalated to new levels in the spring of last year, prompting Richtman to apply to 21 different youth residential care facilities in Iowa and other states. He was denied a spot at every facility, either because of his intellectual disability or because of his behaviors.
Richtman was becoming increasingly concerned her son would end up in the juvenile justice system. The choice to turn to child welfare officials was “the very, very last resort.”
“I was willing to take this step to avoid (the criminal justice system), because I just did not want that for him,” she said. “But it was not a decision that I took lightly. It was not something I wanted to do.”
Under state law, Iowa youth enter the state’s child welfare system through a child in need of assistance, or CINA, adjudication. Typically this legal process takes place if state officials determine there is abuse or neglect, but the law does allow parents and guardians to trigger this process for a vague “good cause” reason that remains undefined under Iowa Code.
In 2019, 148 children entered Iowa’s child welfare system because of mental health or behavioral health concerns, according to state data obtained by The Des Moines Register, part of the USA TODAY Network. That number has dropped significantly in the years since, down to 49 youth by 2024.
However, top state health officials have said publicly that the portion of those youth entering foster care solely because the parents are no longer equipped to take care of behavioral health needs at home has been on the rise.
“Last year, we had 23 children come into foster care through the context of their parents being unable to care for behavioral health needs. No other reason,” Garcia told state lawmakers in January during a committee meeting.
Janee Harvey, director of family well-being and protection for Iowa HHS, said the severity of behaviors from these young Iowans has become much more severe since the pandemic.
“We are definitely on the front lines of seeing youth in pretty extreme social psychological distress, and we’re seeing very intense symptoms,” Harvey told the Register. “I would not say volume-wise the numbers are bigger, but the types of kids we are seeing, it is an all-hands-on-deck, fire-drill situation of trying to figure this out, and we are struggling.”
Harvey said these children, typically between the ages of 12 and 14, were displaying “very, very challenging and sometimes very disturbing, perplexing, hard behavior.”
They were not suicidal but had severe self-harming behavior that included swallowing screws, gouging at their skin or trying to stab their eyeballs. They were also often extremely violent toward others, including their family members.
“We’re beyond our clinical skills or even our human understanding of what maybe some of these kids need,” Harvey said.
As youth needs rise, providers say services and workforce has failed to keep up
Overall, more adolescents and teenagers are grappling with mental health concerns since the coronavirus pandemic first arrived in Iowa.
The total number of youth aged 21 and younger receiving behavioral health and substance use services in the state rose nearly 40% between fiscal years 2018 and 2023, according to data from HHS obtained by the Register.
Between 2021 and 2023 alone, the demand rose 47%.
Yet, research has shown many of those individuals struggled to find support. A 2024 Mental Health America report found half of Iowa children with major depression did not receive any mental health treatment in the prior year.
Nationwide, the prevalence of untreated youth with depression ranged from 31.5% in the District of Columbia to 82.1% in South Dakota.
Even as the mental health needs of youth in Iowa have skyrocketed since the pandemic, supportive services and the workforce to offer that care has not kept up with the demand.
That has been compounded by the lack of a well-organized system to help families, said Scorza of the Crittenton Center. There were many avenues to services and many pockets of services across the state, she said, but Iowa’s system lacked clear guidance to find the right services at the right time.
“Unfortunately for some families, by the time they reach the point of saying ‘I can’t do this,’ they’re exhausted,” Scorza said. “They’ve been trying so hard to get the right services at the right time that they don’t feel like they have enough energy to be a voice in the system, to make the system change.”
Iowa mother had to files cases with the courts to help her children
Nicole Woodley is a Clarion mother of five who is all too familiar with that moment of crisis. She has filed three separate child-in-need-of-assistance cases on two of her adopted children; two for her now 17-year-old son, and another for her now 14-year-old son that was filed last year.
In both cases, she and her husband sought the help of the court to access behavioral health services they needed.
“When you hit a wall over and over and over, eventually you say ‘what is it going to take to make a door in this wall?’ Because I can’t keep doing this. It’s going to kill me. I need to make a hole in this wall, because there’s no way through,” said Woodley, age 44.
Woodley said they first went to their county attorney in 2020 to seek a formal child-in-need-of-assistance case for their older son, who was then 13-years-old. Her son is diagnosed with autism, attention deficit hyperactivity and attachment disorders, among other conditions.
The teenager would prowl the house in the middle of the night, entering his siblings’ rooms and hiding things. He had touched others inappropriately and had convinced his younger brother to run away from home.
By that point, he had been rejected for placements both at pediatric psychiatric medical institutions and at facilities for children with intellectual disabilities, Woodley said.
The Woodleys later were able to find placement in an out-of-state residential care facility. However, they had to file a second child-in-need-of-assistance case in 2024 to guarantee funding for his education while he was at that facility.
The family again turned to the child welfare system for their younger son in February 2024. When he was 11, he would become violent when triggered, breaking windows and attacking his parents. They involved the courts after his health insurance denied continued coverage of his stay at a residential facility in another state and were told it would be at least a 6-month wait for another placement in Iowa.
Through the child-in-need-of-assistance process, they found him a spot at the same out-of-state residential facility as his older brother.
Both still live at that facility, which the Woodleys wouldn’t name for safety reasons. Their older son is set to move to a habilitation home in Iowa soon.
Woodley said they sought to make their children legal wards of the state when they could no longer keep them from being safety risks in their home. In both cases, they had maxed out every available service in the state and saw no other way to avert a continued downward spiral.
“It was a horrendous thing, but I was willing to do it if I knew that the outcome would be better off than watching them continue to decline and not being able to do a darn thing about it,” Woodley said.
State officials say child welfare system does not offer any solutions
State officials have acknowledged this gap in Iowa’s current youth mental health system.
“That’s missing in our system today,” said Marissa Eyanson, behavioral health director for Iowa HHS. “There isn’t a clear way for parents. There isn’t a way right now, today, for folks to navigate.”
The state has stepped in to try to find placement for many of these cases, Garcia said, but it often falls on the state-run institution to take on those youth. Because of these extreme behaviors and the liability risks associated with them, many private providers in Iowa won’t accept those youth into their facilities.
While she knows it’s desperation driving parents down this road, Garcia said involving the courts to question their parental rights is not a solution.
“There’s nothing magic over here that exists other than a shelter bed, which is a necessity in a system that is a firehouse model that accepts kids in the middle of the night that are in dangerous situations, but not a place any one of us would ever willingly consent to putting our child,” she said.
According to HHS officials, the ongoing overhaul of the state’s behavioral health system will address these gaps by ensuring Iowans have access to mental health and substance use services earlier. The new system was signed into law last year by Gov. Kim Reynolds.
By increasing the availability of preventive and early intervention services for youth and adults, state officials hope to ensure Iowans can find care before it becomes a crisis.
“It’s essentially the component that I’m the most excited for, this ability to build a true safety net that’s invested in prevention and early intervention and the recovery work, instead of just the transactional crisis and treatment spaces,” Eyanson said. “Those are important because deep end work is always going to be big. However, it will never stem the tide. The only way that we’re going to solve it is to be able to get to something sooner.”
Behavioral health providers say they are cautiously optimistic the state is aware of the gaps that need to be addressed. However, in order for that effort to be successful, they say the new system also needs to be easier to navigate.
“There needs to be a unified structure for all children to access the services regardless of whether they have private insurance or Medicaid, and regardless of whether they’ve been adopted or they’re in foster care,” Scorza said. “If a child has mental health issues, there needs to be a very clear pathway to getting the right services at the right time, and in the right type of service”
Without it, officials can’t fault parents for feeling they can’t do it anymore, she said.
“There has to be some kind of safety net there for them,” Scorza said.
Despite her extreme step, Richtman said she was unable to get her son the help he needed before he became “stuck” in the juvenile justice system. He resides at the Polk County Juvenile Detention Center after he was arrested for the second time from the group home where he had previously been living.
Asked if she thought he would ever get the help he needed, Richtman admits she doesn’t hold out much hope.
“He still doesn’t have access to a level of care that’s the right level of care for him,” she said. “It’s just kind of like the best of what’s available, which isn’t really anything therapeutic or anything that really gets at those root problems that have always been a struggle for him.”
Even so, Richtman still believes putting her son into state custody was her only choice. There was nothing else she could do to keep everyone safe, including her son.
Richtman believes Iowa needs significantly more investment in youth mental health services and other infrastructure to establish services for children with complex needs, and to better support parents like her who are struggling to find help.
“A parent shouldn’t have to lose custody for their kid to get care,” Richtman said. “There needs to be another way for kids that have complex needs, and right now it’s this. This is the only option for families like mine, and it’s a really complicated, really expensive option for the state, and it’s not even meeting the kids’ needs.”
Michaela Ramm is reporting “Young and in Crisis,” an occasional series exploring Iowa’s youth mental health crisis while participating in the USC Annenberg Center for Health Journalism’s 2024 Data Fellowship. Ramm covers health care for the Des Moines Register, part of the USA TODAY Network. She can be reached at [email protected] .
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