16 th National Conference on Child Abuse and Neglect April 19, 2007 Child Protection and Systems of...

16th National Conference on Child Abuse and NeglectApril 19, 2007

Child Protection and Systems of Care: Assessing Barriers and Opportunities for Collaboration Between Systems

Ilene BersonLouis de la Parte Florida Mental Health Institute, University of South Florida

Frank RiderTA Partnership for Children’s Mental Health

John Fluke

Walter R. McDonald & Associates, Inc.

David Sanders

Casey Family Programs


Overview of Roundtable Issues

John Fluke

Vice President Research

Walter R. McDonald & Associates, Inc.

April 19 16th National Conference on Child Abuse and Neglect

Key Issues

Enumerating Needs

Barriers to Implementation

Opportunities


Rationale for the Roundtable

Assumption Children’s mental health services for child welfare

populations are not adequate to meet needs.

Questions Are both children’s mental health and child

welfare serving the same kids? What are the leverage points to improve services? Are there models for addressing leverage points?


Populations of Focus

Child Protection and Child Welfare – Neglected and Abused Children (NCANDS CM 2005)

3.6 million investigated 899 thousand victimizations

Key Demographic for Victims Average Child Age: 7 African American (25%) Hispanic (17%) White (54%)

Services Investigations/Assessments (100%) Post-investigation Services (35%) Placement (7.5%)



Child Protection and Child Welfare (cont.) – Children Served in Foster Care and Adoption

(AFCARS 2005) 799 thousand children served

Key Demographic for Children Placed (entries) Average Child Age : 8.2 African American (26%) Hispanic (18%) White (47%)


Figure 3-3 Victimization Rates by Maltreatment Type, 2000-2005

Victimization Rates per Thousand by Maltreatment Type, 2000-2005

2.4

7.3

0.5

1.21.0

2.8

2.3

7.1

0.3

1.20.9

3.2

2.3

7.2

0.3

1.20.8

3.3

2.3

7.5

0.3

1.20.8

3.0

2.1

7.4

0.3

1.20.9

3.2

2.0

7.6

0.3

1.10.9

3.1

0

1

2

3

4

5

6

7

8

Physical Abuse Neglect Medical Neglect Sexual Abuse PsychologicalMaltreatment

Other Abuse

Year

Rate

per

1,0

00 C

hild

ren

2000 2001 2002 2003 2004 2005


Profiles of CPS Neglect Populations Victims Based on 35 States Average Age: 6.7 (n = 429,757) Median Age: 6 Male: 50.5% Race/Ethnicity (n= 431,180)

African American: 21.5% Asian/Pacific Islander: 1.0% Hispanic: 18.4% Native American: 1.4% White: 49.9%



Systems of Care – National Evaluation Report to Congress 2002 - 2003 Children with Serious Emotional Disturbance Key Demographic Average Child Age:

Average Child Age 12.3 African American (26.4%) Hispanic (11.3%) White (57%)

Services - National Evaluation Report to Congress 2001 5.8 different services in the first 6 months 10% hospitalized


Characteristics of Children Under 6: System of Care Grantees Funded 2002 - 2004 Data for 912 Children under 6

522: Child Welfare Involved 390: No Identifiable Involvement in Child Welfare

Both Populations 69% At or Below Poverty Biological Family Member Substance Abuse (n=

210) 76%: Child Welfare Involved 58%: No Identifiable Involvement in Child Welfare

Number of Family Risk Factors (n = 215) 2.1: Child Welfare Involved 1.7: No Identifiable Involvement in Child Welfare


Children Under 6 Enrolled in Systems of Care: Phase IV Grantees


Some Barriers* Children’s Mental Health Service Availability

Challenges to Collaboration

Family Involvement and Participation

Service Array

Funding (particularly Medicaid)

*Highlights From McCarthy, J., Marshall, A., Irvine, M., and Jay, B., (2004), An Analysis of Mental Health Issues in States’ Child and Family Service Reviews and Program Improvement Plans: Wash, DC: Georgetown


Some Barriers (cont.)* Among children in child welfare (NSCAW - in-home and placed)

42% of children with significant mental health needs (CBCL) Much more use of mental health services for children placed

compared to in-home Limited use of specialty mental health services “Controlling for level of clinical need, younger children were

much less likely to receive specialty mental health services than older children.”

African American and Hispanic children are less likely get mental health services

Service provider availability doesn’t improve service availability to child welfare populations

*Hurlburt, M., Leslie, L., Landsverk, J., Barth,R., Burns, B., Gibbons, R., Slymen, D., Zhang, J. (2004). Contextual Predictors of Mental Health Service Use Among Children Open to Child Welfare. Arch Gen Psychiatry. 61:1217-1224.


Some Barriers (cont.)

CPS and Child Welfare Population of Focus is Young Children Coercive Interventions Emphasis on Child Safety

Systems of Care Emphasis on SED Diagnostic Criteria Focus on Older Children


Some Opportunities CPS and Child Welfare

Family Group Decision Making Processes Alternative Response Systems Comprehensive Community Service Orientation IVe Waivers Linkages between child welfare and mental health

agencies improved likelihood of services*

Systems of Care Underlying Philosophy of Services Increased Emphasis on Young Children Implementation of Flexible Diagnosis (DC: 0 to 3R) and

Medicaid Funding Emphasis on Community Collaboration Emphasis on Family Driven Services

*Hurlburt, M., et. al. (2004).


Some Opportunities

CPS and Child Welfare Family Group Decision Making Processes Alternative Response Systems Comprehensive Community Service Orientation IVe Waivers

Systems of Care Increased Emphasis on Young Children Implementation of Flexible Diagnosis (DC: 0 to 3R)

and Medicaid Funding Emphasis on Community Collaboration Emphasis on Family Driven Services


A Statewide Integration Effort – the Case of Arizona

Frank Rider

TA Partnership for Children’s Mental Health


Arizona Behavioral Health (BH) and Child Welfare (CW) Systems Were

Misaligned Different expectations Different mandates and external requirements Different funding streams and approaches Different pace of work with family No common outcomes


Terrible outcomes for children: Behavioral health needs going unmet Limited permanency Poor academic achievement by children Extremely high juvenile delinquency among

foster children Family instability damaging children Poor outcomes evident among former foster

children

Consequences of Misalignment of BH and CW Systems


Huge Costs to Families: “Mending the Damage”

Trust (“abandonment”) Triggering traumatic memories Guilt Etc.



Enormous Costs to Both Systems: Inadequately prepared, poorly supported clinical staff Insufficient effort to heal families, which might prevent or

shorten removals of children to foster care Lack of appropriate front loaded behavioral health services

exacerbates family separations Resentment, lack of understanding & mistrust between

systems’ personnel Lack of “shared care” evident Trauma-induced, situational and substance-abuse related BH

needs challenge both systems Overworked personnel discouraged by poor results equates to

high turnover and low morale



Example: CW Focus on Safety Applied at Odds with Permanancy and Well-Being

Arizona: 100 CPS youth placed in out-of-state RTCs (2002)

BH System: Interventions and Supports not Timely; No “Ownership” of Child Welfare Mandates

CW: No evidentiary basis supported effectiveness of residential treatment.

Conclusive evidentiary base supports effectiveness of: Wraparound/Child and Family Teams Therapeutic Foster Care

Bob Friedman, USF (Katie A. Declarations, 10/05)


What Is Effective?

Therapeutic Foster Care (TFC)

Intensive outpatient programs

Maintaining strong ties to the community

Interventions that target change in peer associations

Case managers with smaller caseloads using a “wraparound” model of care

From: U.S. Surgeon General’s Report (1999)


Build A Collaborative Foundation among Child-Serving Systems

Arizona’s Journey: JK Litigation, Discovery (1993-2000) Governor’s Task Force on Behavioral Health Services for

Child Welfare (2000) JK Settlement Agreement (ADHS and AHCCCS, 2001) State-Level Memorandum of Understanding (April 2002). Gov. Janet Napolitano Executive Order (January 2003):

Established a Children’s Cabinet Ordered CPS Reform Federal Revenue Maximization task order

Building Practice, Capacity, Embedding, CQI (2003 to ?)


Building A Common, Collaborative Vision

“In collaboration with the child and family and others, Arizona will provide accessible behavioral health services designed to aid children to:

achieve success in school live with their families avoid delinquency become stable and productive adults.

Services will be tailored to the child and family and provided in the most appropriate setting, in a timely fashion, and in accordance with best practices, while respecting the child’s and family’s cultural heritage.”

J.K. vs. Eden et al. No. CIV 91-261 TUC JMR, Paragraph 18


“Construction Materials” for Integration in Arizona

Common Vision: Outcomes, Values, Language Structural Components:

Funding Covered BH Services Array

Common Processes: An integrated/unified planning process – AZ Child and

Family Teams Assessment – e.g. Urgent BH Response, 0-5 y.o./CAPTA Protocols – e.g. Unique BH Needs of Children and Families

Involved with CPS Targetted Programming


Example: Arizona’s Urgent BH Response Process

“Urgent responses must be initiated upon notification by DES/CPS that a child has been, or will be, removed from their home.”

ADHS Policy 3.2: Appointment Standards and Timeliness of Services[Effective August 15, 2003]

1. Identify immediate safety needs and presenting problems

2. Provide direct therapeutic support to each child3. Provide direct support to each child’s new caregiver4. Initiate development of a Child and Family Team5. Provide CPS caseworker and Court with findings and

recommendations to inform the caseplan


From August 15, 2003 to February 28, 2007, more than 12,000 Arizona children received an urgent behavioral health response beginning within 24 hours of removal by CPS for placement in protective foster care.

582

256

678

301

697

432

595

442

552

382

0

100

200

300

400

500

600

700

Aug 2004~39% Feb 2005~44% Aug 2005~62% Feb 2006~74% 8/1/2006~75%

Children removed

Urgent BH responses


Child and Family Team Process

Services planning is family-centered, strength-based, individually tailored, culturally informed, and collaborative across systems

Families report feeling hopeful, more willing to positively engage their own strengths as respected member of team

Service plans identify and promote reliance on informal and natural supports in combination with formal services


“Wraparound” Works

“Building on family strengths is essential if we are to prevent and control juvenile delinquency behavior. The process that embraces this concept is more formally known as Wraparound. This process can help prevent families from becoming abuse, neglect and delinquency statistics. It works well as an intervention model even for the most severe cases of abuse, neglect or delinquency.”

Hon. David C. Bonfiglio, Superior Court Judge, 6/01 Testimony before Indiana Legislature


Comparing Outcomes for Arizona Children with and without Child and Family Teams (Ages 5-11)

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

CFT

No CFT

CFT 74.6% 69.2% 77.9% 62.9% 77.9% 88.8%

No CFT 59.5% 55.5% 65.1% 52.3% 65.1% 83.3%

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family


Comparing Outcomes for Arizona Youth with and without Child and Family Teams (Ages 12-17)

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

CFT

No CFT

CFT 71.1% 67.3% 70.9% 58.7% 65.1% 75.8%

No CFT 51.3% 51.3% 55.4% 43.4% 49.6% 68.8%

Increased Stability

Increased Safety

Avoids Deliquency

Prep for Adulthood

Success in School

Lives with Family


Coming Home to Arizona:Successful Outcomes

100

38

15 1325

0

20

40

60

80

100

120

Jun-02 Jun-03 Jun-04 Jun-05 Jun-06

Jun-02Jun-03Jun-04Jun-05Jun-06


Implications for Child Welfare, Legal Processes

Use Child and Family Teams to develop and present to the Court “options” leading to a single, unified plan across multiple agencies, intended to respect the mandates of each involved system.

Creative, individualized plans will be based on “discovered” strengths and needs of each child and family, reflecting not only the input of professionals, but of the families and youth themselves.

Advocate that the Court offer flexibility for a child and family team to develop a timely plan to meet defined requirements for safety and well-being. Use this as an alternative to ordering specific placements and treatments for children.


Ilene R. Berson, Ph.D.Associate ProfessorLouis de la Parte Florida Mental Health InstituteUniversity of South Florida

Sarasota Early Childhood Mental Health Partnership


Brief History of Early Childhood Mental Health in Florida

September, 2000 Florida’s Strategic Plan for Infant Mental Health finalized and published [http://www.cpeip.fsu.edu/faimh/IMHPlan.pdf]. This document laid the groundwork for services, training, research and policy changes.

Task force worked on policy changes specific to Community Mental Health services for children ages birth through five and their families.

May, 2002 Policy approved and published by AHCA (Agency for Health Care Administration)-Florida’s Medicaid agency


Development of the Crosswalk Impetus –Change in Medicaid Community Mental

Health Policy to specifically address children ages birth through five and their families with mental health problems.

Context –Policy recommended use of DC: 0-3 for assessment/diagnostic purposes, but still required use of ICD-9-CM for reimbursement


Comprehensive Systems Approach to Early Childhood MH Services

State-level Coordination, Collaboration, Planning, Funding and Advocacy

Local-level Coordination, Collaboration, Planning, Funding and Advocacy

Universal/Preventive Services

Focused Services for At-Risk Children & Families

Tertiary Intervention ServicesEducation

Intervention

Referral

Risk-specific Assessment

Health & Developmental Screening & Assessment

Parenting Education

Referral

Provision of Care

Case Management

Diagnostic Assessment

Treatment for Parent & Child

Direct Infant Mental Health ServicesConsultation

& Referral

Promotion

Promotion

Promotion

Zeanah, Stafford & Nagle, 2005


Why focus on early childhood? Early environments matter, and nurturing

relationships are critical Patterns of attachment between a young child and

caregiver are the most robust predictors of subsequent development


But do babies really need psychologists?


Estimated Prevalence

No national epidemiological data In studies of health care visits, rates of psychosocial

problems=10-21%; externalizing problems=7-17% In Head Start, externalizing problems=10-23% 10-15% typical preschoolers have chronic

mild/moderate behavior problems No data for children under age of 2

Center for Evidence-Based Practice: Young Children with Challenging Behavior


Prior Findings Based on Young Children’s Behavioral Health Services in the State of Florida (Berson et al., 2002, 2003, 2004) Speech and language impairments are the most

prevalent diagnosis across all age groups. Identification of emotional and behavioral

disorders increases in frequency during the preschool years.

Data emphasize the complexity of differential diagnosis and the dilemma of determining the severity of behaviors among young children.


Age at Which Behavioral Health Services Peak for Young Children

29.3%

44.7%

26.1%

45.3%

30.7%

24.0%

0%

10%

20%

30%

40%

50%

Birth to 1 Year 1 Year to 2 Years 2 Years to 3 Years

Age

Per

cen

t o

f C

hild

ren

Ser

ved

2000

2001


Age by Gender

53.5%

60.2%

67.2%

46.5%

39.8%

32.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

0 Years Old 1 Year Old 2 Years OldAge

Per

cen

t

MaleFemale


Young Children at Imminent Risk(Berson, 2006)

Very young children are the largest subgroup among confirmed cases of physical abuse and medical neglect. One-third of infants discharged from foster care re-enter the

child welfare system. Over four-fifths (81%) of victims of fatal child maltreatment in

the U.S. are less than four years of age, with 45% of all victims being under one year of age.

Compared to older children in foster care, young children face far greater risks to their healthy development and future adult well-being. Nearly 80% of young children in foster care are prenatally

exposed to substance abuse. Nearly 40% are born low birthweight and/or premature. More than half have developmental delays or disabilities.

Many young children in foster care experience multiple placements that can inhibit their capacity to form emotional attachments.


Consequences of Aggression: Preschool Expulsion

Gilliam (2005): Pre-K students expelled at a rate 3x higher than K-12 peers (6.67 v. 2.09)

0

5

10

15

20

25

30

Expulsion

PrivateStateK-12


The Sarasota Early Childhood System of Care: Demographics Population ages 0-9 in Sarasota County

30.1% of the population ages 0-5 years are below poverty in Sarasota County.

3,463 children live in high-poverty neighborhoods (where 20% or more of the population is below poverty).

35% of infants and children under age 9 in Sarasota County qualify for free/reduced lunch.

11% of infants and children under age 9 in Sarasota County live in homes in which the primary language is other than English.

Non-Hispanic Hispanic Total White 23,121 3,220 26,341 Black 2,626 142 2,768 Other 62 753 815


Child Welfare Involvement of Young Children Number of Reports of Abuse or Neglect of Children

Ages 0-9 years: 1,960 Children ages 0-8 years placed in out of home care:

4,006 Receiving in-home services: 106 Receiving out-of-home services: 335 Source: Florida Department of Children and Families, Reports During FY 2004-2005

Sarasota is the 2nd highest city in the Suncoast Region for babies born substance exposed.


Prevalence Rates for Behavioral Health Disorders Among Young Children For children under age 9 in Sarasota County:

1,886 children are identified as Severely Emotional Disturbed (SED)

2,514 children are identified with mild to moderate ED

4,400 with a diagnosable psychiatric disorder


Preschool Expulsion in Sarasota County Early Learning and Care Centers in Sarasota County were surveyed regarding expulsion or exclusion of children in the past 12 months due to a child’s behavioral problems. 39 respondents 48 children were terminated. In 87% of these cases the center

requested assistance with the child prior to recommending removal from the program. In most of the cases where assistance was not requested, it was due to the fact that the children were already receiving care.

Out of these early learning and care centers, 108 children with challenging behaviors were able to continue in the programs because support and/or assistance were received.


child

community investment


MISSIONTo strengthen Sarasota’s system of care that supports early childhood mental health & well-being

VISIONAll young children & their families are healthy, happy & thriving in Sarasota County communities

…so what do we mean by early childhood mental health?

• Experiencing & expressing emotions• Forming close, secure relationships• Exploring the environment & learning

• With primary caregivers • In a family• In a cultural context• In a community

emotions learning

relationships

chil

d

family

culture

caregiver


child

linkage / connection

service expansion / enhancement

training / education

feedback / evaluation


Embracing family voices, cultures, strengths & choices

Championing care & safety for all children

Prioritizing the role of caregivers

Valuing relationships & a sense of belonging

Promoting awareness & acceptance of mental health

System of Care Values:Child centered and family focused, with the needs of the child and family dictating the

types and mix of services provided.Community based, with the locus of services as well as management and decision

making responsibility resting at the community level.Culturally Competent, with agencies, programs, and services that are responsive to the

cultural, racial and ethnic differences of the populations they serve.


Challenges Professionalization of Staff

Limited pool of professionals trained in early childhood behavioral health

Increasing Awareness Lack of awareness as to what services for young

children are available within local communities Challenge of changing people’s opinion that one

can simply apply a model that works for older children to this younger age group

Misperception that children should not be treated for a specific disorder until they reach the age of five


Challenges Challenge of distinguishing mental health issues

from other developmental areas (i.e. speech and language, motor, cognitive) in young children Limited capacity of providers with developmentally

specific training Stigma associated with early childhood mental

health and the taboo against diagnosing behavior problems in an early childhood population

Shifting the focus of interventions to the relationship between the child and his/her caregiver(s)

Transformation to a public health approach that seeks to promote, safeguard, and restore mental health for young children and their families.


Ilene R. Berson, Ph.D.Associate ProfessorDirector, Consortium for Child Welfare StudiesDepartment of Child and Family StudiesLouis de la Parte Florida Mental Health InstituteUniversity of South Florida13301 Bruce B. Downs Blvd., MHC2402Tampa, Florida [email protected]


The Mental Health Needs of America’s Most Vulnerable Children

Dr. David Sanders, Executive Vice President, System ImprovementCasey Family Programs


Casey’s 2020 Strategy

Safely reduce the number of children in foster care in America by half – by the year 2020.

Enhance the long-term well-being of children in care by improving outcomes in three areas:

Education Employment Mental Health


2020 Goals, Initiatives, Strategies and Solutions

reduct

ion em

ployment

educa

tion

mental health

prevention at entry

per

man

ency

sa

fety

pre

par

atio

n

get job, keep & advance career

post secondary

assessment & intervention

earlychildhood

2020

rein

vest

men

t

highschool


A Two-County Snapshot Hennepin County, MN

Los Angeles County, CA


Federal CFSR Findings

Requirement of a mental health screening or assessment: 10 states (26%) – Yes; 26 states (68%) -- No

Do foster children receive initial formal mental health screenings/assessments?

The vast majority of states report that screenings and assessments are, at best, done inconsistently (32 states – 84%).

11 states -- even when mental health needs were assessed, needed services were not provided, were ended prematurely, or no follow-up monitoring was provided.

Are services provided to meet the mental health needs of children: 38 states (100%) – Inconsistent practice.

Is there a scarcity or lack of mental health services to meet system needs? 37 states (97%) – Yes.


Federal CFSR Recommended Solutions Assessment and Services (improving assessment of child and family

mental health needs and building/expanding the array and accessibility of mental health services).

Training (child welfare, mental health clinicians and foster parents).

Collaboration (cross-system strategies to address problems, rather than having the child welfare system attempt solutions on its own).

Comprehensive strategies (taking a comprehensive approach – three or more statewide strategies or actions -- to strengthening mental health services for children and families in the child welfare system.


Casey Research

Northwest Alumni Study Mental Health Findings: Compared to the general population, a disproportionate number of alumni had

mental health disorders. Within the 12 months prior to being interviewed, their diagnoses included:

One or more disorders: 54.4% Post-traumatic stress disorder (PTSD): 25.2% (a rate nearly double that

of U.S. war veterans) Major depression: 20.1% Social phobia: 17.1%

Recommendations: Federal and state governments should eliminate barriers to valid assessment

of mental health conditions and evidence-based mental health treatment. Barriers include:

Restrictive eligibility requirements for funding and inadequate worker capacity for identifying and treating mental health problems.

Maintain placement stability.


Casey Research Mental Health Care for Children and Adolescents in Foster Care: Review

of Research Literature

Recommendations: Increase access to care Move beyond the usual institutional and outpatient care Increase the use of evidence-Based interventions in child welfare Use evidence to improve practice and policies in child welfare

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