A Collaboration Project (CAS and Children’s Mental Health) Helping Children and Youth

1. INNOVATIVE PARTNERSHIP: A Collaboration Project (CAS and Children’s Mental Health) Helping Children and Youth In Algoma District

2. Presentation Outline • Welcome/Introductions • Background/history of development • Program model, staffing, clientele • Service process – from referral to discharge • Case Study (interactive) • Statistics, Tools, Evaluations • Overall challenges – Overall strengths • Future Directions • Commitment to growth (interactive) • Questions • Inspirations/Closing

3. A Community Works Together • Oct. 2004 Community Planning Session for Children’s Mental Health. Participants included:- • Child Welfare • Parents • Youth Justice • Psychiatry • Sault Area Hospital • Community-based Children’s Mental Health Services • Aboriginal services • Developmental Services • District School Boards

4. Community Planning cont’d • Participants stressed lack of resources and agreed to prioritize needs of high need/high risk group: * Immediate clinical supports to prevent breakdown of CAS out of home placements within Algoma *Professional resources for assessment/ consultation/ treatment planning through outreach across service sectors *A Local Short Term Residential Assessment and Stabilization Unit

5. Community Planning cont’d • Participants agreed to develop service delivery model in stages beginning with establishment of a Multi-disciplinary Clinical Resource Team. • Proposal developed and submitted to MCYS. Funding approved. Management committee (Community Advisory Committee) established as responsible for developing and maintaining effective collaboration and quality assurance plan. Partnership agreement signed April 2005. • Manager hired and staff interviews completed. Logic Model developed. Full team in place beginning May, 2005.

6. Forming Partnership to meet Children’s Needs Community Advisory Committee (CAC) • Algoma Family Services (Lead agency) • Children’s Aid Society of Algoma • Sault Area Hospital • Local General Psychiatrist • NogDaWinDaMin Family and Community Services • Community Living Algoma (Developmental Services) • Northeast Mental Health Center • Pediatric Liaison with Group Health Center and Dept. of Paeds. • Algoma District School Board • Huron Superior Catholic District School Board • Counseil scolaire catholique du novel-Ontario • Counseil scolaire du district du grand nord d’Ontario

7. SERVICE DELIVERY PRINCIPLES • Focus on Individual Child and Family * Create a FAMILY CENTRED INTEGRATED SERVICE PLAN (FCISP) to address the unique needs/strengths of each child and family. * Empower each child and family to effectively manage their lives. *Involve a “total commitment “ to serve each child and family on an individual basis.

8. SERVICE DELIVERY PRINCIPLES cont’d • Services within most Normalized Environment * Enabling children and youth to remain in the least restrictive, most normalized environment * Services to support lifestyles possible within long-term home (considering realistic transportation and financial constraints) * Support adaptive lifestyles among peer group, school, home and community.

9. SERVICE DELIVERY PRINCIPLES cont’d • Partnership with Families Parental/Child/Youth involvement during all phases of service delivery: *Participation on the treatment planning team *Developing the FCISP *Child/youth and family wishes, strengths and needs are incorporated into FCISP. * Monitoring and evaluating progress. * Transition and discharge planning

10. SERVICE DELIVERY PRINCIPLES cont’d • Collaborative Service Provision * Involvement of all current and newly invited service providers * School personnel * Community mental health (parents/older adolescents) * Respite workers * Religious leaders and programs * Community youth/family programs * Other mental health providers * Extended family members * CAS workers * Youth Justice * Other community partners/members as appropriate All (with consent) are invited to “step in” with team and share service planning/provision

11. SERVICE DELIVERY PRINCIPLES cont’d • Strength-based Philosophy * Assessment always emphasizes strengths, assets, unique talents, coping skills, life histories. * Consider strengths beyond the mental health domain, including all environments and aspects of child/youth/family's life • Culturally Sensitive * Services are responsive to cultural and ethnic differences • Evidence-Based Practice * Intervention for each child/youth/family is based on researched best practice and a review of previous treatment attempts to develop individualized solutions

12. SERVICE DELIVERY PRINCIPLES cont’d • Child/family Focused Care *No youth/family is discharged, or withdrawn from services because of challenging or disturbed behaviors *Providers may have to reconfigure services to meet crises and changing needs rather than referring child elsewhere *At Discharge further treatment (e.g., for parent) may be recommended. • Commitment to Education/Learning * Provide training throughout the community *Student placements regular part of team

13. Clinical Resource Team (CRT)Who are we? Multidisciplinary team of professionals including: • Registered Nurse – 3 days per week • Psychologist – 1 day per week • Child and Youth Workers - 2 full time • Child and Family Counsellor – 3.5 days • Regular consultation with various community consultants including, Psychiatrists, Physicians, Developmental Services, etc. • In-Kind Resources – Behaviour Therapist, Aboriginal Services

14. Clinical Resource Team (CRT)Who do we serve? • Children and youth ages 6 through 18. • Must be involved in Child Welfare System • Experiencing significant impairment in functioning in one or more environments. • Where possible all other available resources have been utilized/exhausted. • Current placement or family home at high risk of imminent breakdown.

15. Presenting Diagnosis • Post-traumatic Stress Disorder (including psychotic symptoms) • Conduct Disorder, Oppositional Defiant Disorder • Developmental Handicap • Learning Disabilities • ADHD • Autism Spectrum Disorders • Clinical Depression • Mood Disorders • Anxiety Disorders • Epilepsy • Encopresis/Enuresis • Attachment Disorders • Speech Impairment • Alcohol Related Neurological Disorders

16. Presenting Concerns • Fire-setting, vandalism • Suicide ideation/behaviours (including cutting) • Defiance, noncompliance, aggression, harm to others • Substance use/abuse • Prostitution, sexualized behaviours, • Sexual trauma, sexual offending • Running, staying away from home without permission • Associating with inappropriate peers • Truancy, repeated suspensions, poor academic performance • Lying, stealing, breaking the law • Conflictual/severed family relationships • Auditory/visual hallucinations • Sleep problems • Hospitalizations for mental health issues • Lack of social skills, peer conflicts, limited friendships

17. Presenting Concerns (cont’d) • Children experiencing grief/loss of normal connection with biological families • Children experiencing repeated grief/loss due to many placements in Child Welfare System. • Children with trust/attachment difficulties due to family history or varied caregivers • Parents/caregivers exhausted, frustrated, ready to ‘give up” • Parents/caregivers struggling with personal challenges such as medical/mental health issues • Poverty, housing issues, lack of social support systems • Parental relationships severed or in conflict

18. Presenting Concerns (cont’d) • Parent conflict with schools/community agencies etc. • Parent’s overall cognitive ability in question • Parent’s capacity to meet challenging needs • Parents with traumatic childhood – unresolved histories of abuse/sexual abuse, neglect, loss/grief • Parents with negative view of systems and helping agencies due to personal history. • Long waitlists, inability to access resources, appropriate resources unavailable, previous services unsuccessful or not generalized to current situation.

19. WOW-! Presenting Strengths • Child/ Youth and Families continue to survive and maintain a “spark of hope” in spite of monumental struggles • Despite many previous attempts in accessing resources, children/youth and families are again asking for help and demonstrating motivation for change • Excellent participation in assessment and treatment interventions, even when asked to try something different.

20. WOW-! More Strengths! • Children/Youth and Parents/Caregivers who may have been hesitant with counselling agree to attend individual/family sessions and join in the therapeutic process. • Awesome collaboration with community partners including schools, medical personnel and many community agencies/professionals

21. Process –Referral to Discharge • Client/family referral made to Algoma Family Services Intake by CAS if in care or by family if involved with CAS but not In care. • BCFPI questionnaire completed to assist in determining eligibility, then forwarded to Algoma Family Services Intake Review Committee to further evaluate fit for service. • If all eligibility requirements met then referral is forwarded to CRT. May be waitlisted as necessary with consideration for immediate service provision given risk determination and current case load. • Team Caseload: approx. 6 to10 client/families at a time dependent upon need/level of resourcing required.

22. Process (cont’) • CRT involved with service provision for approx. 3 to 6 months depending on need and progress. • Focus of initial meeting: begin building therapeutic relationships, evaluate client/family/environmental, strengths and needs. Discuss short term and long term goals of child/youth, parents/caregivers, and CAS. Initial CAFAS completed following opening evaluations. • Plan service provision tailored to fit individual/family’s unique needs. Utilize best practice taking into consideration diagnosis (es), symptoms and behaviours. Team also reviews previous service provision success/weaknesses.

23. Process (cont’) • CRT together with child/youth family, CAS, and input from any other current service providers develop the: FAMILY CENTRED INTEGRATED SERVICE PLAN includes: *Goals *Interventions * Responsibilities (Who) *Time Lines * Expected Outcomes * Planning for Transition from program. * FCISP is signed/dated by all parties * FCISP is reviewed by CRT weekly and with family monthly * Changes are included as amendments to original plan.

24. Process (cont’) • Service Provision may include any or all of the following: * Environmental/behavioural observation/assessment in home, school and community. * Medical assessment including review of current medications and liaison with physician, psychiatrist, medical professionals * Psychiatric/Psychological consult or psychological assessment * Individual/family counselling, Social Skills Group, Individual Training in Pro-Social skill development, Care for Kids (sexuality), TAPP-C (fire setting), Cognitive Behaviour Therapy (CBT), Home/School Behaviour Intervention Plans, Trauma Focused CBT

25. Process (cont’) * Parent/caregiver education, counselling, support, and strategies. * Assist parents/caregivers to deal with their own health/ mental health issues, promoting self care in effort to improve overall family functioning. * Practical assistance to parents re: housing, accessing various community resources, etc. * Education, support and training for school personnel re mental health, developmental issues and behavioural strategies. * Advocacy, referrals and liaison with/to community resources

26. Process (cont’) • Towards end of service child/youth, family, CAS and community partners collaborate in transition planning for follow up resources. • Discharge Report completed with summary of each team member’s work with client/family and recommendations for immediate and long term resources and service provision. • Discharge meeting held with client/youth, parent/caregiver, CAS and other service providers as appropriate. Discharge report reviewed, signed and provided to appropriate parties. • Closing CAFAS completed for each client along with CRT’s Service Satisfaction Interview for each Child/Youth, Parent/caregiver, and CAS worker involved in CRT service.

27. Statistics • Since June 2005, Clinical Resource has provided service to a total of 45 clients and their families. This number does not include several clients who were deemed inappropriate for service and received advocacy for alternate service provision. • Client gender 20 females and 25 males • Clients have ranged in age from 6 years to 17 years. Average age at services is 12 years. • Length of service provision has ranged from 3 to 10 months.

28. Tools/Evaluations • Use of carefully developed assessment and evaluation tools to determine appropriate service provision and effective use of limited resources. • Quality assurance is ongoing and CRT will be participating (along with Lead agency Algoma Family Services) in Children’s Mental Health Accreditation process in fall 2008. Current Tools include: • Brief Child and Family Phone Interview- BCFPI • Child and Adolescent Functional Scale –CAFAS • CRT Service Satisfaction Interview • Collaboration Effectiveness Evaluation Tool - CEET

29. Brief Child and Family Phone Interview The Brief Child and Family Phone Interview (BCFPI) is a 1/2 hour, computer assisted, clinical intake and outcomes interview, used for children 6 yrs - 18 years old, by clinics, agencies, hospitals, schools, child-welfare and corrections facilities, in Canada. • Overview of basic concerns, as seen by the parent(s), youth or teacher(s). • Asks about common behavioural and emotional problems (provides standardized score re 6 specific aspects of mental health + Internalizing, Externalizing and Total Mental Health scores). • Provides standardized scores for 4 aspects of Child Functioning and for 3 aspects of Family Adjustment to the problem. • Provides a standardized score for Caregiver Mood and Family Functioning.

30. BCFPI (cont’d) • Provides a standardized score for 18 empirically relevant Risk and Protective Factors. • Records presence of 16 'Other Concerns' (rarer conditions, e.g. Compulsions, Fears, Sleep problems, Eating problems, Sexual difficulties, etc.) • Determines the family's Readiness to participate in services and identifies potential Barriers to service utilization • Gathers Basic Demographic data with established links to outcome. • BCFPI meets accepted psychometric standards. • Flexibility for Clinical override where other information indicate scores do not accurately reflect child’s needs (e.g. “look good” bias, severe individual behaviours not reflected in BCFPI)

31. Child and Adolescent Functional Assessment Scale: CAFAS • CAFAS is a clinician-rated measure to assess clinical status at beginning, during, and end of treatment. Rating occurs at intake, at 3 month intervals during service, and at discharge. • CAFAS is used to assess severity of impairment in children and adolescents with emotional/behavioural, or substance use symptoms/disorders. The CAFAS provides a visual profile of problem areas across settings. • CAFAS provides ratings in 8 key areas: School/Work, Home, Community, Behaviour Towards Others, Moods/Emotions, Self-Harm Behaviour, Substance Use, and Thinking.

32. CRT Service Satisfaction Interview • The purpose of the interview is to obtain feedback from clients, families and collateral agencies regarding the effectiveness of the CRT. • The interview is conducted (usually by telephone) by either the manager of the CRT or a designate who was not involved with the client at a service level. • Interview obtains subjective opinions of the interviewee and is intended to identify the level of satisfaction with CRT service. • Information is used to identify areas for improvement in the provision of CRT services in the future.

33. Satisfaction Interview Sample Comments • Are you satisfied with how discharge from CRT was planned with you? Foster parent: “Very good, helpful, listened, went with it” • Are you satisfied that the client benefited from CRT’s involvement? Foster parent: “Got us all on the right road” Foster parent: “Yes, has benefited, big turnaround” CAS: “Very good experience for the child, CRT always there knew what was going on, working in both home and school a real plus” • What could be improved? Foster Parents: “ Nothing, CRT staff went above and beyond expectations. They were awesome, there when needed, came running when required, explained things very well to (clients) and whole family. “

34. CEETCollaboration Effectiveness Evaluation Tool • One of the system goals for the CRT and the Community Advisory Committee (CAC) is a high level of community collaboration and partnership in service delivery. • A proposal was submitted to CHEO, Centre of Excellence for funds to assist with development of a Tool for collaboration quality assurance. • Funds approved and a consultant with expertise in Quality Assurance tools was hired to work with AFS (lead agency) to develop CEET.

35. Collaboration Effectiveness Evaluation Tool • Two distinct groups are asked to complete an evaluation survey: * Direct service professionals who have been involved with a child/youth who has received CRT services *Members of the Community Advisory Committee (CAC). • CEET evaluates the level of collaboration and partnership effectiveness in relation to a number of key elements identified in the research literature.

36. (CEET ) Key Elements • Shared values • The right people involved at every level • Follow-through with commitments • The ability to flex organizational mandates to meet client needs • Shared resources • The existence of professional barriers • A reactive/crisis approach to problem solving • Opportunities for mutual gain • Effective leadership • Strong working relationships • Representation of diverse stakeholders • Client involvement / empowerment • The ability to solve problems effectively • Agencies choosing to “go it alone”

37. Key Elements for CEET (cont’d) • The personalization of issues • An understanding that stakeholder’s interests are likely to change over time • Turf protection • Risk taking • Realistic goals for the progressive development of the (CRT) collaboration • Rigidity • Hidden agendas • Active consideration of alternative viewpoints • The ability to communicate quickly and easily • Ready access to required information • Maintenance of the status quo • A willingness to change • Shared goals

38. Key Elements for CEET (cont’d) • Trust • A proactive approach to problem solving/prevention • Decision-making based on self-interest • An interdisciplinary approach to service • An ability to solve problems outside formal meetings • A non-personalized approach to problem solving • Shared decision making • Active agency participation in all aspects of the partnership • A focus on client interests, not agency positions • Shared power and authority • Consideration for other’s view points/roles • Sustainability

39. (CEET ) Results/comments Initial CEET distributedfollowing first year. Scale used: • 1 = “not at all” •         2 = “to a small extent” •         3 = “to a moderate extent” •         4 = “to a great extent” •         5 = “to a very great extent” • Total 16 respondents - • Average score = 3.43 to a moderate (to) great extent • Note: Comments from respondents indicated it was too early following inception too have a good grasp on collaboration. • CEET currently in process of distribution to be completed by end June 2008.

40. Overall Strengths! Clinical Resource Team Perspective • Improvement in community collaboration for high risk children/families. • Overall development of more positive relationships with community partners, particularly CAS and CMH service providers. • Reduction in home/placement breakdowns. • Clients served report improvement in overall child/family functioning. • Community partners accessing valuable training to improve general/specific understanding of mental health issues.

41. Overall Challenges/Barriers Clinical Resource Team Perspective • Distance (size of district served) • Timelines (short term resource for high need clients) • Client numbers (particularly since change in admission criteria). • Limited team resources (staff time, after hours etc.) • Limited community resources/long waitlists • No Ministry approval as yet for STAS Unit, despite continued local prioritization; therefore, we have to rely on the local hospital and/or out of town for stabilization.

42. Overall Strengths! Children’s Aid Society Perspective • Fast immediate service • Good working relationship with foster parents and youth • Multidiscipline team • Neutral party between AFS and CAS helps bridge gaps and provides a collaborative, solution-focussed approach • Helps alleviate tensions between AFS and CAS (e.g., funding proposal for same dollars)

43. Overall Strengths! (cont’d) Children’s Aid Society Perspective • Having medical staff on the team allows us to fast track to medical services • CRT has been able to identify mental health and medical diagnoses • Working relationship with school board, will work hands on with teacher to provide strategies with children and at times facilitate groups, provide information to school staff • Child and Youth Workers are asset to CRT, provide a broad spectrums of ideas, very creative and think outside the box,

44. Overall Strengths! (cont’d) Children’s Aid Society Perspective • Focus on building therapeutic rapport with children. Often children are resistant to working with counselors yet CRT is able to work through this and build rapport • Communication through Case Conferences very helpful and inclusive of all those involved including biological family as appropriate • Identifies roles, responsibilities and goal setting (everyone on the same page) • Discharge identifies work completed and recommendations

45. Overall Challenges/Barriers Children’s Aid Society Perspective • Due lack of services often recommendations cannot be completed or followed through • Short term resource • Feedback from foster parents and children are that they wish they could be involved for longer term

46. Future Directions • Stabilization and Assessment Unit * No Ministry approval as yet for STAS Unit. Continued priorization by local children’s service agencies to lobby ministry for full implementation of priority needs plan for STAS Unit as developed by community partners. • Commitment to Growth * Ongoing commitment to continually evaluate and improve CRT services. * Ongoing commitment to promote understanding, education and advocacy for children’s mental health needs in our community

47. Commitment to GrowthIndividual, Team, Community • Clinical Resource Team is mandated and committed to continually strive for learning as individuals, as a group and within our community. • Consistently include students with CRT; Child and Youth Worker, Nursing, Social Work, Education students gain valuable insight and experience working with the team. • Not only strive to receive professional training but also provide many training opportunities for the Community. This includes: * Psycho-educational training to school personnel, CAS professionals, youth and parents/caregivers regarding various disorders/behaviours assisting with understanding, providing information-what to expect and strategies to assist.

48. Community Trainings Provided Some examples of training provided includes: • What is Autism? • The Choking Game • Mental Health (for high school students) • Challenging Behaviours • Coping with Post Traumatic Stress • Therapeutic Transition • Caregiver Self-Care • Toolbox for Success (Stress Management) Interactive

49. Inspirations • “ When I approach a child he inspires in me two sentiments; tenderness for what he is, and respect for what he may become.”Louis Pasteur • “We must teach our children to dream with their eyes open”Harry Edwards • “Children are likely to live up to what you believe in them.” Lady Bird Johnson • “The greatest gifts you can give children are the roots of responsibility and the wings of independence.”Denis Waitley • “The test of the morality of a society is what it does for its children.”Dietrich Bonhoeffer