Overview of Evidence-based Practices for Youth in Connecticut

1. Overview of Evidence-based Practices for Youth in Connecticut Robert P. Franks, Ph.D. Director Connecticut Center for Effective Practice (CCEP) Child Health & Development Institute

2. Outline • History & Description of the Connecticut Center for Effective Practice • Context for Best Practices: Positive Youth Development • Rationale for Using Evidence-based Practices • History of Adoption and Implementation of Evidence-based Practices in Connecticut V. Current EBPs Being Utilized & Numbers of Youth Served VI. Lessons Learned from MST Implementation: Ongoing MST Progress Report

3. History & Description of the Connecticut Center for Effective Practice

4. History & Description of the Connecticut Center for Effective Practice Founded five years ago in response to identified need in the State to have a mechanism for providing information on best practices in child mental health and to implement evidence-based practice on a large scale. First major project was working with DCF to implement Multisystemic Therapy (MST) across the state.

5. Connecticut Center for Effective Practice (CCEP) Five active partners: • Department of Children and Families (DCF) • Court Support Services Divisions (CSSD) • University of Connecticut Health Services (UCHC), Department of Psychiatry • Yale University School of Medicine • Child Study Center • The Consultation Center • Child Health & Development Institute (CHDI) Funding sources: • State agencies, private foundations, grants

6. CCEP Vision and Mission • The purpose of the Connecticut Center for Effective Practice (CCEP) is to enhance Connecticut's capacity to improve the effectiveness of treatment provided to all children with serious and complex emotional, behavioral and addictive disorders through development, training, dissemination, evaluation and expansion of effective models of practice.

7. CCEP A place to connect the dots…

8. Achieving Vision:Engaging Stakeholders Engage stakeholders in activities that promote systemic change or act as catalyst for change across Connecticut at multiple levels: • Through work with state agencies who serve children and families • Through work with major academic institutions • Through work with policy makers and legislators • Through work with providers of services • Through work with consumers (parents, caregivers and children)

9. Achieving Vision: Four Overarching Strategic Goals of CCEP • Identification, adoption, and implementation of evidence-based and best practices • Research, evaluation and quality assurance of new and existing services • Education and raising public awareness about evidence-based and best practices • Development of infrastructure, systems and mechanisms for implementation and sustainability

10. Context for Best Practices: Positive Youth Development

11. Context for Best Practices: Positive Youth Development(Commission on Positive Youth Development, 2004) • Focuses on youth’s talents, strengths, interests and future potential • Traditional models focus on deficits • Criminal justice models focus on punishment over prevention and rehabilitation • Positive youth development recognizes adversities • Builds on strengths and resiliencies • Emphasizes ecological approach

12. Core Ideas of Positive Youth Development • Adolescents can overcome adversity and thrive by building on resiliencies and strengths • Resiliency alone is not enough – Adolescents are not impervious to unrelenting adversity • Youth that thrive must have both positive individual characteristics and positive characteristics of their families, schools and communities

13. What are the characteristicsof programs that supportpositive youth development?(From meta-analysis published in 2005) • Comprehensive, time-intensive • Earliest possible intervention • Timing is important • High structure is better • Fidelity to model is key to effectiveness

14. Characteristics of programs that support positive youth development 6. Need adult involvement 7. Active, skills-oriented programs 8. Programs that target multiple systems 9. Programs that are sensitive to the individual’s community and culture 10. Programs based on strong theoretical constructs and proven effective by evidence

15. Rationale for Using Evidence-based Practices Evidence-based practices are arguably our best approach to provide consistent, reliable, effective interventions that result in promoting positive youth development.

16. Rationale for Using Evidence-based Practices • Changing “landscape” of practice in mental health, juvenile justice, social work • Push for Accountability…”where is the data?” • Increased quality and relevance of research • Emergence of the concept “Best Practices” • What is a best practice? • More than…”what we already do” • More than a theoretical approach

17. Rationale for Using Evidence-based Practices • Systematic clinical intervention programs that are integrative in nature (practice, research, theory) And use systematic clinical protocols ”clinical maps” • Manual driven • Model congruent assessment procedures • Focus on adherence and treatment fidelity • Models that have strong science/research support • Clinically responsive and individualized to unique “outcome” needs of the client/family to the unique “process” needs of the family • Are able toguide practicewith high expectation of success with specific client problems within specific community settings

18. Biases against Evidence-based Practices “They are too rigid and cookbook” “Doesn’t apply to real world kids with real world, multi-problem histories” “Developed in some lab” “Overly simplistic” “Too difficult to implement in community setting” “Just a band-aid and doesn’t address underlying issues and concerns” “Another passing fad” “My training and expertise are not valued”

19. Barriers to Implementation of Evidence-based Practices in Connecticut • Economic barriers • Community-based and independent providers “barely getting by” • No mechanism for supporting supervision and training necessary for implementing EBP’s in a fee-for-service environment • Providers do not see that up front investment will yield longer term gains • Turnover is high • Medicaid and managed care do not routinely reimburse or create incentives to deliver EBPs

20. Barriers to Implementation of Evidence-based Practices in Connecticut • Workforce Issues • Older clinicians may not share theoretical perspective and see EBPs as incompatible with their worldview • Current clinicians may not receive adequate training and not sufficiently prepared exiting graduate programs • Turnover is high and clinicians are underpaid • For some types of EBPs work can be intensive and not “traditional” • Difficulty finding appropriate supervision

21. Types of Evidence-based Practices in Child Mental Health & Juvenile Justice Outpatient Services/Community-based Services • E.g., treatments for anxiety disorders, conduct disorders, child abuse and trauma related disorders such as CBT and TF-CBT School-based services • E.g., Postive Action (PA) and Cognitive Behavioral Intervention for Trauma in Schools (CBITS) In-home Family-focused Services • E.g., treatments for conduct and substance abuse problems such as Multisystemic Therapy (MST), Functional Family Therapy (FFT) and others Foster Care Programs • E.g., Multidimensional Treatment Foster Care (MTFC) Residential or Inpatient Services • E.g., Sanctuary Model

22. History of Adoption and Implementation of Evidence-based Practices in Connecticut

23. Factors contributing to implementation of EBPs in Connecticut • Identification of need • Acknowledgement that existing services were not working well • Negative media attention • Available resources through grant funding • “Champions” within state government • Legislative and policy changes • Economic factors • Ease of implementation of model • Success of pilot programs

24. Connecticut’s History • of EBP Development • Legislative Program Review: 1997 • DSS/DCF Memorandum of Understanding: 1999 • Report on Financing/Delivering Children’s Mental Health Services: 1999 • DCF developed first Multisystemic Therapy team: 1999 • Connecticut Community KidCare Legislation: 2000 • Blue Ribbon Mental Health Commission Report: 2000 • Development of the Connecticut Center fro Effective Practice 2001 • Connecticut Policy and Economic Council (CPEC) Report: 2002 • Statewide Implementation of MST and other EBPs: 2002 - present

25. CT’s Community KidCare’s Legislation New and Expanded Service Continuum “Enhancing the Traditional Service Model” • Emergency Mobile Psychiatric Services • Care Coordination • Extended Day Treatment • Crisis Stabilization Beds • Therapeutic Mentors • Short-term Residential Treatment • Individualized Support Services • Intensive In-Home Services

26. Other Contextual Factors Leading to Systems Change • Legal action: Two major consent decrees for the Department of Children and Families impacting child protection and juvenile justice (Juan F and Emily J) • Data: Statewide evaluation of juvenile justice programs that called for systems change (CPEC Report, 2002) • Media: Ongoing media coverage of problems at state’s Department of Children & Families

27. Implementation of Evidence-based Practice in Connecticut 1999 - Pilot Multisystemic Therapy (MST) Team in Department of Children and Families 2001 - CT Center for Effective Practice formed to disseminate MST across the state 2001 to Present - Dissemination of MST and other in-home evidence-based practices for juvenile justice youth

28. Implementation of Multisystemic Therapy:WHY MST??? • Identified need to target “deep end” children who were accounting for most of resources • Acknowledgment that existing “business as usual” was not working • Much emphasis on juvenile justice population • Policy focus on keeping children in their communities and providing intensive in-home services through KidCare legislation • Strong evidence-base • Well-defined implementation and delivery system for MST • Champions within the State

29. MST Growth in CT

30. Growth of MST led to implementation of a range of other evidence-based practices for juvenile justice youth in Connecticut

31. Current Evidence-based Practices Being Utilized in Connecticut & Numbers of Youth Served(2007)

32. Evidence-based Practices for Youth in the JJ System in Connecticut • Multisystemic Therapy (MST) • Multidimensional Family Therapy (MDFT) • Functional Family Therapy (FFT) • Brief Strategic Family Therapy (BSFT) • Multidimensional Treatment Foster Care (MTFC) • Intensive In-home Child and Adolescent Psychiatric Services (IICAPS)

33. Multisystemic Therapy (MST) Program Overview: Multisystemic Therapy (MST) is an intensive family- and community-based treatment that addresses the multiple determinants of serious antisocial behavior in juvenile offenders. The multisystemic approach views individuals as being nested within a complex network of interconnected systems that encompass individual, family, and extrafamilial (peer, school, neighborhood) factors. Intervention may be necessary in any one or a combination of these systems. Program Targets: MST targets chronic, violent, or substance abusing juvenile offenders at high risk of out-of-home placement and their families.

34. Multisystemic Therapy (MST) Current Number of MST programs in Connecticut: 10 (DCF) 15 (CSSD) Current Number of MST Specialty Teams: 3 (DCF) Current Capacity for Children Served: 350 (DCF) 625 (CSSD) 975 Total Capacity

35. Multidimensional Family Therapy (MDFT) Program Overview: Multidimensional Family Therapy is an intensive in-home program. MDFT focuses on several core areas of the teen's life simultaneously - parents, schools, other family members and the community. The program also helps the family understand the connections between drug use, criminal behavior and mental health. During treatment, skills are learned which enhance: Positive peer relations; Healthy self-esteem; Connection to school and community activities; Increased autonomy; Emotional connection to family members Parents and family members are also involved by learning and applying skills which: Improve the relationship with their child or sibling; Increase their knowledge of successful parenting practices; Improve day-to-day and intimate communication Program Targets: Adolescents ages 11-18 at risk for drug addiction.

36. Multidimensional Family Therapy (MDFT) Current Number of MDFT Teams in Connecticut: 9 (DCF) Current Number of MDFT Specialty Teams: 5 (DCF) Current Capacity for Children Served: 395 (DCF) 395 Total Capacity

37. Functional Family Therapy (FFT) Program Overview: The FFT clinical model is identifies specific phases which organize intervention in a coherent manner, thereby allowing clinicians to maintain focus in the context of considerable family and individual disruption. Each phase includes specific goals, assessment foci, specific techniques of intervention, and therapist skills necessary for success. Interventions focus on engagement/motivation, behavior change and generalization of new behaviors and skills. Program Targets: Youth ages 10-18, and their families, whose problems range from acting out to conduct disorder to alcohol/substance abuse.

38. Functional Family Therapy (FFT) Current Number of FFT Teams in Connecticut: 4 (DCF) Current Capacity for Children Served: 432 (DCF) 432 Total Capacity

39. Brief Strategic Family Therapy (BSFT) Program Overview: Brief Strategic Family Therapy (BSFT) is a problem-focused, and practical approach to the elimination of substance abuse risk factors. It successfully reduces problem behaviors in children and adolescents and strengthens their families. BSFT provides families with tools to decrease individual and family risk factors through focused interventions that improve problematic family relations and skill building strategies that strengthen families. BSFT fosters parental leadership, appropriate parental involvement, mutual support among parenting figures, family communication, problem solving, clear rules and consequences, nurturing, and shared responsibility for family problems. In addition, the program provides specialized outreach strategies to bring families into therapy. Program Targets: Children and adolescents, 6 to 17 years with conduct problems; associations with anti-social peers; substance use and problematic family relations.

40. Brief Strategic Family Therapy (BSFT) Current Number of BSFT Slots in Connecticut: 180 (CSSD) Current Capacity for Children Served: 450 (CSSD) 450 Total Capacity

41. Multidimensional Treatment Foster Care (MTFC) Program Overview: The goal of the MTFC program is to decrease problem behavior and to increase developmentally appropriate normative and pro-social behavior in children and adolescents who are in need of out-of-home placement. Youth come to MTFC via referrals from the juvenile justice, foster care, and mental health systems. MTFC treatment goals are accomplished by providing: Close supervision; fair and consistent limits ; predictable consequences for rule breaking ; a supportive relationship with at least one mentoring adult; and reduced exposure to peers with similar problems. The intervention is multifaceted and occurs in multiple settings. The intervention components include: Behavioral parent training and support for MTFC foster parents; family therapy for biological parents (or other aftercare resources); skills training for youth; supportive therapy for youth; school-based behavioral interventions and academic support; and psychiatric consultation and medication management, when needed.

42. Multidimensional Treatment Foster Care (MTFC) -continued Program Targets: Children in the foster care system with multiple familial and behavioral concerns. Three forms of MTFC: MTFC-P For preschool-aged children (3-5 years) MTFC-L For latency-aged children (6-11 years) MTFC-A For adolescents (12-18 years)

43. Multidimensional Treatment Foster Care (MTFC) Current Number of MTFC Teams in Connecticut: 3 (DCF) Current Capacity for Children Served: 30 (DCF) 30 Total Capacity

44. Intensive In-home Child and Adolescent Psychiatric Services (IICAPS) Program Overview: IICAPS is a Yale University model created to meet the comprehensive needs of children with severe psychiatric disorders.  The program makes use of a consistent treatment team to provide comprehensive assessments, case management, individual and family treatment, and crisis intervention. Intervention is informed by a synthesis of the medical model, development psychopathology, systems theory, and wraparound concepts.   Program Targets: Children appropriate for IICAPS intervention may be returning home from psychiatric hospitalization, at-risk for institutionalization or hospitalization, or unable to benefit from traditional outpatient treatment. 

45. Intensive In-home Child and Adolescent Psychiatric Services (IICAPS) Current Number of IICAPS programs in Connecticut: 14 (DCF) 5 (CSSD) Current Capacity for Children Served: 598 (DCF) 90 (CSSD) 688 Total Capacity

47. Bottom Line:Almost 2,900 children and adolescents currently receive evidence-based practices through DCF and CSSD annually in Connecticut.

48. Lessons learned from MST Implementation

49. Connecticut Evidence-Based Practices System of Care Development • Systems Changes • Economic Changes • Consumer Changes • Practice Changes • Quality Improvement

50. Lessons learned from MST Implementation Ongoing “Progress Report” being conducted by Connecticut Center for Effective Practice Examining quantitative outcomes of over 1,000 youth receiving MST services through DCF and CSSD Examining qualitative outcomes and implementation factors for families, providers, agency staff, probation officers, judges and others (over 30 focus groups). Report with lessons learned available in July 2007.