Child Protection and Systems of Care: Assessing Barriers and Opportunities for Collaboration Between Systems Ilene Berson Louis de la Parte Florida Mental Health Institute, University of South Florida Frank Rider TA 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.
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%)
Populations of Focus • 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%)
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%
Populations of Focus • 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
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
Consequences of Misalignment of BH and CW Systems 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.
Consequences of Misalignment of BH and CW Systems 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] • Identify immediatesafety needs and presenting problems • Provide direct therapeutic support to each child • Provide direct support to each child’s new caregiver • Initiate development of a Child and Family Team • 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.
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)
Comparing Outcomes for Arizona Youth with and without Child and Family Teams (Ages 12-17)
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.
Sarasota Early Childhood Mental Health Partnership Ilene R. Berson, Ph.D. Associate Professor Louis de la Parte Florida Mental Health Institute University of South Florida
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 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
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 50% 45.3% 44.7% 40% 30.7% 30% 26.1% 29.3% 2000 Percent of Children Served 2001 24.0% 20% 10% 0% Birth to 1 Year 1 Year to 2 Years 2 Years to 3 Years Age
80% 70% 67.2% 60.2% 60% 53.5% 50% 46.5% Percent Male 40% 39.8% Female 32.8% 30% 20% 10% 0% 0 Years Old 1 Year Old 2 Years Old Age Age by Gender
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)
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.
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.