Children at the Interface of Child Mental Health and Child Welfare

1. Children at the Interface of Child Mental Health and Child Welfare Michelle Caza John McLennan 10th Annual Qualitative Health Research Conference May 1, 2004 Banff, Alberta www-fhs.mcmaster.ca/cscr/integration mcaza@ucalgary.ca 403-220-2776

2. Study Overview: • The “Integration Study” is composed of several sub-projects. • Interface service issues in the child welfare and mental health sectors and was driven by: • our partners’ interest • the numerous references to interface issues in interviews with administrators and providers • empirical literature

3. Canadian Data • Child Function Problems (Trocmé et al., 2001): • Behavioral problems, 24% • Depression or anxiety problems, 11% • Developmental delay, 8%

4. American Data • Child Function Problems (Garland et al., 2001) • ADHD, 21% • Conduct Disorder, 16% • Oppositional Defiant Disorder, 14% • Major Depression Disorder, 5% • Separation Anxiety Disorder, 5%

5. Service Utilization • Rates of mental health service utilization are: • difficult to determine (Landsverk & Garland, 1999) • greater for children in state care than in the community (Landsverk & Garland, 1999) • Substantial delays in receiving mental health treatment after onset of emotional problems (Trupin et al., 1993)

6. Service Utilization • Children in foster care: • used mental health services at a rate of approximately 15 times greater than other children (Halfon & Klee, 1991) • 56% had used mental health services after entering state care (Landsverk & Garland 1999) • 14% were referred to mental health services (Glisson 1996)

7. Research Question: What prevents children in the protection of the state from obtaining needed mental health services?

8. Methodology • 11 interviews • Research team used semi-structured interviews • 5 discussion groups • Research team directed discussion • 1 workshop with 15 participants • Research team facilitated discussion by presenting three topics for discussion • Participants discussed one of the three topics in small groups • Summary of the participants’ group discussion reviewed by participants

9. Analysis • Grounded theory approach • Initial analysis • Identified codes • Incorporated emerging themes into subsequent interviews • Subsequent analysis: • Refined codes • Develop model

10. A Preliminary Model Lack of Services Resource (Mis)Allocation Communication Problems Failures in Service Delivery Poor Outcomes For Children

11. Lack of Services we’re constantly scratching our heads at how we’re going to help some kids who have real mental health problems” …provincial child welfare administrator

12. Lack of Services We’ve seen so many kids that are in care for a year or two before they get any kind of mental health assessment, and we know that more than 80% of them have mental health problems …urban mental health provider

13. Lack of Services Nobody wants to take him for treatment. Treatment centers don’t usually take kids unless they are 12 or 13 years old….His needs are becoming higher, he’s basically deteriorating in front of us and we can’t stop it …rural child welfare provider

14. Resource (Mis)Allocation I don’t know why necessarily they access [private mental health services] and not us….Very few of them come to Mental Health first. They come to Mental Health through psychiatry second, third, fourth, fifth, sixth, down the line after they’ve gone through a bunch of private stuff …urban mental health provider …I don’t [blame] them for doing it, I don’t think it’s a good use of money. I think if it was all in one pot together, it could be better utilized. But…they have to have reports for courts…I mean they [have] to do it… …urban mental health administrator

15. Resource (Mis)Allocation There is an issue around, sort of this game that Mental Health and Child Welfare play…sort of pass the hot potato. If the Mental Health clinic is – and they’re all pretty much inundated with service demands and the child welfare worker has a child who also has a mental health issue, we know the child welfare worker can access private service provider to provide services to those children. So it’s a complicated game of between the therapist and the child welfare worker about who actually is to provide service. Unfortunately, what happens a lot of times, in my region anyway, is that sometimes nobody provides the services to the child because they’re still figuring out what to do with the child or the opposite happens in that the [public] clinician is providing services and a private contracted service is also providing service …rural mental health provider

16. Resource (Mis)Allocation all types of models have been attempted, and not because of a change in mandate or a change in approach provincially. But local needs, particularly outside the major centers, whose available, whose living there to provide [mental health] services …provincial child welfare administrator

17. Communication Problems It’s a sort of definition and discipline issue, too, you know. Psychologists and psychiatrists coming from way over here and social workers from way over here. Like they may be talking about the same kid with the same presenting problems but they see him a little differently, and they see the solutions really differently. And quite often they’re looking at each other for the solution. They don’t talk the same language …provincial child welfare administrator

18. Communication Problems Child Welfare got involved because of a sexual abuse disclosure. So now, they’re [child welfare] sending him to me because maybe I can get the information out of him. Well, I don’t go information hunting….Now if you get to talk to them, and explain it, it’s usually okay. But, sometimes they [child welfare] don’t understand why we won’t see certain people or why we can’t do certain things …rural mental health provider

19. Communication Problems I certainly think Mental Health, from their end, they’re very concerned about client confidentiality and, interestingly, what I’ve heard happens is that Mental Health workers will call our workers asking for information, our workers are allowed to share the information and will do it, but they don’t get that back from Mental Health workers. And sometimes they find that Mental Health workers, almost, because they’re advocating for their families, it’s like they’re working at cross-purposes sometimes …rural child welfare administrator

20. Communication Problems …privacy concerns prevent effective information sharing on the behalf of children …provincial child welfare administrator

21. Barriers from Empirical Literature: • Inadequate or absent mental health services (Klee et al., 1997; Trupin et al., 1993) • A lack of properly implemented and/or appropriate mechanisms to identify and refer children with mental health problems to services (Klee et al., 1997; Dale et al., 1999; Glisson et al., 2002) • Lack of cooperation among providers (Trupin et al., 1993)

22. System Characteristic: Lack of services Resource (mis)allocation Communication problems System Failure: Delays in treatment Fractionated services Delays in treatment Duplication of services Inhibits information sharing Contributes to misperceptions each sector has of the other sector Summary

23. Current Initiatives • Address the needs of children: • With multiple impairments, complex mental health and health issues and/or severe behavioural needs; • For whom all currently available resources have been utilized with limited success • Who require fiscal and human resources that strain the capacity of any one ministry • For whom there are questions about the safety of the child, youth, family, or public

24. Current Initiatives • Components of interest: • Case management model • Cross-ministry information sharing

25. Research Team • John D. McLennan, MD, MPH, FRCP(C), Principal Investigator, University of Calgary, Calgary, Alberta • Michael Boyle, MSW, PhD, McMaster University, Hamilton, Ontario • Robin McWilliam, PhD, Vanderbilt University, Nashville, Tennessee • D. R. Offord, MD, FRCP (C), McMaster University, Hamilton, Ontario • Kent Rondeau, MBA, PhD, University of Alberta, Edmonton, Alberta • Debbie Sheehan, BScN, MSW, City of Hamilton, Hamilton, Ontario • Michelle Caza, MA, University of Calgary, Calgary, Alberta • Ellie Deveau, BScN, McMaster University, Hamilton, Ontario

26. The Integration of Health and Social Services for Young Children and their Families Funders • Canadian Health Services Research Foundation • Alberta Heritage Foundation for Medical Research • Ontario Ministry of Health and Long-Term Care • (Canadian Institutes of Health Research)

27. Selected Bibliography Dale G Jr, Kendall JC, Stein Schultz J. 1999. A proposal for universal medical and mental health screening for children entering foster care. In The Foster Care Crisis: Translating Research into Policy and Practice, GD Dale and JC Kendall (editors). Lincoln, NB: University of Nebraska Press, pps. 175 – 192. Garland AF, Hough RL, McCabe KM, Yeh M, Wood PA, Aarons GA. 2001. Prevalence of psychiatric disorders in youths across five sectors of care. Journal of the American Academy of Child and Adolescent Psychiatry 40 (4): 409 – 418. Glisson C. 1996. Judicial and service decisions for children entering state custody: The limited role of mental health. Social Service Review June: 257 – 281. Glisson C, Hemmelgarn A, Post JA. 2002. The shortform assessment for children: An assessment and outcome measure for child welfare and juvenile justice. Research on Social Work Practice 12 (1): 82 – 106. Halfon N & Klee L. 1991. Health and development services for children with multiple needs: The child in foster care. Yale Law & Policy Review 9 (46): 71 – 96. Klee L, Kronstadt D, Zlotnick C. 1997. Foster care’s youngest: A preliminary report. American Journal of Orthopsychiatry 67 (2): 290 – 299. Landsverk JL & Garland AF. 1999. Foster care and pathways to mental health services. In The Foster Care Crisis: Translating Research into Policy and Practice, Curtis PA, Dale GD, & Kendall JC (editors). Lincoln: University of Nebraska Press in association with the Child Welfare League of America. Chapter 9 (pp 193 – 210). Trocmé NM, MacLaurin BJ, Fallon BA, Daciuk JF, Tourigny M, Billingsley DA. 2001. Canadian incidence study of reported child abuse and neglect: Methodology. Canadian Journal of Public Health 92 (4): 259 – 263. Trupin EW, Tarico VS, Low BP, Jemelka R, McClellan J. 1993. Children on child protective service caseloads: Prevalence and nature of serious emotional disturbance. Child Abuse & Neglect 17: 345 – 355.