Addressing the Unique Behavioral Health Needs of Children and Families

in the Child Welfare System

Institute #24

Caraleen Fawcett, Jan McCarthy,Frank Rider, Steve Sparks and Robin Trush

2006 Training InstitutesJuly 2006

Addressing the Unique Behavioral Health Needs of Children and Families in the Child Welfare

System – A National Perspective

Jan McCarthy

National TA Center for Children’s Mental Health

Georgetown University Center for Child and Human Development

Who are the children and families?

Reports of Child Abuse and Neglect

Total reports FY 03 2,900,000

2/3 were investigated 1,914,000

1/3 were confirmed 906,000

10% resulted in child placement 297,000

In placement more than 2 years 40%

Source:AFCARS Report 4/2/05, US DHHS, ACF, ACYF, CB http://www.acf.hhs.gov/programs/cb/stats_research/afcars/tar/report10.htm

Who are the children and families?

Children in foster care 523,000 Median age 10.9 years

16 & older20%

6-15 years50%

Birth - 5 years30%

Birth - 5 years

6-15 years

16 & older

Source: AFCARS Report 4/2/05, US DHHS, ACF, ACYF, CB http://www.acf.hhs.gov/programs/cb/stats_research/afcars/tar/report10.htm

Who are the children and families?

Race/ethnicity of Children in Foster Care

White-Non Hispanic 39% Black-Non Hispanic 35% Hispanic 17% Two or more races-Non Hispanic 3% Unknown 3% American Indian/Alaskan Native 2% Asian-Non Hispanic 1% Hawaiian/Pacific Islander-Non Hispanic 0.2%

Source:AFCARS Report 4/2/05, US DHHS, ACF, ACYF, CB http://www.acf.hhs.gov/programs/cb/stats_research/afcars/tar/report10.htm

Representation of 5 Racial/

Ethnic Groups in Foster Care

Over-represented African American 2.43 Native American 2.16

Under-represented Latinos .79 Non-Latino Whites .76 Asian/Pacific Islanders .39

Source: 11/04 working paper by Robert B. Hill published in Race Matters Consortium, “Over-representation of Child of Color in Foster Care in 2000”

Living Arrangements of Children in Foster Care

Foster Family Home (non-relative) 46%

Foster Family Home (relative) 23%

Group Care (Institution/GH) 19%

Pre-Adoptive Home 5%

Trial Home Visit 4%

Runaway 2%

Supervised Independent Living 1%Source: AFCARS Report, FY 2003

Why Focus on Mental Health Issues?

Prevalent Need for Services children’s vulnerability and risk high prevalence of physical, behavioral,

developmental needs prior life experiences trauma of separation and placement experiences within foster care system parental service needs (MH, SA, DV +) relinquishing custody for treatment services difficulty in accessing services

National Data – MH Needs

National Survey of Child and Adolescent Well-Being (NSCAW)

Number of children studied 3,803 Ages 2 – 14 All involved with child welfare system:

Living in own homes 90% Living in foster, group,

or residential care 10%

SOURCE: Burns, B. et al. 2004 Mental health need and access to MH services by youths

involved with child welfare: A national survey. Journal of the American Academy of Child and Adolescent Psychiatry 43:8: 960-970.

National Data – MH Needs

47.9% of children/youth had significant emotional/

behavior problems (Need was defined by a clinical range score on the Child

Behavior Checklist)

Only 25% of children/youth with significant emotional/behavior problems received specialty mental health care in previous 12 months

SOURCE: Burns, B. et al. 2004 Mental health need and access to MH services by youths involved with child welfare: A national survey. Journal of the American Academy of

Child and Adolescent Psychiatry 43:8: 960-970.

National Data – MH Needs

NSCAW provides documentation of the magnitude of the problem:

• Large gap between service need and service use

• Failure of human service sectors to obtain mental health services needed by group of very high risk children and youth

National Data Demonstrates Need for Whole Family Approach

Children with a clinically significant externalizing score on the CBCL were more than twice as likely to have a caregiver with an alcohol, drug, or mental health problem.

Whole family approach to treatment can: address both child and caregiver needs

support interaction between the two

prevent children from being separated from their parents, e.g., drug and alcohol treatment facilities for the whole family.

Source: Anne M. Libby, University of Colorado, NSCAW data

National Data Shows Benefits

of Collaboration

Analysis of linkages between child serving systems in 92 sites:

Showed that increased coordination between MH and CW is associated with: greater use of services by children with

highest level of need decreased racial/ethnic disparities in receipt

of MH care

Source: Michael S. Hurlburt, CASRC, San Diego, NSCAW Data

Child and Family Services ReviewsCFSRs - Another Source of National Data

The CFSR Process and Mental Health: Focuses on well-being (PH, MH,

Education) Identifies need for MH reform Provides opportunity for reform Encourages participation of other

systems, c/b agencies, families

CFSR Findings2001-2004 Reviews (n = 52 States and

Territories)

PH and MH Needs Met (WB Outcome 3)• In substantial conformity 1 state• NOT in substantial conformity 51

states

MH Needs of the Child Met (Item 23)• Strength 4 states• Area Needing Improvement 48 states

CFSR FindingsAmong the primary reasons for case

openings(2001-04 - N = 2,416 children)

Child’s behavior (11% of all children; 41% of children age 13 +)

Parent’s behavior (including neglect, excluding child abuse)

Family’s mental and physical well being

CFSR Findings 2002-04 Content Analysis of Systemic Factors (N=35 states)

Service Array (for children placed in home and out-of-home) MH assessment and treatment services

are not sufficient to meet children’s needs 31 states Key services for parents lacking (including

substance abuse services) 30 states Lack of culturally appropriate services 18 states

CFSR FindingsStates are working on solutions to the

problems (N = 28 States): Program Improvement Plans (PIPs)

provide opportunity to correct problems identified in Final Reports

2/3 of PIPs identify strategies to improve assessment of MH needs and to expand service array and service capacity

All 28 PIPs mentioned MH issues and most (25) set goals and action steps to address them

CFSR Findings 2/3 of PIPs showed collaboration

across systems to address cross-system problems

1/3 of the PIPs proposed a comprehensive strategy for improving MH services

CFSR Findings Cultural competence – addressed in

very few Final Reports and PIPs in relation to MH and SA services – requires further study

Evidence based practices – very little data about concerted efforts to use evidence based MH practices

Some Trends in Child Welfare

Moving toward family-centered practice Use of child and family teams (including

multiple families in child’s life) Growth of kinship care Privatization Collaboration with other child-serving

systems – especially mental health; child welfare no longer seen as solely responsible

Addressing the Unique Behavioral Health Needs of

Children and Families in Arizona’s Child Welfare

System

Caraleen Fawcett, Pima County Community Network Team

Frank Rider, AZ Division of Behavioral Health Services

Steve Sparks, AZ Division for Children, Youth & Families

Robin Trush, System of Care Veteran, Maricopa County

…and who are you?

One Family’s Experience

Caraleen and Aliyah’s Story

Caraleen’s Themes

Pathologizing People We Serve, vs. Strength-Based, Needs-Driven

Overwhelming Families, vs. “One Family, One Team, One Plan”

Caraleen’s Themes

Parent Professional Partnerships – Equality and Respect

Hopelessness vs. Inspiring Hope

What Went “Right?”      Only one caseworker      Parent highly/self-motivated, resourceful

Pro-bono attorney friend - who happens to serves on the board of treatment center

Parent aide

Ponder this: How many families like Caraleen’s have experienced

comparatively poor outcomes, for their lack of any such fortunate factors?

Arizona’s Child Welfare System

DES(Social Service Agency)

Division of Children, Youth and Families

District IMaricopa County

District II

Pima County

District III

Coconino, Apache, Navajo

& Yavapai Counties

District IVYuma, Mohave

& La Paz Counties

District VI

Cochise, Graham, Greenlee

& Santa Cruz Counties

District VGila & Pinal Counties

Arizona’s Child Welfare System

FEDERAL GOVERNMENT HEALTH AND HUMAN SERVICES ARIZONA STATE

GOVERNMENT (Appropriations)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY DIVISION OF CHILDREN, YOUTH AND FAMILIES

District Offices

Field Offices

$

Administration for Children, Youth and Families

Children’s Bureau

$

$

$

SUBCONTRACTED PROVIDERS

$

Arizona’s Behavioral Health System

AHCCCS (State Medicaid Agency)

Arizona Department of Health Services/Behavioral Health Services

Pascua Yaqui Tribal RBHA

Community Partnership of Southern Arizona

(CPSA)

ValueOptions

Northern Arizona RBHA (NARBHA)

Acute Care Health Plans

Cenpatico BH

Subcontracted Providers

Subcontracted Providers

Subcontracted Providers

Long Term Care Program Contractors

(e.g. DDD)

Gila River Tribal RBHA

Subcontracted Providers

FEDERAL GOVERNMENT HEALTH AND HUMAN SERVICES

ARIZONA STATE GOVERNMENT

(Appropriations)

ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS) DIVISION OF BEHAVIORAL HEALTH SERVICES (DBHS)

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

(AHCCCS)

REGIONAL BEHAVIORAL HEALTH AUTHORITIES (RBHAs) and TRIBAL REGIONAL BEHAVIORAL HEALTH AUTHORITY (TRBHAs)

SUBCONTRACTED PROVIDERS

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION

(SAMHSA)

CENTER FOR MEDICARE AND MEDICAID SERVICES

(CMS)

$

$

$

$

$

$

Arizona’s Behavioral Health System

Arizona Behavioral Health and Child Welfare

Systems

Different expectations Different mandates and external

requirements Different funding streams and

approaches Different pace of work with family No common outcomes

Arizona Behavioral Health and Child Welfare

Systems

The child welfare system had developed its own de facto behavioral health system, to meet the unique needs of children and families it serves – needs that the public behavioral health system did not fully understand, or know how to address; and needs that the child welfare system was neither trained nor equipped to address.

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

Consequences of Misalignment of BH and CW Systems

Enormous Costs to Both Systems: 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

Consequences of Misalignment of BH and CW Systems

What Do Children Experience?

Separation from parents Separation from brothers and sisters Loss of pets Move from familiar

neighborhood/community Change of school Loss of friends Unfamiliar caretakers, routine, expectations Loss of comfort objects Sadness, anger, fear, guilt, shame,

differentness

“We Gotta Get Outta This Mess…”

But How?? How to optimize the existing expertise and resources within each system to meet a common success with a shared family?

Impetus for Change

Community Initiatives High Profile Tragedy CFSR Findings Legislation – Executive

Order System of Care Grant

Program Litigation

Arizona’s Reform Journey

JK Litigation (1991-1997) “Discovery” (1997-2000)

Governor’s Task Force on Behavioral Health and Child Welfare (2000)

JK Settlement Agreement (2001) Governor’s CPS Reform (2003)

The 12 Arizona Principles

Collaboration with the Child and Family Functional Outcomes Collaboration with Others Accessible Services Best Practices Most Appropriate Setting Timeliness Services Tailored to the Child and Family Stability Respect for the Child and Family’s Unique

Cultural Heritage Independence Connection to Natural Supports

Leadership – Being a Change Agent

Leadership Qualities: Philosophical Buy-In Early Innovators Sense of Urgency Commitment to Action

Being a Change Agent Through Parent/Professional Partnerships

Partnering at All Levels Voice, Access and Ownership Mirrors Successful Business

Practices Family is the Constant in

Communities Shared Burden with Change

Building A Common 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

Building A Common Vision

Arizona Children’s Executive Committee: Collaborative Implementation of JK

Actions Family Involvement A Primary Value

(2001) Memorandum of Understanding (2002) Barriers Identification and Resolution

(2003) Commitment to Support CPS Reform

(2004)

Developing a Common Language

12 Arizona Principles Child Welfare Values and

Principles (Safety, Permanence, Well-Being)

Crosswalk #1 - Values and Principles

Crosswalk #2 - Child and Family Teams/ Family Group Conferencing

Developing a Common Language

Awareness Sensitization Empathy Understanding Learning Community

Creating Change in Arizona

Structure Process Outcomes

Structure to Address Unique Needs of Children

and Families Funding Policies: Example – AZ’s Urgent

Response for Children Entering Foster Care

Letters of Agreement/Detailed Protocols

Clinical Guidelines: “How to Operationalize Our Common Work”

Targeted Programming

Funding Maximizing Medicaid – One Single

System Risk-Adjusted Capitation (7/1/04) Program Development to Address

Needs Direct Supports to Caregivers Birth to Five Substance Abuse Specialty Skills and Services Expanded Provider Networks

Policies – Example:Arizona’s Urgent BH

Response for Children Entering Foster Care

One Simple Sentence…

“An urgent response should be initiated in a punctual manner, within a timeframe indicated by the person’s clinical needs, but no later than 24 hours from the initial identification of need. 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]

Arizona’s “Urgent BH Response,” and its Five

PurposesUrgent 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 August 31, 2006, more than 11,500 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

The Unique BH Needs of Children Involved with

CPS

1. Services to the Child2. Services to the Family3. Services to Support Temporary

Protective Caregivers

ADHS Practice Improvement Protocol #15: Addressing the Unique Behavioral Health Needs of Children Involved with CPS

1. Working in Partnership2. Addressing Needs in the Context

of Each Child’s Family3. When the Child Remains with

His/Her Family4. When the Child Is Removed to

Protective Foster Care

ADHS Practice Improvement Protocol #15: Addressing the Unique Behavioral Health Needs of Children Involved with CPS

5. When the Child Returns Home to His/Her Family of Origin from Foster Care

6. When the Child Achieves Permanency through Guardianship or Adoption

7. Special Considerations for Infants, Toddlers and Pre-School Aged Children

8. Preparing the Adolescent for Independent Living

[See www.azdhs.gov/bhs/guidance/unique_cps.htm]

Trauma-Informed Clinical Approaches:

On-Line CEU-Credited Training

  Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) – Medical University of South Carolina -- http://tfcbt.musc.edu

 2.   National Center on Substance Abuse and Child

Welfare (NCSACW) -- http://www.ncsacw.samhsa.gov/tutorials/

 3.   Bonding and Attachment in A Maltreated Child – Bruce Perry MD, Child Trauma Academy - http://

www.childtraumaacademy.com/bonding_attachment/index.html

Trauma-Informed Clinical Approaches

Cognitive Behavioral Intervention for Trauma in Schools (CBITS) ® Manual (Lisa H. Jaycox Ph.D., 2004) www.sopriswest.com or jaycox@rand.org

 Seeking Safety: A Treatment Manual for PTSD and Substance Abuse

(Najavits, Guilford Press, 2002) www.seekingsafety.org  Trauma Adaptive Recovery Group Education & Therapy Model for

Adolescents (TARGET-A; Ford et al., 2000; Ford, Mahoney & Russo, 2004) from www.ptsdfreedom.org or ford@psychiatry.uchc.edu

 Dialectical Behavior Therapy for Adolescents, Rathus, Miller & Linehan (in

press)  School-Based Trauma/Grief Group Psychotherapy Program

(SPARCS; Layne, Saltzman, Pynoos, et al., 2000) from Ruth@bascom.com

Source: Jorielle R. Brown Ph.D, SAMHSA/CSAT, Treating Co-Occurring Disorders (June 2006)

Therapeutic Foster Care: A Programming Success

Story Early Efforts – An Alternative to Congregate

Care Braiding Medicaid and Title IV-E Resources ADHS Practice Improvement Protocols:

#12: Therapeutic Foster Care Services for Children

#14: Out of Home Care Services Recruitment, Licensing and Certification TFC Capacity: From 9 (09/03) to 404 (05/06) PS-MAPP and PS-MAPP TFC Curriculum

Processes Promoting Change

Child and Family Teams/Wraparound

Casey Family – Team Decision Making

Co-location of Behavioral Health with Child Welfare Personnel

Come 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

Promising Data about Arizona Children

(Increased) Stability – Past Six Months Ages 5-11: 14.5% higher with CFT (74.0%) Ages 12-17: 16.9% higher with CFT (70.4%)

(Increased) Safety – Past Six Months Ages 5-11: 10.9% higher with CFT (69.2%) Ages 12-17: 11.4% higher with CFT (66.2%)

ADHS CIS (05/06): N = 31,690 children/families

Promising Data about Arizona Children

Success in School – Past Six Months: Age 5-11: 11.2% higher with CFT (64.2%) Age 12-17: 12.6% higher with CFT (65.1%)

Lives with Family – Past Six Months: Age 5-11: 6.7% higher with CFT (87.0%) Age 12-17: 4.7% higher with CFT (75.5%)

ADHS CIS (05/06): N = 31,690 children/families

Promising Data aboutArizona’s Children

Avoids Delinquency – Past Six Months Age 5-11: 9.2% higher with CFT (72.5%) Age 12-17: 11.0% higher with CFT (69.7%)

Preparation for Adulthood – Past Six Months Age 5-11: 6.3% higher with CFT (57.4%) Age 12-17: 10.1% higher with CFT (57.4%)

ADHS CIS (05/06): N = 31,690 children/families

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

Taking It to the Next Level

Service Integration: “One Family, One Team, One Plan”

AssessmentPlanningThe Whole FamilyFamily to Family

Taking It to the Next Level

Service Delivery Capacity Capability Strengthening and Preserving

Families Service Integration – System Level IV-E Waiver: Expedited Reunification

Taking It to the Next Level

“It Takes A Village”

Community Network Teams

Questions?

Thank you for your attention!