Integrating systems of care in california for youth with severe emotional disturbance II: Initial group home expenditure and utilization findings from the California AB377 Evaluation Project

The California AB377 Evaluation Project was established to study the replication of an innovative system of care in three California counties for youth suffering from severe emotional disturbance. Development of the innovative system of care was pioneered in Ventura County, California, and the replications were legislatively enabled through Assembly Bill 377 (AB377). This paper reports evaluative findings about a central goal of the innovative care system: the reduction of use of highly restrictive out-of-home placements though creation and maintenance of coordinated and effective community-based services. Group home facilities are the focus of the evaluation work because these facilities consume the largest proportion of all public expenditures for youth in residential placements in California. More than 10 years of aggregate county and state level monthly expenditure and utilization data are presented. The results indicate that the demonstration counties have generated lower per capita inflation adjusted rates of expenditures and per capita group home placements than California as a whole. The evaluation results provide evidence that an integrated system of care can reduce group home placements. However, the nature, quality and effectiveness of any and/or all alternative services provided remains a topic for further investigation.     

Integrating systems of care in California for youth with severe emotional disturbance III: Answers that lead to questions about out-of-home placements and the AB377 evaluation project

This paper is the third in a series of reports on preliminary empirical findings from replications of an integrated system of care for youth suffering from serious emotional disturbance. The development of the innovative system of care was pioneered in Ventura County, California, and the replications in three other California counties were legislatively enabled through California legislation (Assembly Bill 377). This report presents results on the expenditure and utilization of foster homes, residential placements made through special education programs, and state hospitals. Evaluation results indicate that foster home and state hospital utilization and expenditures are lower for the counties replicating the innovative system of care than for the state of California as a whole. Expenditures for special education residential placements are either at the state rate or lower in one county. The cumulative evidence supports the conclusion that the replication counties are utilizing restrictive levels of care at lower rates than would be expected, given state-wide patterns. The results, in conjunction with prior findings, are discussed in the context of questions about the possible fates of youth who no longer live in publicly funded residential facilities.     

Demographic, Clinical, and Functional Characteristics of Youth Enrolled in Six California Systems of Care

We describe the demographic, functional, and clinical status of children served across six California counties implementing a longstanding integrated system of care approach called the California System of Care Model. The children enrolled in the care systems are an ethnically diverse group of predominantly pre-adolescent and adolescent males. The level of functional impairment and degree of symptomatology is high. Seventy to 80% of the youth were in the clinical or borderline clinical ranges as measured by the Child Behavior Checklist. Scores on the Child and Adolescent Functional Assessment Scale, provided by the treating clinician, indicated that up to 94% of the youth were in the moderate to severe levels of impairment. Children and adolescents rated themselves on the Youth Self Report as having lower levels of impairment than did parents. Caregivers and youth ratings emphasized externalizing rather than internalizing problems. Clinician ratings as captured by the CAFAS and the clinical diagnoses, presented a mix between internalizing and externalizing diagnoses and functional impairment areas. The six counties are serving children who have levels of impairment, similar to, or higher than, youth enrolled in other systems of care nationwide.     

Demographic Influences on Psychiatric Diagnoses Among Youth Served in California Systems of Care

We examined the influences of demographic factors on diagnostic assignment among youth served in California public mental health systems after adjusting for the effects of county characteristics and standardized symptom and functioning indices. The sample consisted of 12,106 youth with severe emotional disturbance being served in integrated and coordinated service systems in 13 counties of California. African Americans were overrepresented in the sample relative to the ethnic characteristics of the counties and Asian Americans were under-represented. Results from logistic regression analyses showed that gender, age, and ethnicity affected the assignment of eight categories of clinical diagnosis at admission. However, standardized measurement of clinical status and functioning had little relationship to clinicians' assignment of diagnosis. Whereas no significant gender and age differences were found on broadband CBCL syndromes, ethnically diverse youth differed on CBCL internalizing and externalizing scores. Youth's role functioning as assessed by the CAFAS also significantly differed by gender, age, and ethnicity.     

Integrating Systems of Care in California for Youth with Severe Emotional Disturbance IV: Educational Attendance and Achievement

Empirical results are presented from school-based interventions in three California counties that are pioneering participants in a carefully evaluated effort to create an innovative system of care for youth with severe emotional disturbance. Data are presented about the educational attendance and achievement of youth enrolled in clinical and academic programs designed to provide collaborative mental health and education services. Attendance levels were uniformly high. The youth were below expected grade level as measured by standardized tests at program admission. Across programs, two counties demonstrated grade level increases of one year or more for one year in school on all subscales of established measures of educational achievement. The third county demonstrated increases of slightly less than one year on two of three subscales of the educational achievement measures. These results are the first from a multisite demonstration of integrated education and mental health programs embedded within a broader system of care for youth. The findings, combined with those from our prior studies, illustrate that is possible to reduce and control placements in restrictive levels of care while improving the academic performance of a vast majority of the youth enrolled in specialized programs within the care systems.     

Usability of a Smartphone Application to Support the Prevention and Early Intervention of Anxiety in Youth

Mental, emotional, and behavioral disorders are common in youth with anxiety problems being among the most prevalent, typically failing to spontaneously remit, and placing some youth at risk for additional difficulties. Mobile health (mHealth) might be a novel avenue to strengthen prevention efforts for child anxiety, since program effects are generally small. However, although a significant number of mHealth tools have been developed, few have been evaluated in terms of usability (or even clinical effectiveness). Usability testing is the first level of evaluation in responsible mHealth efforts as it is one of the main barriers to usage and adoption. As such, the objective of this research was to evaluate the usability of a smartphone application (app) corresponding to an indicated prevention and early intervention targeting youth anxiety. To accomplish this, 132 children (M_age = 9.65, 63% girls) and 45 service providers (M_age = 29.13, 87% female) rated our app along five established dimensions of usability (ease of use, ease of learning, quality of support information, satisfaction, and stigma). Findings showed that the app was highly and positively rated by youth and providers, with some variations (lower ratings when errors occurred). Path analyses also showed that system understanding was significantly related to greater system satisfaction, but that such relation occurred through the quality of support information offered by the app. Together, this has research and clinical implications as it highlights avenues for advancing youth care via mHealth usability evaluation, including prior to establishing effectiveness.     

Going Home Again: Transitioning Youth to Families After Group Care Placement

This paper presents results from the transitioning youth to families intervention, which aimed to promote family care for youth served in group care programs in the child welfare system. The intervention was conducted in two counties in a Mid-Atlantic state. The effort encompassed administrative case review and family involvement meetings. We assessed the effect of the intervention in promoting placement in family settings within 12 months. We also explored other effects of the intervention identified by participants. Using propensity score matching with administrative data to compare one-year placement settings for the intervention counties and non-intervention counties, a higher rate of family reunification was identified for youth in the treatment counties. To provide a richer contextual understanding of the effects of the intervention, thematic analysis of open-ended comments from youth and caregiver participants was conducted. These resulting themes provided further understanding of the value of the intervention especially in the areas of planning for the transition, improving youth insight about placement options, and the importance of family involvement. Participants also made recommendations for how to enhance the intervention and promote the transition of youth from group care to family settings. Overall, the effect of the intervention in transitioning youth to family settings was nominal; however unanticipated benefits of engaging youth and family in the transition process were noted. From this evaluation, we provide suggestions for future research and the development of effort to transition youth from group care settings.     

Mental Health Problems of Children in Foster Care

We compared the rates of mental health problems in children in foster care across three counties in California. A total of 267 children, ages 0 to 17, were assessed two to four months after entry into foster care using a behavioral screening checklist, a measure of self-concept and, in one county, an adaptive behavior survey. Results confirmed previous research and indicated consistently high rates of mental health problems across the three counties. Behavior problems in the clinical or borderline range of the CBCL were observed at two and a half times the rate expected in a community population. Fewer children fell within the clinical range on the self-concept measure. No significant differences in rates between the three county foster care cohorts were observed, despite the different demographic characteristics of the counties. On the adaptive behavior scale, the mean scores for children in foster care were more than one standard deviation below the norm. Our findings suggest that the most important mental health screening issue with children in foster care is to identify what specific mental health problems need to be addressed so that the most effective treatment services can be provided.     

System-Level Change in Cultural and Linguistic Competence (CLC): How Changes in CLC are Related to Service Experience Outcomes in Systems of Care

As US demographic trends shift toward more diversity, it becomes increasingly necessary to address differential needs of diverse groups of youth in mental health service systems. Cultural and linguistic competence (CLC) is essential to providing the most appropriate mental health services to youth and their families. The successful implementation of CLC often begins at the system level. Though various factors may affect change and system-level factors set the tone for broad acceptance of CLC within systems, there is limited empirical evidence linking culturally competent practices to outcomes. The purpose of the present study was to examine system-level CLC changes over time within systems of care and their associations with service experiences among youth and their families. Participants were 4,512 youth and their families enrolled in the national evaluation of the Children’s Mental Health Initiative (CMHI). Results suggest that implementation of CLC at the system level improves over time in funded systems of care. Further, variation exists in specific system-level components of CLC. In addition, the changes in CLC at the system level are related to family/caregiver participation in treatment. Implications for supporting positive changes in CLC among systems of care communities, and specific strategies for community psychologists, are discussed.     

Supporting the Need for an Integrated System of Care for Youth with Co-occurring Traumatic Stress and Substance Abuse Problems

Adolescents are at high risk for violence exposure and initiation of drug use. Co-occurring substance use and trauma exposure are associated with increased risk of mental health disorders, school underachievement, and involvement with multiple systems of care. Coordination and integration of systems of care are of utmost importance for these vulnerable youth. This study delineates the negative sequelae and increased service utilization patterns of adolescents with a history of trauma, substance abuse, and co-occurring trauma and substance abuse to support the need for integrated mental health and substance abuse services for youth. Data from two national sources, the National Child Traumatic Stress Network and Center for Substance Abuse Treatment demonstrate the increased clinical severity (measured by reports of emotional and behavioral problems), dysfunction, and service utilization patterns for youth with co-occurring trauma exposure and substance abuse. We conclude with recommendations for an integrated system of care that includes trauma-informed mental health treatment and substance abuse services aimed at reducing the morbidity and relapse probability of this high-risk group.     

Psychiatric Issues Among Adjudicated Youth: Challenges,Failures, and Successes

ABSTRACT

Children and adolescents afflicted with psychiatric illness are at particularly high risk for becoming part of the juvenile justice system. More than two thirds of justice-involved youth have psychiatric disorders (Abram et al., 2003; Shufelt & Cocozza, 2006; Teplin et al., 2002). Given the involvement of the legal system, youth being separated from families, and a host of other factors, mental health service delivery in a juvenile detention facility poses unique challenges. This article focuses on an overview of the problems commonly encountered in this setting. A clinical vignette will be used to highlight key points. The role and significance of trauma, common psychiatric disorders, and relevant medication rationale will be explored.     

Quantitative and qualitative analysis of a set of goal attainment forms in primary care mental health services

Aims: The aim of this paper is to present an attempt to collate the results of the client‐completed Goal Attainment Form (GAF) and to explore the usefulness of analysing the data in this way. The GAF is used primarily to add qualitative idiosyncratic data to the quantitative data collected by the CORE‐OM (Clinical Outcomes for Routine Evaluation Outcome Measure) questionnaire. Method: A sample of 477 completed GAF were used during short‐term therapy through primary care mental health services to investigate potential correlations in various different aspects between the GAF and the CORE outcome measure (CORE‐OM). The themes from these forms were qualitatively analysed to compare how clients describe their experience of therapy with clinical perspectives. Results: The results reveal several significant correlations. Themes used by clients to describe their problems and benefits of therapy were different from clinicians' perspectives. Discussion and recommendations: Several suggestions and recommendations are offered regarding evaluation, therapy and primary care short‐term therapy services.     

Assessment of Needs in Residential Care: Perspectives of Youth and Professionals

The evaluation and identification of needs profiles for youth in residential care, through qualitative and quantitative methodologies involving different stakeholders, are still relatively uncommon, even though they are essential in developing specific and effective services. This article will present two studies, one with youth and another with professionals. To assess needs from the standpoint of youth, four focus groups were held with youth in residential care (n = 21). To identify needs profiles of youth from the standpoint of professionals, 47 professionals evaluated a sample of youth in residential care (n = 110) using the RCYNA questionnaire. The results of the study with youth point to needs in three main areas: living situation, social and family relationships, and education. The results of the study with professionals reveal three needs profiles with distinct risk levels: low risk, without emerging needs; intermediate risk, with needs in terms of the economic and living situation; and high risk, with needs in terms of relationships, behavioural, psychological and emotional skills, and education and employment.     

Public acceptance of semi-automated truck platoon driving. A comparison between Germany and California

Platooning technology aims at achieving fuel savings by reducing the distance between two or more electronically coupled vehicles. This technology has recently been tested on public highways with heavy trucks in Germany and California. The objective of this study is to assess the level of acceptance among other road users as well as influencing factors of acceptance. An online questionnaire was administered in Germany and California with a total of N = 536 participants. They received information about truck platoon driving (level-1 and level-2 automation) and answered questions about their attitudes towards the technology as well as their behavioral intention to cooperate with the truck platoons. The overall results showed that 70% of respondents indicated acceptance towards the technology, with acceptance rates being significantly higher in California than in Germany. German respondents were more willing to drive into the gap of platoon vehicles and preferred larger platooning gaps. An adaption of the Technology Acceptance Model (TAM) showed that the expected usefulness, and the expected ease of sharing the highway, were the strongest predictors for the behavioral intention to cooperate with platoon vehicles. However, the intention to cut in between platoon vehicles could not be predicted by these variables. Cut-in vehicles are a potential safety risk and decrease the efficiency of platoon driving. Therefore, future research should focus on finding behavioral countermeasures.     

Mental health services for children. The state of the art

Throughout this century, people in the United States have been concerned about the serious deficiencies in the mental health care of our children. Despite eloquent needs assessment and recommendations for remediation, most of the unserved needs and deficiencies of our mental-health-care-delivery system remain the same. This article reviews the current status of mental health services to children, youth, and families to highlight the necessity of an integrated system of mental health care. The development of a continuum of care that is coordinated across the mental health and non-mental-health systems that naturally occur in all children's lives has the potential to vastly improve mental health services to children, youth, and families.     

Developing comprehensive,individualized community-based services for children and youth with emotional and behavior disorders: Direct service providers' perspectives

Increased attention to the plight of children and youth with emotional or behavioral disorders (EBD) and their families has led to innovations in the manner in which these individuals are served. Two such innovations have been the development of public systems of comprehensive, community-based care and individualized wraparound services. This study was part of one community's attempt to merge these two innovations and provide individualized wraparound services to children and youth with EBD through the auspices of public agencies. Direct service providers were surveyed to gather their input into how such services could best be developed and implemented. The survey focused on existing barriers to providing services and specific service priorities for system development. Methods and results are presented. Implications for the local system and future research needs are discussed.     

The self-concept of traumatized children and adolescents with or without PTSD

This study compared the Piers-Harris 2 scores of youth with PTSD (n=30) to the scores of traumatized youth without PTSD (n=60) and a non-traumatized comparison group (n=39). In the absence of major comorbid disorders, youth with PTSD evidenced significantly lower scores than the traumatized PTSD negatives and controls on five of six Piers-Harris 2 scales. With the exception of scores on an index of perceived parental acceptance of child behavior, trauma exposure in the absence of PTSD was not associated with lower Piers-Harris 2 scores.     

System-of-Care Practice Review Scores as Predictors of Behavioral Symptomatology and Functional Impairment

The longitudinal comparison study of the national evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program assesses factors in service delivery systems that may shape the impact of systems of care. We evaluated the extent to which services embodying the principles of a system of care, as measured by the System-of-Care Practice Review (SOCPR), affect clinical outcomes for children being served in federally-funded systems of care and matched comparison communities. The participants included 75 children and families selected for participation in the SOCPR. Results indicated that experience of services embodying system-of-care principles at a high level was associated with lower symptom and impairment scores one year after entry into services. Children in systems of care were rated to have experienced high levels of system-of-care principles implemented within their services, and their symptom severity and functional impairment did not vary as a function of their experiences. Children in matched comparison communities had more variable rated experiences of system-of-care principles within their services, and their symptom severity and functional impairment decreased as their experiences of the principles increased.