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.     

Integrating systems of care in California for youth with severe emotional disturbance. I. A descriptive overview of the California AB377 evaluation project

This paper presents an overview and an initial set of findings from an evaluation in three California counties of a replication 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 were legislatively enabled through AB377 (Assembly Bill 377). This paper focuses on one set of variables being studied in the evaluation: the characteristics of the youth enrolled in the care systems. This variable is important because personnel in the counties are explicitly deciding which youth are eligible for services given limited available public resources. Within the model system of care, clinical severity and risk status (being at-risk ofor in out-of-home placement) are used as the criteria for enrollment with the intent of serving those most in need as effectively as possible. The gender, age, clinical diagnosis, ethnicity, and global assessment of functioning (GAF) scores of these youth are presented. In general, the youth served are male, have low GAF scores, and predominantly receive clinical diagnoses of affective disorders and disruptive behavior disorders. African-Americans are overrepresented in the care systems relative to the general population and Asian-Americans are underrepresented.     

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.     

Treatment Foster Care in a System of Care: Sequences and Correlates of Residential Placements

We examined Treatment Foster Care (TFC) in residential trajectories for youth with psychiatric disorders and aggressive behavior. We analyzed residential placements of a statewide sample of youth during the 12 months preceding and following admission to TFC. Prior to TFC, the majority of youth were residing in more restrictive settings (group homes or residential treatment). Two-thirds of youth remained in TFC throughout the follow-up year. Of those who left, nearly half returned home, and slightly fewer were discharged to group homes. By the end of the 12-month follow-up period, rates of group home use were similar to those seen in the pre-TFC period. Movement out of TFC during the year was associated with being older at placement and with increased problem behavior (particularly externalizing behaviors). TFC serves as a step-down placement for a substantial number of youth. However, this is not the only way it is used, and models based on short-term transitioning or reunification with families may not be widely implemented or relevant in practice. Additional research is needed to understand current functions of TFC in residential trajectories and to maximize its utility in systems of care.     

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.     

Transitioning from congregate care: Preparation and outcomes

Of particular concern to child welfare professionals working with youth in foster care is the quality of services rendered to youth in foster care who are imminently making the transition to adulthood and independence, i.e., those at risk for aging out of foster care, many of whom live in congregate care facilities. This qualitative study focuses on the experiences of youth in congregate care in New York City's foster care system, the effectiveness of efforts to prepare youth for life after foster care, and post-discharge outcomes for youth, particularly when discharged to independent living. The study included interviews with professionals as well as young adults who had exited foster care after placements in congregate care settings. Results indicated that professionals and young adults were concerned about the quality of independent living preparation, viewed housing as a serious issue for youth exiting foster care, attributed youth's lack of employment to poor pre-discharge educational and work preparation services, and emphasized the importance of personal connections after youth leave care.     

Intensive Home Based Services Within a Comprehensive System of Care for Youth

Within a comprehensive mental health service array for youth, Intensive Home Based Services (IHBS) are designed to meet the needs of youth with significant emotional and behavioral problems in their home communities, avoiding the need for out-of-home services, particularly residential care. We examined youth receiving IHBS as their first service in the state of Hawaii system of care (N = 163) to determine how successful IHBS were in preventing the need for more restrictive services within 12 months of intake. Subsequently, we investigated characteristics that might be predictive of a youth’s need for service intensification within 12 months. Logistic regression analyses found that greater age, level of service need, and functional impairment at intake predicted use of more restrictive services within 12 months of intake, whereas gender, ethnicity, diagnosis, service intensity, and clinician credentials did not. Overall, our findings suggested that IHBS were reasonably successful in preventing residential placements, and provided some basis for determining characteristics of youth likely to require more restrictive placements within a one year period.     

Evaluation of a Congressionally Mandated Wraparound Demonstration

In order to determine whether expenditures for mental health could be reduced and quality improved, Congress mandated that the Department of Defense conduct a demonstration project utilizing a wraparound mental health service system for child and adolescent military dependents. A longitudinal quasiexperimental design was used to evaluate the cost-effectiveness of the demonstration. The results showed that children in the Wraparound Group received more wraparound services than those in the treatment as usual (TAU) Comparison Group. These services included case management, in-home treatment, and other nontraditional services. The Demonstration also provided better continuity of care. Multiple methods were used to investigate the impact of wraparound. Both groups showed some improvement on some measures but there were no differences between the groups in functioning, symptoms, life satisfaction, positive functioning, or sentinel events. Regardless of which statistical model was used to estimate costs, the Demonstration was also more expensive. The higher level of expenditures for the Wraparound group was a result of some expensive traditional care and the addition of nontraditional services. Several possible explanations of these results are provided.     

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.     

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.     

Mental Health and Incarcerated Youth. II: Service Utilization

The incarceration of mentally ill youth is a serious problem not receiving the same attention as in adults. In this study, we examine the level of prior service utilization in incarcerated youth versus youth receiving community mental health services. We randomly recruited youth from middle South Carolina served by a local community mental health center (CMHC; n = 60), hospitalized in the state adolescent inpatient program (n = 50), and incarcerated in the S.C. Dept. of Juvenile Justice facilities (n = 75). We used a Services History to evaluate episodes of prior utilization of mental health, social service, educational, residential, and volunteer services, as well as the DISC-PC 2.3 to evaluate DSM-III-R diagnoses and symptoms and the CBCL and YSR to evaluate behavioral symptomatology. Incarcerated, hospitalized, and CMHC youth utilized similar levels of educational services and social services. Incarcerated youth had a significantly lower lifetime utilization of outpatient and acute mental health services and significantly higher utilization of out-of-home residential services than the other groups. These services utilization variables, along with gender and age, significantly distinguish incarcerated youth from the clinical groups, with clinical variables not serving to significantly distinguish them. Our results indicate the need to develop programs to prevent the entry of mentally ill/emotionally disturbed youth into the juvenile justice system. Youth who are at risk for incarcenation may benefit from intensive mental health services to prevent out-of-home placement and later incarceration.     

Mental Health Services in Kentucky Nursing Homes: A Survey of Administrators

National surveys have shown that mental health problems are prevalent in long-term care and suggest that these settings are largely underserved by mental health services. Nursing home administrators are gatekeepers for mental health services in nursing homes. Administrators of Kentucky nursing homes were surveyed regarding their perceptions of mental health problems, current and future services use, satisfaction with services, and need for consultation. The response rate was 24%. Administrators appeared to underestimate mental health problems among residents. Most facilities were using at least one type of mental health service, but fewer residents received services than would be expected given the problem prevalence. Psychological services were underused, in spite of the fact that behavior management stood out as a major need. Psychiatry was more frequently used, but with less satisfaction. Results indicate significant financial and logistical barriers to mental health services. Future work is needed on developing, assessing, and disseminating models of effective service provision to long-term care.     

Bows and ribbons,tape and twine: Wrapping the wraparound process for children with multi-system needs

The wraparound process for children with multi-system needs is one of the most innovative and popular reform efforts in children's services. Nonetheless, the articles in this special issue are indicative of a service reform process that is still maturing and evolving. In this commentary, three key questions regarding the wraparound process are posed: (a) What is wraparound? (b) What is the current state of research regarding wraparound services? and (c) What are the implications for the future? It is argued that the future of wraparound depends at least in part on: (a) carefully defining the wraparound process, including how to best integrate the process with reforms based on the principles of a comprehensive system of care; and (b) making a strong commitment at all levels to the process of cumulative knowledge, of building and creating innovative research and program efforts over time, one upon the other. It is concluded that a failure to invest in careful definition, refinement, implementation, and research on the wraparound process consitutes a failure to invest in children and families with multi-system needs.     

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.     

Quality care in residential placement for children and youth with developmental disabilities

There is a growing concern for quality care in residential placements outside of the natural family for children and youth with developmental disabilities. Ideally, children with developmental disabilities should remain with their natural parent or parents of parents with appropriate supports until the age when children typically leave home. In reality, parents of children and youth with development disabilities are not always able or willing to care for their children at home, and alternate residential placements must be found. This paper will discuss some of the issues surrounding the provision of quality care in out-of-home residential placements for children and youth with developmental disabilities.     

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.     

Residential and community treatment services utilized by a sample of youth with severe emotional disturbances

Analyzed case records to determine the costs and service usage patterns for a group of 25 youth randomly selected from the case load of a regional mental health agency. Study participants had extensive histories of publicly supported psychiatric hospitalizations. An average of 36.2 contacts per youth (905 total contacts) with human services providers were documented. Approximately 2 out of every 5 contacts resulted in out-of-home placements. The estimated cost of providing services to the 25 youth exceeded 3 million dollars. The types and costs of treatment services provided to study participants are discussed.     

Can Housing and Service Interventions Reduce Family Separations for Families Who Experience Homelessness?

Family break‐up is common in families experiencing homelessness. This paper examines the extent of separations of children from parents and of partners from each other and whether housing and service interventions reduced separations and their precursors among 1,857 families across 12 sites who participated in the Family Options Study. Families in shelters were randomized to offers of one of three interventions: permanent housing subsidies that reduce expenditures for rent to 30% of families’ income, temporary rapid re‐housing subsidies with some services directed at housing and employment, and transitional housing in supervised facilities with extensive psychosocial services. Each group was compared to usual care families who were eligible for that intervention but received no special offer. Twenty months later, permanent housing subsidies almost halved rates of child separation and more than halved rates of foster care placements; the other interventions did not affect separations significantly. Predictors of separation were primarily homelessness and drug abuse (all comparisons), and alcohol dependence (one comparison). Although housing subsidies reduced homelessness, alcohol dependence, intimate partner violence, and economic stressors, the last three variables had no association with child separations in the subsidy comparison; thus subsidies had indirect effects via reductions in homelessness. No intervention reduced partner separations.     

School-Based Acceptance and Commitment Therapy for Adolescents With Anxiety: A Pilot Trial

Anxiety disorders are one of the most prevalent diagnoses in youth, often resulting in impaired social and school functioning. Research on treatments for youth anxiety is primarily based in traditional clinical settings. However, integrating youth psychotherapies into the school environment improves access to evidence-based care. The present study is a pilot, randomized waitlist-controlled trial of a school-based, group Acceptance and Commitment Therapy–based (ACT) intervention for adolescents with anxiety. Students at two separate schools (N = 26) with elevated anxiety were randomized to a 12-week waitlist or to immediate treatment. Participants in the immediate treatment condition reported statistically significant decreases in anxiety and class absences at posttreatment and follow-up compared to the waitlist group. No statistically significant differences were found between groups for depression, psychological flexibility, positive mental health, and student well-being. However, medium within-condition effect sizes were seen in the treatment group for all outcomes. Participants reported the treatment as favorable with good acceptance ratings. Overall, this study supports ACT as a viable intervention for schools and other clinical settings providing services to adolescents with anxiety.     

Validity of Treatment Target Progress Ratings as Indicators of Youth Improvement

We examined whether clinical progress ratings on the Monthly Treatment and Progress Summary form (MTPS), an idiographic treatment progress measure, were meaningfully related to changes measured by two separate standardized instruments; the Child and Adolescent Functional Assessment Scale (CAFAS) and the Child and Adolescent Level of Care Utilization System (CALOCUS). Validity coefficients were examined at intake and three-, six-, and nine-month follow-up periods. Samples were selected for each measure and follow-up period from the population of youth receiving services through the Hawaii Child and Adolescent Mental Health Division’s (CAMHD) system of care. Significant youth improvement was evident on all three measures across all follow-up intervals. The type of changes measured by the MTPS and CAFAS were more alike over longer follow-up intervals than changes measured by the CALOCUS. The MTPS captures distinct aspects of client change that overlaps somewhat with CAFAS and CALOCUS measures. The MTPS is a brief client-tailored measure that seems to provide valid, sensitive, and nonredundant client specific treatment outcome information that can be collected on a frequent basis within a complex system of care.