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.     

Wrapping services in an urban setting

Efforts to reform services for children and their families in Baltimore City have included providing Wraparound services to youth returned or diverted from out-of-state residential treatment. We briefly present the history and evolution of the system reform efforts in Baltimore City that were necessary to support the implementation of a Wraparound model of service delivery. The characteristics of the Wraparound service model is presented along with the referral pathway of the youth into the service system, the components of the service delivery system and an overview of step-down services and linkages utilized to transition the youth. Data are presented that demonstrate the level of community adjustment of a subset of the 121 youth served through the Wraparound model in contrast to the level of community adjustment achieved by nonequivalent comparison groups. We discuss the use of report card type of outcome measures, its user-friendly features, limitations, and the developmental steps needed to refine it further.     

Long-term Outcomes of Children and Youth accessing Residential or Intensive Home-based Treatment: Three year follow up

In this study the long-terms outcomes of children and youth with severe mental health problems receiving residential treatment (RT) or an intensive home-based treatment (IHT) were reported. RT is 24-hour mental health intervention in a highly supervised and structured group living setting where individualized and related therapies are provided. Youths attend a day school within the residential environment. IHT developed as an alternative to residential treatment for youth and comprises the same therapeutic interventions provided in the home as opposed to the residential setting. Youths attend their regular school which could be within a specialized setting, such as a day school. At discharge, there were statistically and clinically significant improvements in psychosocial functioning for children and youth in RT and IHT. There were also statistically significant improvements in scores on symptom severity from admission to 12 to 18 months post-discharge, and these improvements were maintained at 36 to 40 months post-discharge. Differences in demographic data between the two groups suggest that the programs may serve two different populations, and that both programs are important components of a comprehensive mental health plan for children and youth.     

A Business Model for Managing System Change Through Strategic Financing and Performance Indicators: A Case Study

This article describes how a system of care operated by a county government agency used a fiscal crisis as the opportunity to reform its children's system. A cross-system response to the crisis is outlined that includes a system of care framework coupled with a business model, inter-departmental collaboration and leadership, the use of strategic reinvestment strategies, and a quality improvement system that focuses on key indicators. Implementation of the system change is described with a specific focus on cross-system entry points, financing strategies that re-allocate funds from deep-end programs to community-based services, and management oversight through the use of performance indicators to monitor and support effectiveness. This article examines the results of the system change, including the diversion of youth from system penetration, the reduction in residential treatment bed days, the re-allocation of these savings to community-based services, and the outcomes of children who were diverted from residential care and served in the community. The article offers a number of recommendations for other communities contemplating system change.     

Wraparound care in vermont: Program development,implementation, and evaluation of a statewide system of individualized services

Over the past decade, there has been a dramatic shift in the provision of mental health services to children, adolescents, and their families. This shift has been marked by a movement away from restrictive treatment options toward the development of comprehensive community-based systems of care designed to keep the most challenging children in their homes, schools, and communities. Based on a model of intensive case management referred to as Wraparound Care, Vermont's statewide approach emphasizes aggressive outreach, use of the least restrictive treatment options, and care that is flexible, unconditional, and child- and family-centered. We chart the development of Vermont's Wraparound Care Initiative and present residential, educational, and behavioral outcome data for a cohort of 40 youth receiving Wraparound Care over a 12-month period. The results showed that after 12-months, youth who had been previously removed from their homes or were at imminent risk of such removal, were residing in significantly less restrictive community-based living arrangements and exhibiting significantly fewer problem behaviors than at intake. These results are discussed in light of recent national studies and previous studies on similar cohorts of Vermont youth receiving Wraparound Care.     

Do children's attention processes mediate the link between family predictors and school readiness?

The role of attention processes as possible mediators between family environment and school readiness was analyzed with data from 1,002 children and their families. Data on children's sustained attention, impulsivity, and school readiness (i.e., cognitive, achievement, language, and social development) were obtained at 54 months of age, and quality of the family environment was assessed throughout the first 54 months. Mediation tests showed that children's sustained attention partially accounted for the link between family environment and achievement and language outcomes. Impulsivity partially accounted for the link between family environment and achievement, social competence, and externalizing behaviors. The roles of sustained attention and of inhibition of impulsive responding in the relation between family characteristics and school readiness are discussed.     

Context-Dependent Pathways of the Transmission of Risk from Communities to Individuals

Research has consistently documented the role of environmental risk factors in the onset of delinquent behavior among youth. Less is known about the processes through which these contextual risks are translated to individual youth behavior. The aim of the current study is to examine the role of family risk factors in the transmission of community risk. Data was obtained from a nationally representative sample of over 30,000 middle school youth and community key informants (CKI). A multilevel, moderated mediation model was estimated with family risk as the moderator of the effect of CKI ratings of community risk on youth perceptions of risk. Results showed that when youth came from low risk families (measured by parental use of positive family management strategies), youth perceptions of risk mediated the effects of community risk on youth delinquency; however, there was no evidence of a significant mediated effect under conditions of high risk (measured by poor family management). This appears to be because youth from high-risk families perceived their neighborhoods as high-risk, regardless of actual levels of risk (as reported by CKI). This study finds that the relationship between communities and adolescent behavior is complex and interacts with the family environment.     

The Relationship of Parental Divorce to Health Status of Parents and Children

Based on data from the divorce adjustment project conducted by the National Association of School Psychologists and Kent State University, the study reported herein focused on physical and mental health status of children and parents. The nationwide sample included 341 children from divorced families and 358 from intact families randomly selected from first, third, and fifth grade classrooms by 144 school psychologists. Results from ANOVAs indicated that health ratings for divorced-family children as well as their parents and siblings were lower than ratings for their counterparts in intact families. Correlational and multiple regression results revealed a wide array of both concurrent and longitudinal relationships, illustrating interdependence among divorce, physical and mental health condition, stress indices, and academic and social competence criteria. Implications of the results for school-based special services providers are discussed.     

Children and youth in neighborhood contexts

Neighborhoods are increasingly studied as a context where children and youth develop; however, the extent of neighborhoods' impact remains debatable because it is difficult to disentangle this impact from that of the family context, in part because families have some choice as to where they live. Evidence from randomized experiments, studies using advanced statistical models, and longitudinal studies that control for family characteristics indicates that neighborhoods do matter. In nonexperimental studies, small to moderate associations were found, suggesting that children and adolescents living in high-income neighborhoods had higher cognitive ability and school achievement than those living in middle-income neighborhoods, and children and adolescents living in low-income neighborhoods had more mental and physical health problems than those living in middle-income neighborhoods. The home environment has been shown to be partly responsible for the link between neighborhood and children's development. For adolescents, neighborhood effects are partially accounted for by community social control. Experimental studies in which families were randomly assigned to move to low-poverty neighborhoods from housing projects found larger neighborhood effects than nonexperi-mental research, particularly for boys' outcomes. Additional issues reviewed are relevant neighborhood characteristics, theoretical models explaining the pathways underlying neighborhood effects, methods for research assessing neighborhood processes, and policy implications.     

Family Transitions in Cohabiting Families: a Longitudinal Investigation of the Role of Parent Depressive Symptoms in Youth Problem Behaviors

Cohabiting family structures are becoming increasingly prevalent in the United States but are less stable than married family unions. In this longitudinal study we examine the change in psychosocial adjustment of adolescents when a non-biologically related male cohabiting partner (MCP) transitions out of the family home. Of particular interest, the role of maternal and MCP depressive symptoms was examined as a moderator. At wave 1, the sample was comprised of 111 low-income urban Black families, consisting of an adolescent (42.3 % male; Mage = 13), a biological mother, and a non-biologically-related male cohabiting partner (MCP). Wave 2 and 3 assessments occurred over the course of the subsequent 29 months, with 38 % of MCPs transitioning out of the home. We used latent growth curve modeling to characterize trajectories of youth internalizing and externalizing symptom change across the 3 waves. Both maternal and MCP depressive symptoms interacted with whether a transition occurred, consistent with the notion that adolescent problem behaviors are shaped by the dynamic interplay of individual- and family-characteristics.     

Relations between maternal power-assertive parenting and adjustment in Chinese children: A longitudinal study

This 1-year longitudinal study examined relations between maternal power-assertive parenting and children's social, academic and psychological adjustment in China. Participants were 316 elementary school children (mean age = 11 years, 153 boys). Maternal power-assertive parenting was assessed using children's self-reports. Data on children's social and school adjustment were obtained from peer evaluations and teacher ratings. In addition, children completed measures of loneliness and depression. Cross-lagged analyses indicated that whereas maternal power-assertive parenting was only related to later academic adjustment, children's adjustment in socioemotional and academic domains contributed to the prediction of later maternal power-assertive parenting. The results were discussed in the Chinese context.     

Building a research base for community services for children and families: What we know and what we need to learn

We examine the knowledge base for community-based mental health services for youth and their families. A brief historical perspective on the development of community services is presented, and the fundamental components of a comprehensive child mental health service system are described. Outcome studies for service components as well as the service system as a whole are summarized. Research related to the context of treatment, i.e., service setting, cost, is presented. The authors conclude that a research base for child and family services is emerging, but there is still a paucity of well designed studies that address the complexities of a community-based system as well as the critical outcome questions that need to be addressed. Finally, promising service system developments are described and recommendations for future research are presented.     

Applying a Theory of Change Approach to Interagency Planning in Child Mental Health

This paper describes the use of a theory of change approach to community-based cross-agency service planning for children with serious emotional disturbance and their families. Public agency planners in Contra Costa County, California used the theory of change approach to organize service planning for a population of youth who had been arrested and involved with juvenile probation. The theory of change process described in this paper links community outcomes with planned activities with the assumptions or principles that underlie the community planning efforts. When complete, a theory of change logic model can serve as a guide for implementation, ensuring that community plans for service delivery remain true to their intent. The theory of change development process includes twelve stages and is based on a step-by-step approach. Theory of change logic models establish a context for articulating a community's shared beliefs and prompt local stakeholders to establish logical connections between the population to be served, expected results, and strategies intended to achieve those results.     

Beyond home-based family intervention: A multi-family approach toward change

A growing specialty area in the mental health field involves working with emotionally disturbed youth and families-at-risk by providing services in the context of the home environment. A review of the literature provides documentation for family systems, social learning, and ecological interventions with at-risk families receiving home-based intervention but there is an absence of material on the use of multi-family groups with this population. The purpose of this article is to outline the implementation of a multi-family therapy (MFT) component for home-based programs serving at-risk families. Advantages and disadvantages when using MFT are also addressed.The authors are grateful to Linda Pannell for her helpful comments on drafts of this article.     

The Mental Health Needs of Youth with Emotional and Behavioral Disabilities Placed in Special Education Programs in Urban Schools

We describe the psychosocial characteristics of youth with an average age of 11.8 years served in special education due to emotional disturbances in urban communities (N = 158). Data were also collected describing service utilization, academic functioning, and family characteristics. Ten schools in three mid-size urban cities participated. Results from the administration of standardized assessments revealed that the majority of students scored in the clinical range on the parent version of the Child Behavior Checklist and the Columbia Impairment Scale, indicating significant levels of emotional and behavioral impairment. Further, behavior problems began at an early age with 80% of the youth using outpatient services beginning at the average age of 7.5 years and 29% of the youth using inpatient services beginning at an average age of 8.4 years of age. Most of the youths' school careers (67%) have been in a special education setting. The most common services currently being supplied by school personnel was individual counseling and this was provided for 63% of the students while child-serving agency personnel were providing individual counseling for 17% of the youth. Implications for the development of multi-agency collaborative services are presented.     

The Inconsolable Doll Task: Prenatal coparenting behavioral dynamics under stress predicting child cognitive development at 18 months

Studies have demonstrated that coparenting can be assessed prenatally through playful observational conditions, including simulated baby enactments. Regrettably, there is a lack of empirical research examining how prenatal coparenting under the emotional stress elicited by the distress of a simulated infant predicts children’s cognitive development. The current longitudinal study introduces a novel procedure—the Inconsolable Doll Task—to assess prenatal coparenting behavioral dynamics under the stress of a non-responsive doll simulator, and examines the extent to which prenatal interaction patterns predict the child’s cognitive development at 18 months. The sample consists of 105 community-based, co-living, expectant fathers and mothers. Data were collected prenatally, at three, six, and 18 months in home and lab visits. Results indicate that the prenatal coparenting dynamic of negative escalation explains a unique variance in children’s cognitive development at 18 months. This effect is evident even when accounting for both prenatal and postnatal assessments of low-stress coparenting behavioral patterns or self-reported coparenting perceptions, and when controlling for parental education. These findings are discussed in terms of their methodical, empirical, and clinical implications.     

Educational Cultural Brokers and the School Adaptation of Refugee Children and Families: Challenges and Opportunities

Canadian schools are utilizing services previously provided by settlement and community-based agencies to ensure the successful school adaptation of refugee children and families. This study examined the role of educational cultural brokers during the adaptation. Research queries addressed include strategies that cultural brokers use to facilitate the adaptation of refugee children in school settings, and opportunities and barriers to cultural brokering that exist in educational settings. A qualitative case study of eight educational cultural brokers was employed, using focus groups, critical incidents, document review, and semistructured interviews. Results suggest brokers engage in micro- and macrolevel activities through six brokering roles, with each role encompassing challenges and opportunities at the school, agency, and community level. This paper discusses aspects of these roles that have relevance for practice and policy for both cultural brokers and other providers of school-based services to refugee families.     

ASSESSING MEDIATED MODELS OF FAMILY CHANGE IN RESPONSE TO INFANT HOME VISITING: A TWO-PHASE LONGITUDINAL ANALYSIS

The objective of this study was to assess whether a mediated model of change could account for the long-term effects of infant home-visiting services observed at ages 5 and 7 years in a high-risk cohort. Participants were 41 mothers and infants from low-income families who were referred to parent-infant home-visiting services during the first 9 months of life due to concerns about the caretaking environment. Services ended when infants reached 18 months of age. Families received between 0 and 18 months of weekly home visits based on infant age of entry into the study. During childhood (ages 5 and 7 years), teachers rated children's behavior problems using standardized instruments. Early home-visiting services accounted for positive child outcomes at 18 months, 5 years, and 7 years of age; however, earlier positive outcomes related to intervention did not account for intervention-related effects at later ages. Further inspection of the data revealed that two additional principles, one of escalating morbidity among less intensively served groups and one of generalized family problem-solving skills, were needed to account for the pattern of effects over time. We conclude that the "domino models" assessed by mediational analyses may be too simple to capture the intervention-related change processes occurring in high-risk cohorts over time.     

Inadequate Housing Among Families Under Investigation for Child Abuse and Neglect: Prevalence from a National Probability Sample

This study aimed to estimate the prevalence of inadequate housing that threaten out-of-home placement among families under investigation by child welfare. Data came from the National Survey of Child and Adolescent Well-Being, a nationally representative longitudinal survey of child welfare-involved families. Child protective services caseworkers as well as caregivers provided information on families whose child remained in the home after initial investigation (N = 3,867). Multilevel latent class analyses tested the presence of inadequately housed subgroups using 4 housing problem indicators at baseline. Logistic regressions assessed convergent and predictive validity. A two class latent solution best fit the data. Findings indicated that inadequate housing contributed to risk for out-of-home placement in approximately 16 % of intact families under investigation by child protective services. These families were 4 times more likely to need housing services 12 months later. Federal legislation emphasizes integration of social services as necessary to end homelessness. This study demonstrates overlap across public agencies. Enhanced coordination of child welfare and housing services facilitates interventions to prevent and mitigate homelessness.     

Creating Comprehensive and Collaborative Systems

To improve outcomes for children and youth with serious emotional disturbance and their families, we need to create comprehensive and collaborative systems to promote systems change resulting in the development of coherent services built around their individual needs. These services should be family-centered, community-based, and appropriately funded. Unfortunately, barriers to understanding and operationalizing this level of collaboration persist, which challenges the aims of parents, practitioners, policy makers, and others to provide efficient and effective services to these students. I explore the seventh strategic target of the National Agenda for Achieving Better Results for Children and Youth with Serious Emotional Disturbance; provide examples of collaboration that relate to the National Agenda's other six strategic targets; and briefly discuss the present opportunities for and challenges to collaboration.