Seneca center data dashboards - CMH Conferencecmhconference.com/files/27/presentations/s44-2.pdf · 2014-11-01 · Mental Health Crisis Events • Mental health disorders and family

3/14/2014

1

Emotional Regulation and Mental Health Crisis Events for Youth Served by a Family Agency

Seneca Family of Agencies

Kate Cordell, MPH, UC Berkeley

Shannon Dickerson, Seneca

Melissa Mollard, PhD, Seneca

Research under Supervision of Lonnie Snowden, PhD, UC Berkeley

Purpose • Evaluate the association between youth mental

health crisis events (MCHE) and presenting

emotional regulation issues identified on CANS

o Frustration Management

o Anger Control

o Anxiety / Anxious Disposition

o Irritability

• MCHE identified in first sixth months of family services

for 1,397 youth served in nine California counties

between 2009 and 2012

3/14/2014

2

Study Participants • Youth served are enrolled in program based on

agency contract with organization, characteristics

of youth risk, type of service and intensity needed:

o (1) School-based: school-based services for youth with emotional/social or behavioral issues in public or nonpublic schools;

o (2) Probation: intensive case management and mental health services for youth with delinquent behavior;

o (3) Wraparound: intensive case management and mental health services for youth at risk of out of home placement;

o (4) Residential: 24-hour residence and care for youth who have been removed from home;

o (5) CMH: structured mental health services provided to youth within the community.

Study Participants

• 1,715 unique youth served for at least 6 months in

time period

• 1,397 (81.5%) had an enrollment CANS

• For youth served in multiple programs, the episode

was selected for use from the first program in which

he or she was enrolled for at least 6 months

3/14/2014

3

Study Site • Seneca Family of Agencies, non-profit agency founded 1985

o Provides comprehensive care for thousands of families and youth

with mental illness, social and/or behavioral problems California

o provides mobile crisis response, crisis stabilization, therapeutic

foster family care, wraparound, community mental health,

therapeutic behavior services, multisystemic therapy, and

intensive case management for probation-involved youth

• In 2010-2011, the agency responded to >750 mobile crisis

events and provided >3,000 episodes of crisis stabilization to

children experiencing high levels of distress

SONOMA

SOLANO

MARIN

SANTA

CLARA

CONTRA

COSTA

ALAMEDA

SF

MONTEREY

SAN LUIS

OBISPO

LOS

ANGELES

ORANGE

SAN BERNARDINO

3/14/2014

4

Seneca Family of Agencies

• Education Services

• Community-Based

• Crisis and Short-term

Services

• Residential and

Placement-Based

• Seneca Institute for

Advanced Practice

Mental Health Crisis Events

• Mental health disorders and family functioning (1)

put youth at risk of MCHE

• Mental health crisis events (MHCE) o Danger to others

o Danger to Self

o Runaway

o Serious, safety-related disruptions

• Crisis stabilization and crisis intervention model o AHIMSA

(1) Röll, J., Koglin, U., & Petermann, F. (2012). Emotion regulation and childhood aggression:

longitudinal associations. Child Psychiatry and Human Development, 43(6), 909–23. doi:10.1007/s10578-

012-0303-4

3/14/2014

5

AHIMSA Model • In 2010, Seneca implemented the Ahimsa model - a

relational approach for responding to crisis

• Cultural shift that changed the agency’s perception • Use of restraint and seclusion seen as a failure of treatment and barrier to

academic achievement (2)

• Any and all alternative interventions sought out and tried

• Treating everyone with respect and dignity core values of behavioral work

• Using Unconditional Care Clinical practice to

incorporate the child’s internal working model and

staff’s disconfirming stance intentionally • Getting to know and recognize antecedent behavior and triggers

• Disconfirming stance to redirect and de-escalate behaviors

• Create highly individualized plans

• (2) Curie, C. G. (2005). SAMHSA's commitment to eliminating the use of seclusion and restraint. Psychiatric

Services (Washington, D.C.), 56(9), 1139-1140.

The Escalation Curve

3/14/2014

6

Appropriate Response

Research Questions • (1) among children treated in an agency with comprehensive

programs serving children with mental illness and other

emotional and behavioral problems, were independent

emotional dysregulation issues associated with mental health

crises requiring a crisis response within programs

• (2) were there program type differences which affected crisis

and crisis response between the program types, including,

school-based, probation, wraparound programs, residential

facilities and community mental health (CMH)

• (3) how much of program-type differences were mediated by

initially identified participant’s emotional dysregulation issues

3/14/2014

7

Outcome & Exposure • Number of crisis events for youth between day 1

and 182 of service

• Admission CANS administered generally within first

month of service (83.4%) identified presence of the

four emotional regulation issues

• Length of time (days) to CANS assessment was not

associated with likelihood of identification of

emotional regulation issue

Child and Adolescent Needs and Strengths (CANS)

• Multi-purpose tool designed to support: o Decision making

o Facilitate quality improvement initiatives

o Monitor outcomes of services

• Widely employed- currently used in 25 states in child

welfare, mental health, juvenile justice, and early

intervention applications

• CANS answers drive service planning

3/14/2014

8

Emotional Regulation Construct

Frustration Mgmt. Anger Control Anxiety/

Anxiousness Irritability

Frustration Mgmt. 1.00

Anger Control 0.37 (p<0.001) 1.00

Anxiety/Anxiousness 0.09 (p=0.003) -0.01 (p=1.00) 1.00

Irritability 0.18 (p<0.001) 0.06 (p=0.10) 0.17 (p<0.001) 1.00

Correlation of CANS Rated Emotional Regulation Exposure Variables

Study Design • 57 programs (serving 1 to 160 youth)

• Multi-level random intercept model of youth nested

in programs

• Youth level covariates: o Age as integer

o Gender: Female vs Male (reference)

o Race: Black, Latino, Other with Caucasian as the reference category

• Program-level covariates: o Program type

• School-based (reference)

• Probation

• Wraparound

• Residential

• CMH

3/14/2014

9

Results • Descriptive

• 37.4% of youth (n= 523) with at least one crisis event

• 3.5 events per youth

• 9.4 events per youth with events

Poisson of No. of Crisis Events with Random Program Intercepts – Univariable Models

3/14/2014

10

Poisson of No. of Crisis Events with Random Program Intercepts – Univariable Models (Cont.)

Poisson of No. of Crisis Events with Random Program Intercepts – Individual Models

3/14/2014

11

Results • Research Question 1:

o Individual-level Emotional Regulation while controlling for race, age, gender, program-level proportions of emotionally dysregulated youth and program type was:

• frustration management (IRR=1.51, p<0.001)

• anger control (IRR=1.73, p<0.001)

• anxiety (IRR=1.26, p<0.001)

• No evidence for irritability

• Research Questions 2: o From base model, there were no significant differences in rates of crisis

events by program type, while controlling for age, race and gender

Poisson of No. of Crisis Events with Random Program Intercepts – Full Model

3/14/2014

12

Full Model Results

• Rate of crisis events at the subject-level, while

controlling for other variables in the model:

o 1.4 (p<0.001) fold increased incidence rate with frustration management

o 1.4 (p<0.001) fold increased incidence rate with anger control issues

o 1.2 (p<0.001) fold increased incidence rate with anxiety/anxiousness

o 14% (p<0.001) decrease in incidence rate of crisis events when irritability present

Results • Research Question 3:

o There were no program type differences in the base model which could be mediated by accounting for emotional regulation issues in the full model

o There was no evidence that programs with increased proportion of youth with emotional regulation issues experienced higher rates of crisis events

after adjusting for subject-level emotional regulation issues, while controlling for other covariates.

3/14/2014

13

Discussion o CANS-measured aspects (i.e., anger control, frustration

management, anxiety and irritability) of an emotional regulation

construct were associated with rate of mental health crisis events

o Evidence of ability to identify emotional dysregulation in the

clinical setting with simple ubiquitous measure

o Suggests that youth may not experience varying levels of crisis

due to program-level procedures or environmental factors

o Suggests that a variety of different types of programs can utilize

common crisis prevention models across programs

Limitations & Strengths o Limitations

• Observational cross-sectional secondary data analysis

• One agency’s existing data primarily collected for the

purpose of serving families

• Possible that crisis events in first few days could have alerted

clinicians to emotional regulation issues for the youth

o Strengths

• Study still identifies the ability clinicians to use the CANS to

identify increased risk of mental health crisis

• Clinician need not wait for crisis event to occur to identify

youth at risk and in need of crisis intervention services

• Design circumvents frequent translational issues of study results

from research to practice

3/14/2014

14

Conclusion

Emotional regulation issues identified on CANS

assessment can be identified early in the clinical

setting to identify youth at risk of crisis events

There is a lack of research which focuses on the

trajectory of youth mental health crises in the

community

Thank you!

6925 Chabot Road • Oakland, CA 94618

Office: 510.654.4004

Web: www.senecacenter.org

Kate Cordell [email protected]

Shannon Dickerson [email protected]

Melissa Martin-Mollard [email protected]