Coming Together to Improve Outcomes for Vulnerable Children and YouthBRYAN SAMUELS, COMMISSIONERADMINISTRATION ON CHILDREN, YOUTH AND FAMILIES
CHILDREN IN FOSTER CARE ON 9/30
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STATE CHANGES IN CASELOADS: 2002-2011
-80.0%
-60.0%
-40.0%
-20.0%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
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Cal
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Illin
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Wis
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Rho
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Tenn
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Ala
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Nor
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Data Source: Adoption and Foster Care Analysis and Reporting System, U.S. Department of Health and Human Services7/24/2013 3
ACYF’s Priority:
INTEGRATING WELL-BEING WITH SAFETY AND PERMANENCY TO ACHIEVE BETTER OUTCOMES FOR CHILDREN, YOUTH, AND FAMILIES
WELL-BEING
PERMANENCYSAFETY
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Supportive, responsive relationships promote healing and recovery and reinforce growing social and emotional skills
Nurturing environments provide security and promote positive outcomes
Systems and policies promote and sustain screening, assessment, the use of evidence-based interventions, progress monitoring, and continuous quality improvement
Assessment drives individualized treatment plan with evidence-based interventions
Systematic approaches to teaching coping skills and social skills
Intensive Intervention
Targeted Social and Emotional Supports
Stress Reducing and Developmentally Appropriate Environments
Safe, Supportive, and Responsive Relationships
Knowledgeable and Effective Workforce
Healing and RecoverySOCIAL AND EMOTIONAL WELL-BEING FOR CHILDREN, YOUTH, AND FAMILIES
Adapted from the Technical Assistance Center on Social Emotional Intervention for Children and the Center on the Social and Emotional Foundations for Early Learning
Functional Assessment
Validated Screening
Clinical Assessment
Evidence-based
Intervention(s)
Case Planning for
Safety, Permanency,
and Well-being
Progress Monitoringsocial-emotional functioning
ACHIEVING BETTER OUTCOMEScontext: therapeutic, responsive & supportive settings & relationships
Outcomes: Safety,
Permanency, Well-Being
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INTEGRATING A FOCUS ON WELL-BEING THROUGHOUT CHILD WELFARE
maltreatment investigation and removal
recruitment and retention of quality
foster homes
case plan development with
involvement from birth and foster families
monthly caseworker visits with child and foster parents the role of
supervised visits with biological parents
processes of returning children to
their biological families
processes of adoption or subsidized
guardianship
the role of maintaining
connections to biological siblings
addressing placement disruptions, dissolutions
or (un)anticipated moves
transitioning “aging out” youth to
independent living or adult service systems
case management and interface with other
service systems (e.g., education, mental health,
physical health)
Many child welfare requirements and activities already taking place could be reconceived to support children’s well-being:
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ESTABLISHING THE RIGHT SERVICES ARRAY: DE-SCALING WHAT DOESN’T WORK, SCALING UP WHAT DOES
RESEARCH-BASED APPROACHES
INEFFECTIVE APPROACHES
De-scaling what doesn’t
work
Investing in what does
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A TRAUMA-FIRST APPROACH CAN IMPROVE OUTCOMES FOR CHILDREN WITH COMPLEX NEEDS
• Children who have experienced trauma have significant behavioral health needs, which drive their health care costs
• The Academy of Child and Adolescent Psychiatrists recommends psychotherapy as the first-line treatment for PTSD; yet many children receive medication first and in the absence of evidence-based psychosocial intervention.
• A trial of Cognitive Behavioral Therapy (CBT) with 3-6 year-old children with PTSD demonstrated improvement across symptom categories:
Scheeringa, 2013
Number of symptoms pre- and post-treatment with CBT among children 3-6 years-old with PTSD
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EXAMPLE: PERMANENCY INNOVATIONS INITIATIVE
EXAMPLE FROM PII: KANSAS INTENSIVE PERMANENCY PROJECT (KIPP)
• Part of the Permanency Innovations Initiative (PII), KIPP is conducting a five-year demonstration to reduce long-term foster care, targeting children ages 3-8 with severe emotional disturbances (SED)
• During the planning year, KIPP engaged in an intensive, intentional process to understand their population and design an effective intervention strategy
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DEFINING THE TARGET POPULATION• Research indicates that children with SED are
more likely than their peers to experience long-term foster care. KIPP had to identify these children and understand who they are in order to design an intervention strategy.
• SED status is determined by the presence of any two of the following criteria:
– A mental health diagnosis
– A CBCL t-score of 70 on any of the 3 subscales or a CAFAS total score of 100, or 30 on any two subscales
– Psychiatric hospitalization7/24/2013 12
CONDUCTING EXTENSIVE DATA ANALYSIS• Bivariate and multivariate analysis of child and case characteristics
associated with long-term foster care
• Case record review of family risk factors in 30 long-term foster care cases
• Electronic survey of systemic barriers to permanency for children with SED
Findings• Children with SED are more than 3 times more likely than their
peers to experience long-term foster care
• Children with SED who experience long-term foster care are more likely than children in every other comparison group to have both internalizing and externalizing diagnoses. They are also more likely to present with co-occurring developmental disorders.
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REVIEWING AVAILABLE EVIDENCE-BASED INTERVENTIONS
• Began exploring models of Intensive Family Reunification Services (IFRS). Consultation with child welfare researchers shifted focus to evidence-based parent training models to supplement IFRS.
• Worked to line up potential interventions with expected child- and system-level outcomes.
• Considered implementation science, including adaptability and sustainability
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SELECTING AN INTERVENTION AND PLANNING FOR IMPLEMENTATION• Narrowed down to two options, and selected Parent
Management Training-Oregon Model (PMTO)
• Factors impacting selection of evidence-based parent training model:
– Fit with needs of target population
– Ability of intervention to reduce long-term foster care
– Long-term sustainability and anticipated systems changes
• Consulted with EBP purveyors and some of its implementers with specific focus on tailoring it to the needs of the foster care population with SED.
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KIPP SERVICE MODEL OVERVIEW
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AN EVIDENCE-BASED INTERVENTION THAT INTEGRATES SAFETY, PERMANENCY, AND WELL-BEING: KEEP
KEEPING FOSTER & KIN PARENTS SUPPORTED AND TRAINED (KEEP)• Group intervention for foster and kin families with children who have
demonstrated externalizing problems, mental health problems, problems in school, or problems with peer groups.
• KEEP is a form of Multi-dimensional Treatment Foster Care for regular foster and kinship families.
• Essential components include:
Weekly parent support and training
group sessions
Supervision for parents in behavior
management methods
Parent Daily Report Checklist Calls
• Reduces changes in placement, increases reunification, increases positive parenting skills for foster parents.
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OVERVIEW OF KEEP COMPONENTS
Who is served? Regular state hired foster and kinship parents caring for children 4-12 years old
Duration components
16 weeks: (1) weekly foster/kinship parent support groups (90 min each); (2) weekly data collection on child behavior problems/progress
Staffing requirements
For 3 groups up to 90 foster/kin families- Paraprofessional lead facilitator (1.0 FTE)- Co-facilitator (.75 FTE)- On-site supervisor (.10 FTE)
Implementation Support
5-day training + weekly consultation until facilitator is certified
Major Outcomes Reduced changes in placement, increased reunification, and positive parenting skills for foster/kinship parents
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OUTCOMES FROM KEEP IMPLEMENTATION
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KEEP was effective in reducing behavioral problems among children with mild to severe behavior problems at baseline.Price, JM; Roesch, SC; & Walsh, NE. (2012). Effectiveness of the KEEP foster parent intervention during an implementation trial. Children and Youth Services Review. 34:2487.
EXAMPLE OF STATEWIDE KEEP IMPLEMENTATION• According to an evaluation of KEEP results, if the
intervention were implemented in a large State, the following outcomes could be expected:
Results derived from in: Price, JM; Chamberlain, P; Landsverk, J; Reid, J; Leve, L; & Laurent, H. (2008). Effects of a foster parent training intervention on placement changes of children in foster care. Child Maltreatment. 13(1):64.; model and analyses by F. Wulczyn, Chapin Hall, University of Chicago, and Jeremy Goldhaber-Fiebert, Stanford University Medical School.
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OPPORTUNITIES TO MOVE FORWARD TOGETHER
HELPING VICTIMS OF TRAUMA HEAL AND RECOVER• Guidance to State child welfare, mental health,
and Medicaid directors released on June 11, 2013 encourages comprehensive approaches to addressing trauma among children and youth known to child welfare
• Describes mechanisms in each system to finance better trauma screening, assessments, and evidence-based interventions
• http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-13-004.pdf 7/24/2013 23
ONE WAY TO INTEGRATE SAFETY, PERMANENCY AND WELL-BEING: LEGISLATIVE ACTION• Connecticut
2013 Conn. Acts, SB 972, P.A. 178: Requires the Department of Children and Families to develop a comprehensive implementation plan for meeting the emotional and behavioral health needs of all children in the state. The plan, must: (1) strengthen families through home visitation and parenting education programs; (2) increase mental, emotional, or behavioral health issue awareness within elementary and secondary schools; (3) improve the current system of addressing such issues in youths; and (4) provide public and private reimbursement for some mental, emotional, or behavioral health services.
• West Virginia 2010 W.V. Acts, HB 4164, Chap. 20: Establishes a pilot program (to be known as Jacob’s Law) for the placement of children ages 4 to 10 in foster care to provide children in crisis with early intervention, assistance with emotional needs, medical evaluations, independent advocates, and foster family training and education. The law also requires immediate evaluation and testing following removal from a home.
• Wisconsin2010 Wis. Laws, AB 823, Act 336: Requires that all foster parents complete training regarding the care and support needs of children who are placed in foster care or treatment foster care. The training shall be completed on an ongoing basis and include parenting skills, the teaching and encouragement of independent living skills, and issues that may confront foster parents of children with special needs.
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ONE WAY TO INTEGRATE SAFETY, PERMANENCY AND WELL-BEING: USE MEDICAID TO ADDRESS TRAUMA
• Multiple Medicaid vehicles allow for identification and treatment of complex trauma:
– EPSDT
– State Plan Services, including preventive services, described in section 1905(b) of SSA
– Alternative Benefit Plans
– Home and Community-Based Services
– Health Homes
– Managed Care
– Integrated Care Models
– Section 1115 Research and Demonstration Programs7/24/2013 25
ONE WAY TO INTEGRATE SAFETY, PERMANENCY AND WELL-BEING: SAFE BABIES COURT TEAMS• Major findings from ZERO TO THREE’s
Safe Babies Court Teams evaluations:
– 99.05% of the 186 infant and toddler cases examined were protected from further maltreatment while under court supervision. (JBA, 2009)
– 97% of the 186 children received needed services. (JBA, 2009)
– Children monitored by the Safe Babies Court Teams Project reached permanency 2.67 times faster than the national comparison group (p=.000). (McCombs-Thornton, 2011)
10 Core Components:Judicial Leadership
Local Community Coordinator
Active Court Teams Focus on the Big Picture
Targeting Infants and Toddlers in Out-of-Home Care
Placement and Concurrent Planning
Family Team Meetings Monthly to Review All Open Cases
Parent-Child Contact
Continuum of Mental Health Services
Training and Technical Assistance
Evaluation
ELEMENTS OF SYSTEMS THAT FOCUS ON CHILD AND FAMILY WELL-BEING
Focus on child & family level
outcomes
Monitor progress for improved
child/youth functioning
Proactive approach to social and
emotional needs
Developmentally specific approach
Promotion of healthy
relationships
Capacity to deliver EBPs