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%

Mai

ne

Haw

aii

Mar

ylan

d P

uert

o R

ico DC

New

Jer

sey

Ohi

o N

ew H

amps

hire

G

eorg

ia

Cal

iforn

ia

New

Yor

k F

lorid

a M

inne

sota

V

erm

ont

Pen

nsyl

vani

a V

irgin

ia

Mas

sach

uset

ts

Col

orad

o M

ichi

gan

Illin

ois

Wis

cons

in

Rho

de I

slan

d S

outh

Car

olin

a M

isso

uri

Ten

ness

ee

Con

nect

icut

A

lask

a N

orth

Dak

ota

Neb

rask

a A

laba

ma

Nor

th C

arol

ina

Mon

tana

Lo

uisi

ana

Okl

ahom

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ansa

s D

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Wyo

min

g O

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n K

entu

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Was

hing

ton

New

Mex

ico

Sou

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a Id

aho

Iow

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Mis

siss

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W

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Virg

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T

exas

Nev

ada

Ariz

ona

Data Source: Adoption and Foster Care Analysis and Reporting System, U.S. Department of Health and Human Services

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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 OUTCOMES

context: 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 strategy7/24/2013 11

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 hospitalization 7/24/2013 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 Programs 7/24/2013 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