diana j. english phd university of washington senior research … · 2018. 11. 1. · diana j....
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Diana J. English PhD University of Washington Senior Research Scientist
August 21,2018
} Crossroad } Research to Practice } Data-Based Organizational Change } Values Driven
} Least Restrictive/Community Based } Child Safety } Child Well Being } Family Focused/Family Based
} Add: } Effective interventions } Match Between Needs and Services } Community Connections } Culturally Appropriate
3.6 Million Referrals – 6.6 Million Children (15% increase since 2010)
2.2 Million Screened in (61%) – 3.2 Million Children
702,000 Victims (22% Substantiated)
410,448 (58%) Post Response Service.
147,462 OOH (2% of all referrals);
(36% of post response), (22% of
Victims)
4
*ACF – ACYF 2014 Child Maltreatment Reports
} Although few involved in most intrusive
levels of service – if involved more likely to have experienced complex trauma
} What kind and levels of service needed?
} Use and reasons for RT varies substantially across communities,
} Average 12% in RT types of care – 8 prior placements
} Many have average LOS of 36 months
} 41% of youth had no clinical indicators
} 32% had a child behavior problem indicator
} 20% had a DSM diagnostic indicator.
} 7% had disability indicator.
} 24% entered RT as their first placement.
} The Family First Prevention Services Act (FFPSA) ◦ Keep families together ◦ Allow repurposing of funds to include prevention of
placement. ◦ Incentives to reduce Residential Treatment
-What to replace current approach in order to achieve outcomes? Waivers
– Opportunity to refine service system to better achieve outcomes
-Appropriate service based on level of need
} Assumption: Level of care is sequential, lower to higher
} Some children/youth may need higher levels of care at first placement, but
} Most/many do not, or would not need higher level of care if there are effective interventions available and provided at pre-placement or at earlier placements opportunities. (avg. number of placements is 8).
} Many could benefit from shorter-term placements and stabilization services
} Research mixed on the effectiveness of lesser restrictive alternatives (foster care) as well as effectiveness of residential treatment – however, some good news
} Promising research on IFPS Preservation Services } Promising research on Therapeutic Residential TX } Significant research on effective interventions for
issues that bring families and children/youth to the attention of Child Welfare (see Effective Interventions Brief).
} Effective Practice ◦ Family involvement ◦ Post re-unification placement services ◦ After care support (Hair, 2005)
} Short Term - 6 month - concentrated evidence-based residential programs accompanied by comprehensive in-community support for child/youth and family can be effective in achieving outcomes (Lyons, 2009)
} In the absence of definitive information have to make decisions based on available data
} Overlooked, but significant data available in child welfare and cross-system data bases.
} Interesting possibilities for integrated data systems
} Difference between actions of line staff and leadership
} In some instances more restrictive settings should be first resort ◦ Danger to themselves or others ◦ Emotional and physical dysregulation (type and
degree) ◦ Suicidal ideation vs. active planning ◦ Sexually aggressive behaviors ◦ Psychosis, ◦ Question: How long, and what for – short or long-
term, family-based, community connections
} Comprehensive Assessment - social, emotional, behavioral, developmental and academic functioning of children/youth
} Family - Characteristics and Need if plan includes connections and/or reunification.
} Effective elements of practice and effective interventions. (See Pecora & English, 2017 – Effective Interventions Research Brief)
} Should not be based on utilization of existing resources
} Complex trauma – exposures across time } If it didn’t work the first two times, why
would you do the same thing over again a third, fourth, fifth, sixth, seventh or eighth time.
} Upstream interventions - community settings and close proximity to families.
} Readiness for change } Identification of target population –
characteristics and needs } Match between needs and services } Algorithm predicting likelihood of achieving
outcomes } Return on Investment/Cost Benefit Analysis
} What are the characteristics of the children/families currently served in residential care?
} Are children matched with the appropriate level of care?
} If not, what are effective interventions for children who are currently identified as “high” need and require residential treatment compared to those who could benefit from less restrictive alternatives?
} How many and what types of services needed
} CANS – utilizing 5 sub-scales and 71 items – (exposure to trauma, child strengths, life functioning, behavioral and emotional needs and child risk behaviors).
} 4 pt. rating scale ◦ 0 = Strengths ◦ 1 = “watchful waiting” ◦ 2 = Services needed but not immediate ◦ 3 = Immediate action needed
} Latent Class Analysis – groups children with like characteristics and how many in each group.
We identified three major groups of youth in Residential Treatment :
1. Youth who could benefit from group home care, residential treatment or psychiatric hospitalization – with aftercare services. (30-40%)
2. Youth who could benefit from intensive community-based services such as intensive family preservation services, Wraparound services, foster care or treatment foster care.
3. Youth who could benefit from targeted but less intensive treatment strategies to support successful community-based living. (These services would help maintain youth in their communities and with their families and tribal clan members.)
} (Mostly 2’s – something needs to happen, but not necessarily today)
} Psychosis (11%) } Sexually aggressive (5%) } Suicide Watch (17%) } Self Mutilation (18%) } Poor Judgment – Danger to Self or Others
(30%) } Fire-setting (2%)
} Adjustment to trauma } Social, emotional and behavioral functioning ◦ Anger, emotional dysregulation, physical dysregulation,
impulsive behavior, depression, PTSD, anxiety } Interpersonal skills – communication and lack of
self-esteem } Lack of Attachment/relational connections } Problems with school behavior/academics } Family Functioning – parenting capacity/
attachment, mental health, DV, substance abuse, social support and concrete services.
} Not risk behaviors
} Emotional dysregulation/impulsive behavior ◦ AF-CBT – Family – Cognitive Behavioral Therapy ◦ CFTSI – Child and Family Traumatic Stress
Intervention ◦ CPC- CBT – Combined Parent-Child CBT
◦ Report summarizes level of evidence supporting intervention, length of treatment, provider qualifications, specific areas effective with and cost of intervention ◦ Aggregate data helps leadership determine “how
many” of specific kinds of services are needed.
LCA Groups 3 and 4: Need Group Home or Residential
Treatment
LCA Group 2: Need Wraparound, Intensive Home-Based/Family
Preservation Services, or possibly Foster Care or Treatment Foster Care
LCA Group 1: Need Community-Based Counseling Services or Wraparound Services
§ Adolescent Coping with Depression (CWD-A)**
§ Aggression Replacement Training*® (ART®)
§ Attachment-Based Family Therapy (ABFT)*
§ Cognitive Behavioral Therapy (CBT)***
§ Coping Cat* § Dialectical Behavior
Therapy (DBT)** § Parent Management
Training – Oregon Model (PMTO)***
§ Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)***
§ Aggression Replacement Training*® (ART®)
§ Cognitive Behavioral Therapy (CBT)***
§ Coping Cat* § Family Preservation
Services – Homebuilders Model**
§ Multisystemic Therapy**
§ Parent Management Training – Oregon Model (PMTO)***
§ Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)***
§ Wraparound Services**
§ Child-Parent Psychotherapy** § Child and Family Traumatic Stress
Intervention (CFTSI)* § Cognitive Behavioral Intervention for
Trauma in Schools (CBITS)** § Cognitive Behavioral Therapy (CBT)*** § Coping Cat* § Family Preservation Services -
Homebuilders model of family-based services**
§ Functional Family Therapy (FFT)** § Multisystemic Therapy (MST)** § Parent Management Training – Oregon
Model (PMTO)*** § Trauma-Focused Cognitive Behavioral
Therapy (TF-CBT)*** § Wraparound Services**
• Attachment Bio behavioral Catch-up (ABC)
• Cognitive Behavioral therapy (CBT)
• Cognitive Processing Therapy
• Coping Cat
• Ecologically-Based Family Therapy
• Eye movement desensitization and reprocessing (EMDR)
• Multisystemic Therapy (MST) for Youth with Problem Sexual Behavior
• PAX Good Behavior Game (PAX GBG)
• Trauma-Focused Cognitive Behavioral Therapy
} Collaboration with Schools – Mental Health } Computerized CBT – and Other Computer
Based Interventions } Cultural Approaches
} This data may not reflect the characteristics of the children/youth served in high end placements in Australia – if not, what are the characteristics and what are the most effective interventions?
} What are the values that reflect practice and how do they influence the kinds of programs and practices adopted in child welfare services? For example, least restrictive alternative, length of stay etc.,
} What would a best practice model look like, for whom, and for how long? How do you know this model will achieve the identified objectives?
} Importance of carefully pairing specific interventions with child needs, by providing the most effective interventions and improve child, family and system outcomes,
} If we agree that reductions in placement, reductions in level of restrictiveness, increased program effectiveness, minimizing length of stay, and increasing the number of children successfully “stepping down” to lower levels of care including reunification and/or other permanent family arrangement are prevailing values, then we must intentionally focus on the utilization of data and the development of programs that will help achieve these objectives.
} If we agree that ◦ reductions in placement, ◦ reductions in level of restrictiveness, ◦ increased program effectiveness, ◦ minimizing length of stay, and ◦ increasing the number of children successfully
“stepping down” to lower levels of care including reunification and/or other permanent family arrangement are prevailing values, ◦ then we must intentionally focus on the utilization
of data and the development of programs that will help achieve these objectives.
} Pecora, P.J. Elements of Effective Practice for Children and Youth Served by Therapeutic Residential Care. (Webinar for the State of Arkansas, May 25, 2016)
} Pecora, P.J. & English, D.J. (2016). Elements of Effective Practice for Children and Youth Served by Therapeutic Residential Care. Seattle: Casey Family Programs. Retrieved May 23, 2016 from http://www.casey.org/residential-care/
} For a catalog of interventions see English, D., Pecora, P.J., Goodman, D. & Wackerman, J. (2017). Interventions with special relevance for child welfare, with age range, treatment duration, effect sizes and cost data. Seattle, WA: Casey Family Programs.
} Pecora, P., and Davis, C., (2018) Effective Strategies for Serving Montana Youth with Different Levels of Need: National Context and Local Findings. PPT.
} Ainsworth, F., & Hansen, P., (2015) Group Homes for Children and Young People: The Problem Not the Solution