Communitybased Treatment Alternatives for Justiceinvolved Youth in Child

Community-based Treatment Alternatives for Justiceinvolved Youth in Child Welfare One year Follow-up Norín Dollard Kimberly Mc. Grath Mary Armstrong John Robst Melissa Johnson James Gimbel Presented at the FADAA-FCCMH’s 28 th Annual Conference, August 7, 2014, Orlando, Florida

Support This work is supported in part by the Florida Agency for Health Care Administration contract #MED 134 Louis de la Parte Florida Mental Health Institute

Why enhanced therapeutic foster care? Many interventions targeted to youth with justice involvement are not effective (Henggeler & Schoenwald, 2011). ♦ Blueprints Initiative reviewed the evidence base for over 600 prevention and intervention programs ♦ Of the few found effective, Multidimensional Treatment Foster Care was included Louis de la Parte Florida Mental Health Institute Evidence for the presence of a group contagion effect with delinquent youth in group settings (Lee & Thompson, 2009)

Why enhanced therapeutic foster care? Florida studies over the past five years suggest: ♦ There are large proportions of youth entering Statewide Inpatient Psychiatric Programs (SIPP) (42%, n=195) and Therapeutic Group Care (TGC) (31%, n=86) with juvenile justice contacts in the six months prior to placement ♦ The higher the proportion of justice-involved youth in SIPPs or TGC, the more likely youth treated in these settings will have higher rates of future criminal activity after discharge. Louis de la Parte Florida Mental Health Institute ♦ Youth treated in Specialized Therapeutic Foster Care have lower rates of delinquent activity after discharge.

Florida Context No standardized practice model with evidence base for Specialized Therapeutic Foster Care Closure of youth commitment settings in Miami-Dade Statewide move towards adopting EBPs ♦ Re. Directions (AHCA – DJJ) and DCF Louis de la Parte Florida Mental Health Institute ♦ Georgetown Crossover Youth Practice Model ♦ Wraparound--DCF

Implementation of a Pilot Program Engagement of system partners at state and community level Commitment to identify evidence-based model that is cost feasible statewide within Florida’s publicly funded children’s system Louis de la Parte Florida Mental Health Institute Review of evidence base for therapeutic foster care ♦ Investigation of feasibility of Multidimensional Treatment Foster Care ♦ Decision to use Together Facing the Challenge

What is Together Facing the Challenge? Evidence-based model that includes training and coaching for treatment foster care supervisors and parents on: ♦ Supportive and involved relationships between supervisors and treatment parents; ♦ Effective use of behavior management strategies by treatment parents; and; Louis de la Parte Florida Mental Health Institute ♦ Supportive and involved relationships between treatment parents and youth • Farmer, E. M. , Burns, B. J. , Wagner, H. R. , Murray, M. M. , & Southerland, D. G. (2010)

What is Together Facing the Challenge? Foster parents are active members of the treatment team and are held accountable for behavioral interventions. Allows therapists the opportunity to focus on core clinical issues with their clients while still addressing behavioral concerns. Provides a structured and consistent framework for parents within a system which reduces differences between homes in the program. Louis de la Parte Florida Mental Health Institute Provides clear, consistent and obtainable treatment goals for clients.

Study Purpose To implement and evaluate a small pilot study (n=10) of Together Facing the Challenge in Miami ♦ For feasibility in real world public sector settings, ♦ With fidelity to the supervision and teaching model, ♦ Tracking outcomes and costs. Louis de la Parte Florida Mental Health Institute

Research Questions 1. To what extent is Together Facing the Challenge implemented with fidelity? 2. How are youth outcomes for this pilot in comparison with outcomes of similar youth in other out-of-home settings? 3. What are the program costs? Louis de la Parte Florida Mental Health Institute

Population Inclusion criteria ♦ 9 -17 years old ♦ History of juvenile justice involvement ♦ Referred by Miami-Dade multidisciplinary child welfare team for appropriate placement ♦ Meets criteria for Florida’s Specialized Therapeutic Foster Care according to Medicaid handbook Louis de la Parte Florida Mental Health Institute ♦ Is in the child welfare dependency system ♦ Is enrolled in Medicaid ♦ Assent and consent obtained, as well court authorization if applicable

Population (continued) Exclusion criteria ♦ Sex offenders (Felony sex offenses including kidnapping involving sex offenses, sexual assaults, sexual battery, lewd & lascivious, and other felony sex offenses) Louis de la Parte Florida Mental Health Institute ♦ Violent offenders (Violent crime includes murder, forcible sex offenses, robbery, and aggravated assault) ♦ Axis I diagnosis of substance abuse

Data Collection Fidelity data to ensure fidelity of implementation Data from Citrus, adult and youth justice, state mental health, and Medicaid management information systems Louis de la Parte Florida Mental Health Institute Primary data collected from youth and their caregivers at baseline, every three months while in treatment, discharge, and three and six months post-discharge

Fidelity Data Therapeutic Treatment Parents as Front. Line Treatment Providers - the caregiver’s ability to effectively implement the parenting skills and techniques presented during the training on the Together Facing the Challenge curriculum Louis de la Parte Florida Mental Health Institute

MIS Data Elements Age, race / ethnicity, gender, and diagnoses Louis de la Parte Florida Mental Health Institute Completion of the program, run away behaviors, delinquent behaviors, permanency goal attainment, treatment plan goal attainment, academic outcomes (e. g. , grades, suspensions, expulsions, referrals for behavior), response to treatment, positive interactions with adults and peers, and Baker Act initiations

Outcome Data Collected from Youth & Caregivers Delinquent peer associations: assessed using the Interaction with Antisocial Peers Scale (Youth Report) Wellness: Child Health Questionnaire Indicators of physical wellness, psychosocial wellness and overall wellness (Caregiver Report) Louis de la Parte Florida Mental Health Institute Youth strengths: Behavioral and Emotional Rating Scale—Second Edition, Parent Rating Scale and Youth Rating Scale (Caregiver & Youth Report)

Outcome Data – Mental Health Issues Child Behavior Checklist & Youth Self. Report (Youth and Caregiver Report) ♦ Total Problem Behavior Score, Internalizing Behaviors and Externalizing Behaviors. ♦ Narrow band syndromes including Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints, Social Problems, Thought Problems, Attention Problems, Rule. Breaking Behavior, and Aggressive Behavior Louis de la Parte Florida Mental Health Institute Strengths and Difficulties Questionnaire (Caregiver Report) ♦ One overall scale and Four scales – Emotional Symptoms, Conduct Problems, Hyperactivity Scale, Peer Problems.

Pilot Findings Youth Demographics (n = 10) ♦ 40% Male ♦ 90% Black or African American ♦ 10% Hispanic / Latino ♦ 60% were 15 -17 years of age at baseline (range 13 -17) Louis de la Parte Florida Mental Health Institute

Diagnoses Louis de la Parte Florida Mental Health Institute % (N=9) Conduct Disorder 66. 7% Mood Disorder 55. 5% Substance Abuse 44. 4% Attention Deficit 33. 3% Oppositional Defiant Disorder 33. 3% Bipolar Disorder 22. 2% Adjustment Disorder 11. 1% Major Depressive Disorder 11. 1%

Therapeutic Treatment Parents as Front-Line Treatment Providers • Interrupts the conflict cycle • Establishes and maintains house rules • Gives effective instructions • Tracks positive and negative change • Uses praise to encourage positive. . . • Teaches cooperation • Est. & effectively uses a daily checkin • Builds a therapeutic relationship • 0% • 10% • 20% • 30% • 40% • 50% • 60% • 70% • 80% • 90% • 100% Louis de la Parte Florida Mental Health Institute • Not at all N=8 • Somewhat like • Moderately • Like • Very much like

Therapeutic Treatment Parents as Front-Line Treatment Providers • Takes care of self • Teaches relevant life skills • Addresses thoughts, feelings & behaviors • Utilizes problem solving techniques • Incorporates family fun time • Uses effective communication • Implements consequences • Develops & implements behavior. . . • 0% • 10% • 20% • 30% • 40% • 50% • 60% • 70% • 80% • 90% • 100% Louis de la Parte Florida Mental Health Institute • Not at all • Somewhat like • Moderately • Like • Very much like

Youth Strengths at Baseline – Caregiver Report Strength subscalea BERS 2 C Average Score Baseline (n = 8) Interpersonal Strength Louis de la Parte Florida Mental Health Institute 3 months (n = 10) 6 months (n = 6) 9 months (n = 3) 10. 25 7. 00 7. 67 8. 67 Family Involvement 8. 75 6. 60 7. 67 8. 33 Intrapersonal Strength 8. 25 7. 40 6. 20 8. 67 School Functioning 5. 25 5. 00 6. 83 6. 33 Affective Strength 9. 25 8. 30 8. 17 9. 33 Career Strength 10. 00 8. 50 6. 50 9. 67 Strength Index b 88. 38 77. 40 80. 00 88. 00

Youth Strengths at Baseline – Youth Report Strength subscalea BERS 2 Y Average Score Baseline (n = 10) Louis de la Parte Florida Mental Health Institute 3 months (n = 10) 6 months (n = 6) 9 months (n = 5) Interpersonal Strength 7. 50 10. 22 12. 83 11. 2 Family Involvement 6. 40 8. 67 9. 60 Intrapersonal Strength 9. 10 12. 10 13. 83 12. 80 School Functioning 6. 90 9. 11 10. 00 9. 20 Affective Strength 6. 90 8. 60 10. 67 9. 60 Career Strength 10. 90 14. 20 13. 83 14. 00 Strength Index b 81. 70 95. 40 107. 83 103. 00 [a] Strength subscales on the BERS– 2 C range from 1 to 16, and on the BERS– 2 Y from 1 to 18. Average scores on both instruments range between 8 and 12. Higher scores indicate greater strength. [b] Strength Indexes for both BERS– 2 C and BERS– 2 Y range from 38 to 161, with an average index between 90 and 110. A higher index indicates greater overall strengths.

BERS Strengths Quotient Index • 120 • 100 • 80 • 107, 8 • 88, 4 • 81, 7 • 95, 4 • 77, 4 • 80 • 103 • 88 • 60 • 40 • 20 Louis de la Parte Florida Mental Health Institute • 0 • Baseline • 3 month • Caregiver • 6 month • Youth • 9 month

Strengths and Difficulties Questionnaire SDQ Scale Louis de la Parte Florida Mental Health Institute Proportion of youth scoring in the ‘normal’ range Baseline (N =8) 3 M (N=10) 6 M (N=6) 9 months (N=3) Emotional Symptoms 62. 5% 70% 66. 7% 33. 3% Conduct Problems 62. 5% 50% 66. 7% 33. 3% Hyperactivity 25. 0% 33. 3% 0% Peer Problems 62. 5% 70% 33. 3% Prosocial 0% 30% 16. 7% 33. 3% Total Difficulties 0% 10% 33. 3% 0%

Problem Behaviors & Symptoms – Caregiver Report Strength subscalea Child Behavior Checklist Average Score Baseline (n = 8) 3 months (n = 10) 6 months (n = 5) 9 months (n = 3) Internalizing T-Score 59. 8 57. 1 56. 2 55. 3 Externalizing T-Score 62. 0 65. 6 63. 6 64. 3 Total Problem T-score 63. 0 63. 8 63. 0 63. 7 Louis de la Parte Florida Mental Health Institute [a] Borderline clinical range 60 -63, clinical range 64 and higher

Problem Behaviors & Symptoms – Youth Report Strength subscalea Child Behavior Checklist Average Score Baseline (n = 10) 3 months (n = 9) 6 months (n = 5) 9 months (n = 4) Internalizing T-Score 44. 5 45. 1 49. 6 46. 5 Externalizing T-Score 56. 3 52. 1 54. 8 53. 5 Total Problem T-score 47. 7 48. 1 51. 6 46. 8 Louis de la Parte Florida Mental Health Institute [a] Borderline clinical range 60 -63, clinical range 64 and higher

Child and Youth Physical Wellbeing – Caregiver’s Impression of Overall Health • 50% • 40% • 30% • 20% • 25, 0% • 40, 0% • 37, 5% • 25, 0% • 30, 0% • 20, 0% • 12, 5% • 20, 0% • 10% • 0, 0% • 0% • Baseline Louis de la Parte Florida Mental Health Institute • Excellent • 3 months • Very Good • 6 months • Fair

How often has your child's health or behavior…. * • …caused disagreements / arguments • …. caused you to cancel / change plans suddenly? • 0, 0% • . . . caused tension / conflict • 0, 0% • . . . limited ability to pick up and go on a moment's notice • . . . interrupted everyday family activities • . . . limited the types of family activities Louis de la Parte Florida Mental Health Institute • 0, 0% • 11, 1% • 14, 3% • 0, 0% • 16, 7% • 14, 3% • 16, 7% • 22, 2% • 0, 0% • 14, 3% • 0, 0% • 22, 2% • 11, 1% • 22, 2% • 28, 6% • 0% • 5% • 10% • 15% • 20% • 25% • 30% • 35% • 6 months (n = 6) • 3 months (n = 9) • Baseline (N=7) *very often or fairly often

In the past 4 weeks, how much did you worry / concern did you have about your child’s * • your child's attention or learning abilities • 44, 4% • 40, 0% • 44, 4% • your child's emotional wellbeing • your child's physical health • 83, 3% • 66, 6% • 33, 3% • 22, 2% • 16, 7% • 0% • 10% • 20% • 30% • 40% • 50% • 60% • 70% • 80% • 90% Louis de la Parte Florida Mental Health Institute • 6 months (n =6) * Quit a bit or alot • 3 months (n =9) • Baseline (n = 6)

In the past year, proportion with at least one friend who… ou t ed ro p • D ar as • W pe d re st to ed tri or le to • S d ol • S . . . s ru g ille ga ld ha a ed ar ri • C Louis de la Parte Florida Mental Health Institute • W as su sp e nd ed nd g. . . • 80% • 66, 7% • 70% • 60, 0% • 60% • 55, 6% • 50, 0% • 44, 4% • 50% • 40, 0% • 33, 3% • 30, 0% • 33, 3% • 40% • 30, 0% • 30% • 16, 7% • 20% • 11, 1% • 10% • 0% • Baseline (N = 9) • 6 months (n =6) • 3 months (n = 10)

Adverse Events All youth had JJ histories at admission, but only 4 had subsequent encounters (5 total encounters) 3 youth had involuntary examinations (4 total) 7 youth ran away while receiving services ranging from 2 -21 days AWOL Louis de la Parte Florida Mental Health Institute

Costs for Treatment/Placement Alternatives Per diem Room & board Total Cost ETFC 9 months additional services 136 90 61, 813 45 0 12, 319 Total cost 74, 132 Residential MH Center (RTC) 9 months RTC Louis de la Parte Florida Mental Health Institute 408 0 111, 690 408 0 74, 460 45 0 4, 106 Residential MH Center (assumed discharge to home) 6 months RTC 3 months community services Total cost 78, 566

Costs for Treatment/Placement Alternatives Per diem RTC + Therapeutic Group Care (TGC) Room & board Total Cost 6 months RTC 408 0 74, 460 3 months TGC 180 90 24, 638 45 0 4, 106 3 months additional services Total cost 103, 204 RTC + Treatment Foster Care (TFC) Louis de la Parte Florida Mental Health Institute 6 months RTC 408 0 74, 460 3 months TFC 136 18 14, 034 45 0 4, 106 3 months additional services Total cost 92, 601

Costs for Treatment/Placement Alternatives Per diem Room & board Total Cost TGC 9 months additional services Total cost 180 90 73, 913 45 0 12, 319 86, 231 Juvenile Justice (JJ) commitment Louis de la Parte Florida Mental Health Institute Juvenile Justice (JJ) commitment 9 months JJ group home (BHOS) + medications Total cost 240 0 65, 591 48 0 13, 003 78, 594

Conclusions Training costs for Together Facing the Challenge are modest and sustainable (use a train-the trainer approach) Foster parents are able to learn and apply the ETFC skills Louis de la Parte Florida Mental Health Institute Caregivers have a stable view of youth strengths. Youth’s perceptions of their own strengths improved over time Caregivers report higher levels of difficulties with externalizing and total problem behaviors than the youth

Conclusions Caregivers report progress in integrating youth into their families over time with fewer disruptions Relatively few adverse incidents (JJ encounters and Baker Acts) Costs favor ETFC over RTC, RTC plus step down and JJ program costs) Louis de la Parte Florida Mental Health Institute

Recommendations School is the biggest challenge as evidenced by caregiver and youth report on their strengths, and grade point average. Identifying ways to address runaways is crucial Louis de la Parte Florida Mental Health Institute Engagement = there appears to be a ‘honeymoon’ period in the first 3 months, then spikes, and then subsequent improvements

Limitations We are still collecting 9, 12 and post discharge data so the data are not yet complete. Louis de la Parte Florida Mental Health Institute

Challenges to Implementation Acquiring administrative or executive support and understanding within your agency of the implementation process is essential. Transitioning staff from “Business as usual” to implementation of new techniques and procedures can be challenging! Be prepared to face resistance to change from your foster parents –especially experienced or “expert” parents. Louis de la Parte Florida Mental Health Institute Foster parents may feel as though they are being critiqued or evaluated unfairly during the implementation process.

Challenges to Implementation Successful implementation requires constant training and education for system partners (i. e judicial system, CBC providers, GAL) regarding the program requirements and the treatment process. Incentives and rewards for participation in the evaluation process help keep clients and parents engaged throughout the treatment process. Louis de la Parte Florida Mental Health Institute

Strengths & Successes This program provides an opportunity for intensive treatment services in the community for a population of clients that typically would not be served at this level of care. We are now integrated into the system of care in Dade county and we have a waiting list. Foster parents and staff are receptive to expanding the program. Case example of a successful client: D. L. Louis de la Parte Florida Mental Health Institute

Next Steps Working with AHCA to modify discharge criteria for STFC pilot programs to allow children the opportunity to benefit from one year of treatment services. Engaging in intensive foster parent recruitment efforts to facilitate program expansion. Agreement from the FL Department of Juvenile Justice to share in the program costs Louis de la Parte Florida Mental Health Institute Work with Our Kids to move towards county-wide implementation

Questions? Louis de la Parte Florida Mental Health Institute