CONNECTING THE DOTS: Safety, Permanency, and Well-being

Bryan Samuels, Executive DirectorChapin Hall Center for ChildrenUniversity of Chicago

Illinois’ Child Welfare Population 1990 to 2003

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 20020

10,000

20,000

30,000

40,000

50,000

60,000

23,400

51,000

20,848

Pat

hw

ay t

o P

oo

r O

utc

om

es

for

Ch

ildre

n a

nd

Yo

uth

Abusive or Neglectful Parenting

Poor Outcomes

Psychological Distress

Poor Social Functionin

g, Disturbed

Peer Relationshi

ps

Maladaptive Coping

Strategies

Insecure Attachment

s & Emotional

Dysregulation

Re-Defining Success: Focusing on Well-being

1. Redesign performance-based contracting to emphasize well-being outcomes in addition to permanency.

2. Implement new placement system to keep children in the same school they attended prior to substitute care.

3. Implement comprehensive assessment.4. Re-design transitional living and

independent living programs to prepare youth for transition to adulthood.

5. Creat a child location unit that tracks all youth who run away.

6. Introduce evidence-based services to address trauma.

7. Establish a common outcome measures for residential treatment and group homes.

25% DECLINE IN CASELOADS 2002-2011

-80.0%

-60.0%

-40.0%

-20.0%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%M

ain

e

Haw

aii

Mary

land

Puert

o R

ico

DC

New

Jers

ey

Ohio

N

ew

Ham

psh

ire

Georg

ia

Califo

rnia

N

ew

York

F

lori

da

Min

neso

ta

Verm

ont

Pennsy

lvania

V

irgin

ia

Mass

ach

use

tts

Colo

rado

Mic

hig

an

Illinois

W

isco

nsi

n

Rhode I

sland

South

Caro

lina

Mis

souri

T

enness

ee

Connect

icut

Ala

ska

Nort

h D

akota

N

ebra

ska

Ala

bam

aN

ort

h C

aro

lina

Monta

na

Louis

iana

Okla

hom

a

Kansa

s D

ela

ware

W

yom

ing

Ore

gon

Kentu

cky

Wash

ingto

n

New

Mexi

co

South

Dakota

Id

aho Io

wa

Ark

ansa

s In

dia

na

Uta

h

Mis

siss

ippi

West

Vir

gin

ia

Texa

s Neva

da

Ari

zona

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

COMPLEX TRAUMA AMONG CHILDREN ENTERING FOSTER CARE

Neg

lect

Domes

tic v

iole

nce

Emot

iona

l abu

se

Phys

ical

abu

se

Sexu

al a

buse

Sexu

al a

ssau

lt0%

10%20%30%40%50%60%70%80%90%

Types of Abuse among Children Entering Foster Care

Greeson, JKP; et al. (2011). Complex trauma and mental health in children and adolescents placed in foster care: findings from the National Child Traumatic Stress Network. Child Welfare. 90(6):91.

4/11/2013 6

CHALLENGES AMONG CHILDREN KNOWN TO CHILD WELFARE

31%

24%

40%

20%

37%

18%

45%

19%

38%

24%

41%

24%

In-Home, Connected to ServicesIn-Home, Not Connected to ServicesOut-of-Home

Dolan, M., Casanueva, C., Smith, K., & Ringeisen, H. (2011). NSCAW Child Well-Being Spotlight: Children Placed Outside the Home and Children Who Remain In-Home after a Maltreatment Investigation Have Similar and Extensive Service Needs. OPRE Report #2012-32, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

In Home Kinship Care Foster care

34% 33%

43%41%

36%

43%

Social Skills Problems Emotional Problems

RELATIONAL SKILLS ARE BOUND UP IN SOCIAL-EMOTIONAL PROBLEMS

Safety & Permanency are Necessary but not Sufficient to Ensure Well-Being

REUNIFICATION

• “Children who went home and stayed home had a four fold increase in internalizing behavior problems from baseline to 18-month follow-up. Though the percentage of children with behavior problems at 36-month follow-up decreased, still twice as many children met or exceeded clinical levels as compared to baseline” (1).

KINSHIP CARE

• “Kinship placements were not predictive of mental health outcomes regardless of the amount of time in kinship care. …[M]multiple causes of mental health problems often occur previous to placement in care and may not be mediated by the child’s foster care experience enough to show significant differences” (2).

ADOPTION

• In assessments of children at 2, 4, and 8 years following adoption, “Adopted foster youth were more behaviorally impaired than their non-FC counterparts, although a striking number of non-FC youth displayed behavior problems as well” (3)

1. Bellamy, J. (2008). Behavioral problems following reunification of children in long-term foster care. Children and Youth Services Review. 30:216.

2. Fechter-Leggett, MO & O’Brien, K. (2010). The effects of kinship care on adult mental heath outcomes of alumni of foster care. Children and Youth Services Review. 32(2):206.

3. Simmel, C.; et al. (2007). Adopted youths psychosocial functioning: A longitudinal perspective. Child and Family Social Work. 12(4):336.

Chaffee Programs Yield Poor Outcomes

Chaffee Foster Care Independence Program Type Outcomes Measures FindingsTutoring and Mentoring

Age percentile in reading and math, school grades, high school completion, highest grade completed, and school behavior problems

No statistically significant difference on key outcomes

Life Skills Training

High school completion, current employment, earnings, net worth, economic hardship, receipt of financial assistance, residential instability, homelessness, delinquency, pregnancy, possession of personal documents, any bank account, and sense of preparedness in 18 areas of adult living

No statistically significant difference on key outcomes

Employment High school completion, college attendance, current employment, earnings, net worth, economic hardship, receipt of financial assistance, residential instability, homelessness, delinquency, pregnancy, possession of personal documents, any bank account, and sense of preparedness in 18 areas of adult living

No statistically significant difference on key outcomes

Intensive Case Management and Mentoring

High school completion, college enrollment and persistence, current employment, employment past year, earnings, net worth, economic hardship, receipt of financial assistance, residential instability, homelessness, delinquency, pregnancy, possession of personal documents, any bank account, and sense of preparedness in 18 areas of adult living

Higher rates of college attendance and persistence among treatment than control group youth but difference was largely explained by continued child welfare system involvement among youth in the treatment group

Koball, Heather, et al. (2011). Synthesis of Research and Resources to Support At-Risk Youth, OPRE Report # OPRE 2011-22, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

AVERAGE LIFETIME COST OF MALTREATMENT IS $210,000

Crimin

al ju

stice co

sts

Child

welfa

re cos

ts

Special

edu

catio

n co

sts

Long-

term

hea

lth car

e co

sts

Short-te

rm h

ealth

car

e co

sts

Produ

ctivity

loss

es

$6,747 $7,728 $7,999 $10,530

$32,648

$144,360

X. Fang et al., 2012

“There is no doubt that children in harm’s way should be removed from a dangerous situation. However, simply moving a child out of immediate danger does not in itself reverse or eliminate the way that he or she has learned to be fearful. The child’s memory retains those learned links, and such thoughts and memories are sufficient to elicit ongoing fear and make a child anxious.”National Scientific Council on the Developing Child (2010). Persistent Fear and Anxiety Can Affect Young Children’s Learning and Development: Working Paper No. 9. Retrieved fromwww.developingchild.harvard.edu (emphasis added)

“Traditional child welfare approaches to maltreatment focus largely on physical injury, the relative risk of recurrent harm, and questions of child custody, in conjunction with a criminal justice orientation. In contrast, when viewed through a child development lens, the abuse or neglect of young children should be evaluated and treated as a matter of child health and development within the context of a family relationship crisis, which requires sophisticated expertise in both early childhood and adult mental health.”

 National Scientific Council on the Developing Child (2004). Young Children Develop in an Environment of Relationships: Working Paper No. 1. Retrieved from www.developingchild.harvard.edu (emphasis added)

Emotional, and Social Capacities Are Inextricably Intertwined Within the

Architecture of the Brain

Maltreatment during early childhood can

cause vital regions of the brain to develop

improperly, leading to a variety of physical, emotional, cognitive,

and mental health problems.

Maltreatment results in difficulties

regulating emotional reactions, rage, dissociation,

somatization, changes in

perception of self and others, and

changes in understanding and interpreting events.

i. Siegel, DJ. (2001). Toward an interpersonal neurobiology of the developing mind: Attachment relationships, “mindsight,” and neural integration. Infant Mental Health. 22(1-2):67.

ii.Terr, LC. (1991). Acute responses to external events and Posttraumatic stress disorders. In Lewis, M (Ed.). Child and adolescent psychiatry: a comprehensive textbook New Haven, CT: Williams & Wilkins.

• Refers to children’s experiences of multiple traumatic events that occur within the caregiving system – the social environment that is supposed to be the source of safety and stability in a child’s life.

• Typically, complex trauma exposure refers to the simultaneous or sequential occurrences of child maltreatment—including emotional abuse and neglect, sexual abuse, physical abuse, and witnessing domestic violence—that are chronic and begin in early childhood.

• Moreover, the initial traumatic experiences (e.g., parental neglect and emotional abuse) and the resulting emotional dysregulation, loss of a safe base, loss of direction, and inability to detect or respond to danger cues, often lead to subsequent trauma exposure (e.g., physical and sexual abuse, or community violence).”

Maltreatment & Complex Trauma

Impact of Trauma on Brain DevelopmentBRAIN

Hormones, chemicals,

and cellular systems

prepare for a tough life in an evil

world

INDIVIDUAL

> Edgy

> Hot temper

> Hyper vigilant

> “Brawn over brains”

OUTCOME

Individual and

species survive

the worst conditions

BRAINHormones, chemicals,

and cellular systems

prepare for life in a

benevolent world

INDIVIDUAL

> Laid back

> Relationship-

oriented

> Think things

through

> “Process over power”

OUTCOMEIndividual

and species live

peacefully in good times;

vulnerable in poor

conditions

Traumatic Stress

Adapted from: Family Policy Council. (2007). The High Cost of Adverse Childhood Experiences (PPT). Olympia, WA: Author.

NEUTRAL START

Active alcohol abuse by primary caregiver

Active drug abuse by primary caregiver

Active domestic violence against caregiver

Primary caregiver had serious mental health problem

History of abuse or neglect of primary caregiver

History of domestic violence against caregiver

0 5 10 15 20 25 30 35

Child Placed Out of Home

Toxic Stress in Home of Children Involved in Child Welfare

Toxic Stress in Home of Children Involved in Child Welfare

Primary caregiver described or act toward child in predominately neg-

ative terms

Parent had unreal expectations of child

Child had major special needs or behavioral problems

Low social support

Prior reports of child maltreatment

0 10 20 30 40 50 60 70 80

Child Placed Out of Home

Percent

Early Experiences Alter Gene Expression

Extensive scientific research has shown that the healthy development depends on how much and when certain genes are expressed in the cells of these systems.

Research has shown that environmental factors and early experiences have the power to impact whether genes are turned "on" or "off"—essentially whether and when genes are activated to do certain tasks.

Toxic Stress Evident in Social & Emotional Problems of Maltreated Children

19

1.5-5 Years 6-10 Years 11-17 Years0%

10%

20%

30%

40%

50%

60%

70%

20.5%

49.5%

57.2%

Risk of Social-Emotional Problems

Age Group

Perc

en

t of

Ch

ildre

n R

eport

ed t

o C

hil

d

Pro

tecti

ve S

erv

ices

A FRAMEWORK FOR WELL-BEING

Environmental

Supports

Personal Characteris

tics

Developmental Stage

Cognitive Functionin

g

Physical Health and Developme

nt

Emotional/ Behavioral Functionin

g

Social Functionin

g

The framework identifies four basic domains of well being: (a) cognitive functioning, (b) physical health and development, (c) behavioral/emotional functioning, and (d) social functioning. Within each domain, the characteristics of healthy functioning related directly to how children and youth navigate their daily lives: how they engage in relationships, cope with challenges, and handle responsibilities.

4/8/2013 20

Two Days in May - Ohio 21

Screening, Functional Assessment & Progress Monitoring

• “Functional assessment—assessment of multiple aspects of a child’s social-emotional functioning (Bracken, Keith, & Walker, 1998)—involves sets of measures that account for the major domains of well-being.”

• “Child welfare systems often use assessment as a point-in-time diagnostic activity to determine if a child has a particular set of symptoms or requires a specific intervention. Functional assessment, however, can be used to measure improvement in skill and competencies that contribute to well-being and allows for on-going monitoring of children’s progress towards functional outcomes.”

• “Rather than using a “one size fits all” assessment for children and youth in foster care, systems serving children receiving child welfare services should have an array of assessment tools available. This allows systems to appropriately evaluate functioning across the domains of social-emotional well-being for children across age groups (O’Brien, 2011) and accounting for the trauma- and mental health-related challenges faced by children and youth who have experienced abuse or neglect.”

May 11, 2012

Valid and reliable mental and behavioral health and developmental screening and assessment tools should be used to understand the impact of maltreatment on vulnerable children and youth.

TRAUMA SCREENING

• Child and Adolescent Needs and Strengths (CANS) Trauma Version

• Childhood Trauma Questionnaire (CTQ)

• Pediatric Emotional Distress Scale (PEDS)

FUNCTIONAL ASSESSMENT

• Strengths and Difficulties Questionnaire (SDQ)

• Child Behavior Checklist (CBCL), the Social Skills Rating Scale (SSRS)

• Emotional Quotient Inventory Youth Version (EQ-i:YV)

Time to Stop Counting Service“It is common for child welfare systems to gauge their success based on whether or not services are being delivered. One way to focus attention on well-being is to measure how young people are doing behaviorally, socially, and emotionally and track whether or not they are improving in these areas as they receive services” (ACYF-CB-IM-12-04).

Measuring ServicesHow many children received…?How many hours of training were delivered?What percent of children got…?

Measuring OutcomesAre trauma symptoms reduced?

Did services increase relationship skills?

Do children have healthier coping strategies?

RESEARCH-BASED APPROACHES

INEFFECTIVE APPROACHES

De-scaling

what doesn’t

work

Investing in what does

DE-SCALING WHAT DOESN’T WORK, SCALING UP WHAT DOES

Pre- and post-tx sx, n=25, 3-6 yrs old

PTSD MDD SAD ADHD ODD0

1

2

3

4

5

6

7

8

9

Pre-treatment Post-treatment

Nu

mb

er

of

sym

pto

ms

**

***

*

*p<.001, **p<.0001

Scheeringa, M. and Gonzales, R.. Clinical treatment approaches to trauma. Tulane University School of Medicine. (April 15, 2013 presentation to at the CWLA Neuroscience and Child Maltreatment Conference).4/25/2013 24

INTERVENTIONS NEED TO BE STRONG ENOUGH TO MEET COMPLEX NEEDS OF CHILDREN/YOUTH

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

processes of returning children to their biological

families

processes of adoption or subsidized

guardianship

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 Are Missed Opportunities to Promote Well-being

PromotingWell-being

Focus on child & family

behavior, skills competencies,

outcomes

Monitor progress for

improved child/youth functioning

Change practice to

address trauma

Take developmental

approaches

Actively promote healthy

relationships

Build capacity for more intensive EBP/RBIs

Connecting the Dots To Well-being

• Reduced caseload ratios in public and private sectors form 20 cases per worker to 14 cases per worker.

• Decreased child welfare population declined from 23,500 to16,500 statewide.

• Reduced disproportionate representation of African American children in child welfare system declined from 69.3% to 60%.

• Decreased number of youth “on run” decreased by 40% and number of days “on run” decreased by 50%.

• Decreased late child protection investigations by 60%.• Reduced distance between home of origin and foster

care placement reduced from 20 miles to 7.8 using new school placement strategy.

• Reduced time in residential treatment by 20%.

• Reduced caseload ratios in public and private sectors form 20 cases per worker to 14 cases per worker.

• Reduced disproportionate representation of African American children in child welfare system declined from 69.3% to 60%.

• Decreased number of youth “on run” decreased by 40% and number of days “on run” decreased by 50%.

• Decreased late child protection investigations by 60%.• Reduced distance between home of origin and foster

care placement reduced from 20 miles to 7.8 using new school placement strategy.

• Reduced time in residential treatment by 20%. • Decreased child welfare population declined from 23,500

to16,500 statewide.

RE-DEFINING SUCCESS: STATE OF ILLINIOS

QUESTIONS?

MATCHING POPULATIONS, OUTCOMES, AND APPROACHES: IV-E WAIVER EXAMPLES

Population

Children, 8-17

Children, 13-17

Children, 2-7

Screening&

Assessment- UCLA PTSD Index

- Strengths & Difficulties

Questionnaire- Child &

Adolescent Needs & Strengths

- Strengths & Difficulties

Questionnaire- Child & Adolescent Needs & Strengths

- Trauma Symptoms Checklist for Young

Children- Infant Toddler

Emotional Assessment- CBCL

EBIs

Trauma-Focused Cognitive

Behavioral Therapy

Multisystemic Therapy

Parent-Child Interaction Therapy

Outcomes

- Behavior problems

- PTS symptoms- Depression

- Delinquency/Drugs- Peer problems

- Family cohesion

- Conduct disorders- Parent distress

- Parent-child interaction

Connecting the Dots of Promising Practices

To promote emotional, social, cognitive, and physical development broadly, promising practices including a range of strength building strategies that:

1. Reduce stress in children’s lives, both by addressing its source and helping them learn how to cope with it in the company of competent, calming adults;

2. Foster social connection and open-ended creative play, supported by adults;

3. Incorporate vigorous physical exercise into daily activities, which has been shown to positively affect stress levels, social skills, and brain development;

4. Increase the complexity of skills step-by-step by finding each child’s “zone” of being challenged but not frustrated; and

5. Include repeated practice of skills over time by setting up opportunities for children to learn in the presence of supportive mentors and peers.

Focus on Relationships—Children develop in an environment of relationships. This starts in the home and extends to caregivers, teachers, medical and human services professionals, foster parents, and peers. Children are more likely to build effective executive function skills if the important adults in their lives are able to: 1. Support their efforts; 2. Model the skills; 3. Engage in activities in which they practice the skills; 4. Provide a consistent, reliable presence that young children

can trust; 5. Guide them from complete dependence on adults to gradual

independence; and 6. Protect them from chaos, violence, and chronic adversity,

because toxic stress caused by these environments disrupts the brain circuits required for executive functioning and triggers impulsive, “act-now-think-later” behavior.

Connecting Dots of Promising Practices

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 Recovery

SOCIAL 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

4/30/2013 33

PROMOTING WELL-BEING ACROSS THE U.S.Regional Partnership Grants to Increase Well-Being and Improve Permanency Outcomes for Children Affected by Substance Abuse

Partnerships to Demonstrate the Effectiveness of Supportive Housing for Families in the Child Welfare System

Title IV-E Child Welfare Demonstration Projects, Approved in FY 2012

Working with Children’s Bureau for Title IV-E Child Welfare Demonstration Projects, for FY 2013

Permanency Innovations Initiative

6/3/2013 34

Common Concerns & Evidence-Based Interventions (1 of 2)

Diagnosis/Concern/Activity

Evidence-Based Interventions (Examples) Age

Screening Activities

Identification of Mental Health & Behavioral Health Issues

SCREENING TOOLS

• Child & Adolescent Needs & Strengths—Trauma (CANS)

• Pediatric Symptom Checklist (PSC)• Strengths and Difficulties Questionnaire (SDQ)• Child Behavior Checklist (CBCL)

0-184-164-174-18

Most Common Mental Health Diagnoses for Children in Foster Care (bold red text indicates parent or caregiver component)

Conduct Disorder/Oppositional Defiant Disorder

• Parent-Child Interaction Therapy (PCIT)• Strengthening Families Program (SFP)• Early Risers – Skills for Success• Brief Strategic Family Therapy (BSFT)• Multisystemic Therapy (MST)• Familias Unidas• Multidimensional Treatment Foster Care (MTFC)

2-73-166-126-179-1712-1712-17

Attention Deficit Hyperactivity Disorder

• Parent–Child Interaction Therapy (PCIT)• Triple P• Children’s Summer Treatment Program (STP)

2-70-166-12

Major Depression • Adolescents Coping with Depression (CWD-A)• Cognitive Behavioral Therapy (CBT) for Adolescent

Depression• Alternative for Families-Cognitive Behavioral

Therapy (AF-CBT)

13-1713-254-16

Common Concerns & Evidence-Based Interventions (2 of 2)Diagnosis/Concern/Activity

Evidence-Based Interventions (Examples) Age

Trauma

Actionable Trauma Symptoms

Posttraumatic Stress Disorder

• Child-Parent Psychotherapy (CPP)• Parent-Child Interaction Therapy (PCIT)• Combined Parent-Child Cognitive Behavioral

Therapy for Families at Risk for Child Physical Abuse (CPC-CBT)

• Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

• Alternatives for Families/Abuse Focused Cognitive Behavioral Therapy (AF-CBT)

• Cognitive Behavioral Intervention for Trauma in Schools (CBITS)

• Trauma Affect Regulation: Guide for Education and Therapy (TARGET-A)

• Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS)

• Prolonged Exposure (PE) Therapy for Youth 18-25

0-62-173-17

4-555-17

6-1210-55

13-21

18-25

Behavioral Concerns

Internalizing/Externalizing Behaviors Behavioral Problems and Relational Concerns

• Child Parent Psychotherapy (CPP)• Promoting Alternative Thinking Strategies (PATHS)• Incredible Years• Triple P• Parenting Wisely • Nurturing Parenting Programs (NPP)• Brief Strategic Family Therapy (BSFT)• Fostering Healthy Futures (FHF) – mentoring +

skills training• Functional Family Therapy (FFT)

0-60-120-120-160-176-126-179-1110-18