Presented at the FADAA-FCCMH’s 28th Annual Conference, August 7, 2014, Orlando, Florida

1. Community-based Treatment Alternatives for Justice-involved Youth in Child Welfare One year Follow-upNorín DollardKimberly McGrathMary ArmstrongJohn RobstMelissa JohnsonJames Gimbel Presented at the FADAA-FCCMH’s 28th Annual Conference, August 7, 2014, Orlando, Florida

2. Support This work is supported in part by the Florida Agency for Health Care Administration contract #MED134

3. 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 • Evidence for the presence of a group contagion effect with delinquent youth in group settings (Lee & Thompson, 2009)

4. 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. • Youth treated in Specialized Therapeutic Foster Care have lower rates of delinquent activity after discharge.

5. 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 • ReDirections (AHCA – DJJ) and DCF • Georgetown Crossover Youth Practice Model • Wraparound--DCF

6. 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 • Review of evidence base for therapeutic foster care • Investigation of feasibility of Multidimensional Treatment Foster Care • Decision to use Together Facing the Challenge

7. 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; • 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)

8. 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. • Provides clear, consistent and obtainable treatment goals for clients.

9. Study Purpose • To implement and evaluate a small pilot study (n=10) of Together Facing the Challengein Miami • Forfeasibility in real world public sector settings, • With fidelity to the supervision and teaching model, • Tracking outcomes and costs.

10. Research Questions • To what extent is Together Facing the Challengeimplemented with fidelity? • How are youth outcomes for this pilot in comparison with outcomes of similar youth in other out-of-home settings? • What are the program costs?

11. 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 • Is in the child welfare dependency system • Is enrolled in Medicaid • Assent and consent obtained, as well court authorization if applicable

12. 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) • Violent offenders (Violent crime includes murder, forcible sex offenses, robbery, and aggravated assault) • Axis I diagnosis of substance abuse

13. Data Collection • Fidelity data to ensure fidelity of implementation • Data from Citrus, adult and youth justice, state mental health, and Medicaid management information systems • Primary data collected from youth and their caregivers at baseline, every three months while in treatment, discharge, and three and six months post-discharge

14. 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

15. MIS Data Elements • Age, race / ethnicity, gender, and diagnoses • 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

16. 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) • Youth strengths: Behavioral and Emotional Rating Scale—Second Edition, Parent Rating Scale and Youth Rating Scale (Caregiver & Youth Report)

17. 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 • Strengths and Difficulties Questionnaire (Caregiver Report) • One overall scale and Four scales – Emotional Symptoms, Conduct Problems, Hyperactivity Scale, Peer Problems.

18. 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)

19. Diagnoses

20. Therapeutic Treatment Parents as Front-Line Treatment Providers N = 8

21. Therapeutic Treatment Parents as Front-Line Treatment Providers

22. Youth Strengths at Baseline – Caregiver Report

23. Youth Strengths at Baseline – Youth Report [a] Strength subscales on the BERS–2C range from 1 to 16, and on the BERS–2Y 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–2C and BERS–2Y range from 38 to 161, with an average index between 90 and 110. A higher index indicates greater overall strengths.

24. BERS Strengths Quotient Index

25. Strengths and Difficulties Questionnaire

26. Problem Behaviors & Symptoms – Caregiver Report [a] Borderline clinical range 60-63, clinical range 64 and higher

27. Problem Behaviors & Symptoms – Youth Report [a] Borderline clinical range 60-63, clinical range 64 and higher

28. Child and Youth Physical Well-being – Caregiver’s Impression of Overall Health

29. How often has your child's health or behavior….* *very often or fairly often

30. In the past 4 weeks, how much did you worry / concern did you have about your child’s * * Quit a bit or alot

31. In the past year, proportion with at least one friend who…

32. 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

33. Costs for Treatment/Placement Alternatives

34. Costs for Treatment/Placement Alternatives

35. Costs for Treatment/Placement Alternatives

36. 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 • 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

37. 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)

38. 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 • Engagement = there appears to be a ‘honeymoon’ period in the first 3 months, then spikes, and then subsequent improvements

39. Limitations • We are still collecting 9, 12 and post discharge data so the data are not yet complete.

40. 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. • Foster parents may feel as though they are being critiqued or evaluated unfairly during the implementation process.

41. 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.

42. 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.

43. 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 • Work with Our Kids to move towards county-wide implementation

44. Questions?