Colorado Residential Care Outcome Study

1. Colorado Residential Care Outcome Study A partnership of the Colorado Health Foundation and the Colorado Association of Family and Children’s Agencies (CAFCA)

2. Participating Agencies • Alternative Homes for Youth • Children’s ARK • Denver Children’s Home • Devereux Cleo Wallace Centers • Excelsior Youth Center • Griffith Centers for Children • Jefferson Hills • Mt. St. Vincent Home • Shiloh Home • Tennyson Center for Children • Third Way Center

3. The Study • 24 months (2009-2010) • Over 1200 admissions • Data analysis is being conducted by PSI (David Price and Anita Cohen), independent contractors reimbursed by the Colorado Health Foundation

4. Data Collected • Admission Data (CANS and admission information) • Discharge Data (CANS and discharge information) • Post-Discharge Follow-up Data (CANS and follow-up information at 4 and 12 months) • Colorado TRAILS data is in the process of being integrated with the data collected

5. Demographicsof Participants • Ages • 5-11 13.2% • 12-14 25.5% • 14-17 52.7% • 18+ 8.6% • Gender • Male 58.7% • Female 41.3%

6. Setting Prior to Placement • Home 15.4% • Foster Care 13.8% • Group Care 15.8% • Psychiatric Hospital 13.6% • Detention 32.8% • DYC Commitment 8.3%

7. The Study Found • Residential Care was found to be effective • All of the seven CANS clinical domains demonstrated statistically significant change • The data from post-discharge follow-up shows a trend towards continued improvement after discharge • This study found very similar levels of reliable change to a multi-year study in Indiana of residential treatment

8. Results and Discharge Status • Discharged to a less restrictive 65% • Home 40% • Whereas only 14% of the children referred by Child Welfare were living at home at the time of referral • Foster/Kinship Care 16% • Group/CPA 9%

9. Significant Results Findings • Medications • 70% of the youth admitted without a prescription for medication were NOT prescribed a medication • A statistically significant decline in the number of medications was found for youth treated in residential care • High Risk Behaviors Declined with Treatment • Decreases were found in suicide attempts, homicidal treats, psychiatric hospitalizations and run-away behavior

10. Comparison Kids on CANS Percentage of Actionable Items Males Females • Trauma 82.0% 70.9% • Trauma Symptoms 59.6% 55.8% • Beh/Emot Needs 92.8% 80.1% • Life Domain 92.8% 80.9% • Risk Behavior 88.1% 75.1% • Transition to Ad 68.2% 63.4% • Child Strengths 90.2% 79.9% • Caregiver Stren 56.4% 48.2%

11. What Surprised Us We have known: • The family environments these children come from have contributed to their problems • Treatment for the whole family system is an important part of addressing the needs of the children

12. Parental Rights Terminations • Parental Rights had already been Terminated or were Pending Termination for 24% of all youth referred to residential treatment • This is associated with increased client acuity: • More frequently special education • More previous hospitalizations • Greater history of runs from placement • More frequently adopted • A greater trauma history on the CANS • Younger children were more likely to have parental rights terminated • Ages 5-11 44.1% • Ages 12-14 24.1% • Ages 15-17 19.1%

13. Comparison Kids on CANS Scale Scores Intact PRT • Trauma 7.7 10.6 • Beh/Emot Needs 11.3 11.8 • Life Domain 10.0 10.0 • Child Strengths 14.5 16.1 • Caregiver Strengths 6.9 6.4

14. Comparison Kids on CANS Percentage of Actionable Items Intact PRT • Trauma 74.2% 88.8% • Trauma Symptoms 53.2% 74.6% • Beh/Emot Needs 87.7% 89.9% • Life Domain 87.5% 92.2% • Risk Behavior 82.5% 85.1% • Transition to Ad 65.6% 69.0% • Child Strengths 85.7% 89.2% • Caregiver Stren 54.5% 46.2%

15. Recommendation 1 • Parental Rights Termination is a major stressor that needs to be better addressed • Any youth who is undergoing or had their parental rights relinquished needs intensive trauma focused treatment to deal with that loss • All of these youth should be monitored throughout their childhood • Additional services should be provided when issues resurface • If they are too young at the time of relinquishment to benefit from treatment then ongoing monitoring should be vigilant in assessing when treatment services are likely to be beneficial

16. Permanency and Adoptions Percentage of Youth Adopted17.1% • 5-11 16.3% • 12-14% 19.0% • 15-17 15.9% • >18 20.0% • Not all of these are the result of parental rights terminations; they include private and out-of-country adoptions

17. Recommendation 2 • Families whoadopt children from the child welfare system or who assume guardianship of children from the system need to be better supported • They need accurate information at the time of placement • Need to be provided services that will make the placement successful • They need to be able to come back later and ask for help/treatment • We need to have a serious dialogue regarding families who have privately adopted being held accountable for not walking away from their children

18. Permanency Continued • Caregivers Not Wanting Youth to Return Home • Total 23.8% • 5-11 years 18.3% • 12-14 years 8.7% • 15-17 years 24.6% • >18 years 65.9%

19. Recommendation 3 • As we address the permanency discussions we need to address kids with families that do not want them to return home and the underlying issues • Concerns about safety • Lack of services to manage children in these homes • Parental issues such as mental health, substance abuse and legal issues

20. Critical Finding • Clients referred to Residential Care have experienced extreme trauma histories • 98.7% had experienced some type of trauma event in their life • 80.3% had experienced four or more different types of trauma (versus 16.4% of the general population) • 51.3% had experienced seven or more different types of trauma • 53% Sexual Abuse • 67.2% Physical Abuse • 70% Neglect • 76.4% Emotional Abuse • 65% Family Violence

21. Recommendation 4 • All youth entering care should have a trauma assessment and receive trauma informed services based on that evaluation • We applaud CDHS for making this a priority in the Title IV-E Waiver • High Need Children (4 or more Adverse Childhood Experiences – 80% of youth entering residential care have experienced this level of trauma which correlates with major life problems) need to be identified and treated • CAFCA had a positive experience utilizing the CANS and volunteers to work with the State regarding the selection of a proper assessment tool • Severely traumatized youth need more than just a loving home, they require treatment

22. Profound Mental Health Needs The Youth in the Study had profound mental health needs: • 45.6% had been in a psychiatric hospital and 29.6% had been hospitalized more than once • 79.8% of youth referred had a GAF (Global Assessment of Functioning) score of 50 or less and 44% had a score of 40 or less (the level that several years ago was proposed as the criterion for Psychiatric Residential Treatment Facilities/PRTFs) • 81% of youth referred had multiple diagnoses at the time of admission • 55% were on psychotropic medication at the time of admission

23. Understanding Congregate Care usage in Colorado • At this year’s JBC hearing on Mental Health it was reported that Colorado ranks 48th on the percentage of psychiatric hospital beds per capita • In the mid-90s Colorado closed over 700 psychiatric hospitals for children and adolescents in Colorado. Today we have fewer than 200 psychiatric hospital beds for children and adolescents. • The study compared youth in child welfare, the division of youth corrections, youth referred by mental health and youth referred privately or who came from other states and found few differences between the populations

24. Study Highlights • Inquires regarding psychiatric hospitalization have revealed that only about 15-25% of the psychiatric hospital beds in Colorado are occupied by youth with Medicaid • It’s not bad but Colorado has organized its continuum of care differently; children who in other states would be in the hospital or Psychiatric Residential Treatment Facilities are served in Colorado’s Residential Child Care Facilities. The study estimated that approximately 26% of youth served in the RCCFs would qualify for an inpatient level of care using the Indiana Decision Support Instrument for the determination of the level of mental health service needed while also suggesting that as many as 61% of the youth in the study might have been treated at a lower level of care if appropriate services were available.

25. Study Highlights CW DYC • Adjudicated 41.7% 100% • Substance Abuse 19.9% 48.7% • Danger to Others 32.4% 16.4% • Sexual Aggression 12.6% 10.8% • Runaway History 25.3% 32.0% • Developmentally Delayed 12.6% 5.6%

26. Study Highlights • Critical Treatment Issues • Child Welfare referrals who were in 32.6% Detention immediately prior to placement • History of Homicidal Threats 31.4% • Danger to Others 30.9% • Prior OOH Placement History 74.0% • Identified as Special Ed 58.9% • Runaway History From Home 37.1% • Runaway History From Placement 28.9% • History of Fire Setting 3.4%

27. Comparison Kids on CANS Scale Scores CW DYC MH Private • Trauma 9.2 8.1 7.8 6.0 • Beh/Emot Needs 11.6 11.0 12.4 10.5 • Life Domain 10.2 9.8 9.0 10.0 • Risk Behavior 8.6 8.4 8.2 8.6 • Child Strengths 14.9 14.2 13.4 16.7 • Caregiver Strengths 7.8 6.7 4.6 4.7

28. Comparison Kids on CANS Percentage of Actionable Items CW DYC MH Private • Trauma83% 78% 78% 59% • Trauma Symptoms 66% 49% 67% 37% • Beh/Emot Needs91%86%92% 75% • Life Domain92% 87% 90% 76% • Risk Behavior86% 81% 87% 72% • Transition to Ad 65% 72% 56% 59% • Child Strengths90% 81% 90% 75% • Caregiver Stren62% 50% 48% 34%

29. Congregate Care in Colorado • Concerns have been raised about the poor outcomes for children in residential treatment. These kids have poor outcomes for the same reason that so many of them stay in care for so long. • THEY HAVE A VERY HIGH LEVEL OF NEED DUE TOSEVERE EMOTIONAL/BEHAVIORAL PROBLEMS • THEY HAVE EXPERIENCED VERYHIGH LEVELS OF TRAUMA

30. Most Frequent Diagnoses • The Outcome Study found the following were most frequent diagnoses given to youth in residential treatment • Mood Disorders 33.3% • Conduct Disorders 22.8% • PTSD 18.9%

31. Treatment of Severe Mental Illness is Extremely Difficult • Does this mean we are wasting resources treating patients that suffer from major psychiatric problems? • Would we restrict physical health hospitalization because not all clients are cured? • Would we eliminate involuntary commitment procedures? • How about the treatment of substance abuse? It has even higher recidivism rates………

32. Recommendation 5 • The Colorado System of Care serving youth and families needs to be more effectively organized into an integrated continuum of services • We need to breakdown the silos • Every piece of the system needs to be strong: Children accessing services anywhere in the system need to be more effectively served. • Transitions should be better managed: Traumatized youth have greater difficulty with transitions. Children transitioning between out-of-home care and community based services need effective transition plans to address recidivism

33. Recommendation 6 • The State/Counties need a universal, reliable and standardized way to accurately assess treatment needs, measure outcomes and do program evaluation of the agencies serving them • Too many fields in TRAILs are optional resulting in an inability to clearly define the treatment population we are dealing with. • Treatment needs should be determined with a reliable assessment procedure that can be utilized across systems of care • Client needs should be matched with the proper treatment modalities • Whichever assessment tool is utilized it should have utility for both the determiner of services and the agency providing services, and should be able to be used to assess treatment effectiveness (for the client and for the agency providing the service)

34. Lesson Learned from the Study • Residential Treatment is an effective treatment methodology for the mental health problems of child welfare and juvenile justice youth • While CAFCA supports the state’s current Permanency Initiatives, we believe that these permanence connections absolutely have to be supported with appropriate services to ensure their success • We think that the new Waiver money and the reinvestment of current saving should be targeted towards areas of greatest need • The new AECF recommendation for differential reimbursement to the counties for utilization of residential care is likely to further inhibit the ability of youth to access appropriate and necessary mental health services within the child welfare system and should be opposed

35. For more information The complete report can be reviewed at www.tennysoncenter.org?documents.doc?id=138 Or contact Dr. Skip Barber at • skipbarber@earthlink.net • 720-570-8402