Alliance for Child Welfare Excellence

1. Alliance for Child Welfare Excellence

2. The Alliance for Child Welfare Excellence is Washington’s first comprehensive statewide training partnership dedicated to developing professional expertise for social workers and enhancing the skills of foster parents and caregivers working with vulnerable children and families.  The Power of Partnership

3. Mental Health: In-Depth Applications for Child Welfare Training developed by: Suzanne Kerns, Ph.D. & Sarah Holland University of Washington School of Medicine Division of Public Behavioral Health and Justice Policy Barb Putnam, MSW, LICSW WA State Department of Children, Youth, and Families Funded by the US Department of Health and Human Services, Administration for Children and Families, Children’s Bureau, Grant #90C01103 Thank you to collaborators:

4. Improved functioning of children, youth, and families involved in child welfare • Why mental health is important and why do we want to talk about it? • Considerations about mental health • How do we know when unmet mental health needs are present? • What do we do about it? Goals of Today’s Training

5. Where does Mental Health Fit into Your Caseload?

6. Prevalence of Mental Health for Children and Youth Source: NSCAW Wave 2 Report, 2012

7. Children and Youth in Washington State In FY15, of the 62% of Children (Ages 3 - 17) that were Flagged for a Potential Mental Health Concern on the Child Health and Education Tracking (CHET):

8. Small Group Activity What are the implications for an un-treated mental health need for a child or youth?

9. Mental Health Needs and Permanency • Implications of untreated mental health needs: • Disrupted placements • Restrictive and expensive placements, group homes, residential or inpatient • Less likely to reunify quickly or be adopted

10. Goals of Today’s Training Improved functioning of children, youth, and families involved in child welfare • Why mental health is important and why do we want to talk about it? • Considerations about mental health • How do we know when unmet mental health needs are present? • What do we do about it?

11. Group Activity What does a healthy person look like?

12. Catch the Smoke before the Fire

13. Child Development Developmental Causes for Concern Nightmares, unable to sleep, obsessive, overly vigilant, over-sexualized behaviors

14. Externalizing “Acting Out Behaviors” • Internalizing “Feelings or Emotional” Behaviors Common Mental Health and Behavior Challenges

15. Small Group Activity • See Handout – Child Welfare Case Scenarios • Identify child presenting symptoms • Write down symptoms on post-it note and place into one of the buckets • Internalizing • Externalizing • Attention Challenges • Low frequency

16. Improved functioning of children, youth, and families involved in child welfare • Why mental health is important and why do we want to talk about it? • Considerations about mental health • How do we know when unmet mental health needs are present? • What do we do about it? Goals of Today’s Training

17. Investigation or Non Dependency Cases • Referral • Safety Plans • General observations or conversations • Reports or information from previous treatment providers • Previous questionnaires, assessments (e.g., GAIN-SS) Where do I Look? In the Case File or in FamLink? • Dependency Cases • Referral • Safety Plans • General observations, conversations, and Health and Safety visits • Reports or information from previous treatment providers • Previous questionnaires, assessments (e.g., GAIN-SS) • Child Health and Education Tracking (CHET), Ongoing Mental Health Screening (OMH) and other screening tools

18. Ages and Stages Questionnaire – Social Emotional (ASQ-SE) • Age of child: 3 months – 65 months old • Screens for social or emotional difficulty (self regulation, etc.) • Completed by the parent, caregiver, teachers, and other important adults Pediatric Symptom Checklist – 17 (PSC-17) • Age of child: 66 months – 17 years old • Screens for emotional and behavioral health problems including: internalizing, externalizing, attention problems • Completed by the child, youth, parent, and caregiver Screen for Child Anxiety Related Emotional Disorders (SCARED) aka Trauma Tool • Age of child: 7-17 years old • Screens for anxiety and post-traumatic stress • Completed by either the child, youth, parent, or caregiver Global Appraisal of Individual Needs – Short Screen (GAIN-SS) • Ages of child: 13 – 17 years old • Screens for internalizing, externalizing, substance abuse, and co-occurring disorders. • Only screen that asks about suicide • Completed by the youth CHET Screening Tools about Mental Health:

19. Review the Emotional/Behavioral Domain • - Are there any possible concerns? • Review the CHET Screener’s observations -What did the caregiver or parent say about the child or youth? -What did the child say (e.g., report of substance abuse, etc.)? -Observations (e.g., odd behavior, obsessive behavior, etc.) Review the CHET

20. CHET Report Interpretation Scores well below the cut-off: likely not a concern Scores close to the cut-off: watchful waiting or referral if other areas of concern are noted Scores equal to or above the cut-off: need a mental health referral Other concerns noted: child may not have identified concerns on screening tool but difficulty indicated by child or caregiver. Mental health referral

21. Ongoing Mental Health ScreeningLive in July 2014 • Screening unit re-screens children and youth after having been in care for 6 months • Similar to CHET process • Ongoing Mental Health Screener use the ASQ-SE, the PSC-17 and the SCARED (aka Trauma Tool) • Triage with social worker around child/youth needs • Screening information can be used to assess change in wellbeing and treatment progress • Screeners make recommendations to social worker • Screeners upload recommendations into FamLink

22. Ongoing Mental Health ScreeningLive in July 2014 • Ongoing Mental Health Screening program re-administered 4,952total screens to caregivers of children/youth placed into care between July 2014 and March 2018. • 1,709SCARED Trauma Tool screens completed by caregivers at the OMH timepoint. • Approximately 47%of all children/youth re-screened at OMH had an elevated clinical score, indicating a possible mental health concern.

23. Improved functioning of children, youth, and families involved in child welfare • Why mental health is important and why do we want to talk about it? • Considerations about mental health • How do we know when unmet mental health needs are present? • What do we do about it? Goals of Today’s Training

24. Assessing Mental Health Treatment Options

25. Most EBPs for children and youth MH • treatment are: • Behavioral Therapy (BT) • Addresses behavior that is problematic or getting in the way • Cognitive Behavior Therapies (CBT) • Addresses behavior that is problematic or getting in the way • Addresses thoughts and feelings that are problematic or getting in the way • Systemic or Ecological Interventions • Broad interventions: Addresses multiple factors in the youth’s environment contributing to problem behavior (e.g. parental monitoring, increasing social support) • Often includes some BT and CBT components • For children and youth, most evidence based interventions require work with the parent, caregiver, and child! Boiling Down EBPs

26. Education • Teaching about why symptoms developed and how maintained (e.g., lying, hoarding) • Connecting thoughts, feelings, and behavior • Analyzing and ‘correcting’ inaccurate or unhelpful thoughts to feel better (e.g., “It’s my fault I’m in foster care.”) • Parenting skills/Behavior management • Rewards, ignoring, consequences • Coping Strategies • Breathing, relaxation, coping statements (“Stay calm. Take 5 deep breaths.” “Its not my fault.”) CBT: Topics Covered During CBT Interventions

27. Guided set of principles or manual that guides the therapist • Short-term treatment • Less than 6 months in most cases • Therapist is directive • Sets agendas and plan for treatment, though client has input • Clear goals • Reduce temper tantrums • Present focused • Skills taught and practiced in session • Homework assigned (practiced outside session) • To child and parent, caregiver, if involved • Try new skills at home and school CBT: Qualities of CBT Interventions

28. Letting the child or parent direct the session • “Tell me where we should start today” • The relationship between the therapist and youth as treatment • While the relationship is important, it isn’t the ‘treatment’ • Play therapy • Play as therapy as opposed to a vehicle of treatment • ‘Play therapy’ as treatment is not CBT • Long-term therapy (unless module-based) • Therapy overly focused on the cause of the problem, or the past, without a focus on the now • Taking a year or more to see improvement • Taking months to build a relationship before starting the treatment CBT: Qualities Inconsistent with CBT or other EBP Interventions

29. Area of Difficulty: Rule breaking, anger outbursts, not listening, aggression, etc. Principle: Behavior is reinforced by the environment and/or people. The solution requires changing the response in the environment. Behavior Therapy: • The parent or caregiver’s participation is required! • Change and improve their response to, and supervision of, the child or youth’s behavior • Therapist may also work with the child • Teach problem solving skills and skills for dealing with angry feelings • However, therapist-child work is notthe most important ingredient Externalizing “Acting Out” Behavior Challenges

30. Examples: Young Children • Parent-Child Interaction Therapy (PCIT) • Age: 2 – 7 years old • How it works: Caregiver is coached to respond to child by praising positive behavior, ignoring obnoxious behavior and handling problem behavior effectively. Also increases positivity in caregiver-child relationship. Older Children and Youth • Functional Family Therapy (FFT) • Age: 11 – 18 years old • How it works: Secures agreement between child and caregiver to solve problems, teaches specific skills to deal with conflict or communication problems. Externalizing “Acting Out” Behavior Challenges – EBP’s

31. Area of Difficulty: Depression (sadness), anxiety (worries and fears), trauma related responses or problems Principle: Cognitive Behavior Therapy: Learn how thoughts, feelings, and actions relate Behavior Therapy: • Emphasizes the connection between thoughts, feelings, and behaviors • Increase positive activities and changes inaccurate/unhelpful thoughts • Helps teach coping strategies and skills to help children learn and manage their own emotions • Individual work with the child or youth • Some caregiver involvement necessary to increase awareness of internal stress and support child in adopting new skills Internalizing “Feelings or Emotional” Challenges

32. Example: Young & Older Children and Youth: • Trauma-Focused CBT • Age: 3 – 18 years old • How it works: Children and parent learn new skills to help process thoughts and feelings related to traumatic life events and enhance safety, growth, parenting skills, and family communication Internalizing “Feelings or Emotional” Challenges – EBP’s

33. Area of Difficulty: Trouble paying attention, impulsive behavior, trouble sitting still Principle: Therapy with medication is often the most effective treatment Behavior Therapy & Medication Treatment: • Behavior therapy without medication may not be very helpful • If a youth has internalizing and/or externalizing problems, consider Cognitive Behavior Therapy (CBT) or Behavior Therapy (BT) Attention Challenges (ADHD)

34. CBT+ in WA • EBP Training program in public mental health: • CBT for anxiety (internalizing) • CBT for depression (internalizing) • TF-CBT for trauma specific impact (internalizing) • Behavior Management Training/CBT for behavior problems (externalizing) and attention problems (attention) • Coverage: • 80% of diagnoses of children enrolled in WA public mental health • Availability: • Providers have been trained in the 4 EBPs in all mental health centers serving children in WA

35. Examples: Young Children • Parent-Child Interaction Therapy (PCIT) • Age: 2 – 7 years old • How it works: Caregiver is coached to respond to child by praising positive behavior, ignoring obnoxious behavior and handling problem behavior effectively. Also increases positivity in caregiver-child relationship. Older Children and Youth • Functional Family Therapy (FFT) • Age: 11 – 18 years old • How it works: Secures agreement between child and caregiver to solve problems, teaches specific skills to deal with conflict or communication problems. Parenting – EBP’s Do you notice how the parenting EBP’s are very similar to the externalizing EBP’s?

36. Wraparound with Intensive Services (WISe) • What is WISe? • WISe is a voluntary service that takes a team approach to meeting a child’s needs. • It provides intensive mental health services to support a child and family reach their goals • Youth who might benefit from WISeinclude those who: • Are experiencing disruptions in placement or are having difficulty in achieving a permanency plan, due to mental health reasons. • Examples of this could include: • At risk of out of home placement • Multiple in-home or out of home placementdisruptions • Pre-Adopt/Adoptive placement disruptions • Return home plan is at significant risk for failure • Frequent Runaway/Missing from care • Special Education and/or have a 504 plan with multiple school suspensions • Multi-system involvement (i.e., CA, Juvenile Rehabilitation, Developmental Disabilities Administration (DDA), or mental health) • For more information visit: • https://www.dshs.wa.gov/bha/division-behavioral-health-and-recovery/wraparound-intensive-services-wise-implementation

38. For children birth to age 3, Department of Children, Youth, and FamiliesEarly Support for Infants & Toddlers program offers great resources, visit : http://www.dcyf.wa.gov/services/child-development-supports/esit • Things to Consider: • Specific mental health or behavior health need/s • EBPs available in the area • Consider child or youth’s age • Family preferences (e.g., group v individual) • Who delivers this service? • Consideration to engagement • Engages and involves parents in treatment (to varying degrees) • Accommodates parent needs • Collaboration with family, child, youth, and SW • Provide all available collateral information at the point of referral I am an Advocate for MH Treatments for Children and Youth … Now What?

39. The Role of Mental Health Professionals Evidence Based Treatments Apple Health Core Connections - 1-844-354-9876

40. Small Group Activity What are the NEXT steps?

41. Refer to community mental health agency for comprehensive mental health evaluation • Work with the agency or assigned therapist around the child or youth’s needs • Be a informed consumer • Do they offer CBT or BT? • Additional support from Apple Health When a specific EBP is Not Available …

42. CA EBP Directory http://ca.dshs.wa.gov/intranet/ebp/index.asp

43. Small Group Activity Changing and Assessing the Service Direction for Children and Youth in Therapy • What happens when the current services are not effective? • What if the circumstances change and the child/youth may need a new provider or service? • Consider continuity of treatment and school

44. Compared to the other 9-states, WA had the lower percentage of foster children and youth using antipsychotics medication Washington Antipsychotic Medication Usage Foster children and youth are more likely to be on multiple meds and to receive doses that exceed recommendations Medicaid Medical Directors Learning Network – Antipsychotic Medication Use in Medicaid Children and Adolescents (2009)

45. Five Questions to Ask about Psychotropic Medication Usage Bench card?

46. CW Informed Consent Process • Must have biological parent permission for the administration of psychotropic medication • If parent is unavailable, unwilling or unable to consent, the SW shall obtain a court order • SW can consent to psychotropic medications if weekend, holiday or emergency - SW can consent, but still must obtain court authorization (RCW 13.34.060) • For children that are legally free and in the permanent custody of the department, the SW may authorize the administration of psychotropic medications (Policy #: 45413. Standard) – SW should still obtain court authorization • If over age 13, youth must consent to the administration of their own medications • Over age 13 youth also have the right to confidentiality of information (RCW 71.34) Psychotropic Medications Policy

47. Psychotropic medications prescribed to children under 6 • More concern if: Medication the only approach (not paired with psychosocial intervention) Multiple medications • If you are worried: • Consult with Apple Health Core Connections - 1-844-354-9876 Possible Red Flags

48. Safety Net

49. Medications across the buckets Consult with Apple Health Core Connections Care Coordinators for medication consultations

50. Youth Testimonial https://youtu.be/y6odfKdbCM4