Outcomes of a treatment foster care pilot for youth with complex multi-system needs

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Outcomes of a treatment foster care pilot for youth with complex

multi-system needs

Melissa Johnson Kimberly McGrath

Mary Armstrong Norín Dollard

John Robst René Anderson

Presented at the 28th Annual Research and Policy Conference on Child, Adolescent, and Young Adult Behavioral Health, March 23rd, 2015, Tampa, Florida

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Louis de la Parte Florida Mental Health Institute

Support

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

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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)

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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.

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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

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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

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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)

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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.

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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.

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Research Questions

1. What are the outcomes for children and youth enrolled in an enhanced

therapeutic foster care model?

2. What are the program costs?

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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

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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

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Data Collection

Administrative 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

post-discharge

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Administrative 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

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Outcome Data Collected from Youth & Caregivers

Child Health Questionnaire (Caregiver Report)

Behavioral and Emotional Rating Scale—

Second Edition, (Caregiver & Youth Report)

Child Behavior Checklist & Youth Self-

Report (Youth and Caregiver Report)

Strengths and Difficulties Questionnaire

(Caregiver Report)

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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)

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Diagnoses

Diagnoses % (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%

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BERS Strengths Quotient Index

88.4

77.4 78.167

73.25 81.7

95.4

102.33

97.625

0 20 40 60 80 100 120

Baseline 3 month 6 month Discharge Caregiver Youth

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Strengths and Difficulties Questionnaire

SDQ Scale Proportion of youth scoring in the

‘normal’ range Baseline

(N =8)

3M (N=10)

6M (N=6)

Discharge (N=8) Emotional

Symptoms

62.5% 70% 66.7% 75%

Conduct Problems 37.5% 40% 50% 25%

Hyperactivity 50% 70% 83.3% 75%

Peer Problems 50% 50% 33.3% 25%

Prosocial 87.5% 50% 83.3% 50%

Total Difficulties 0% 10% 0% 25%

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CBCL Caregiver Report T- scores

0 10 20 30 40 50 60 70 80

Baseline 3 months 6 months Discharge Internalizing Externalizing Total

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Youth Self-Report T-scores

0 10 20 30 40 50 60 70

Baseline 3 months 6 months Discharge Internalizing Externalizing Total Problem

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In the past 4 weeks, how much did you worry / concern did you have about your child’s *

0% 20% 40% 60% 80% 100%

your child's physical health your child's emotional well-

being

your child's attention or learning abilities

Discharge (n = 8) 6 months (n =6) 3 months (n =9) Baseline (n = 6)

*

Quit a bit or alot

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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

4 youth required a higher level of care

and were stepped up to SIPP (inpatient

treatment)

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Program Completion

6 youth successfully completed the ETFC program and were either reunified or stepped down to a lower level of care

Median length of time in ETFC was 11 months for youth who completed the program

Youth requiring more intensive inpatient treatment (n = 4) were all identified as having CSEC-

involvement, which may explain why this program was not effective for them

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Costs

Costs favor 9 months of ETFC ($74K) over

♦ 9 months RTC ($112K)

♦ 6 six months of RTC and 3 months of community-based services ($79K)

♦ 6 months RTC and 3 months of Therapeutic Group Care (TGC, $103K)

♦ 6 months of RTC & 3 months of TFC ($92K)

♦ 9 months of TGC & 9 months community services ($86K)

9 months of ETFC ($74K) costs the same as

♦ 9 months of Juvenile commitment & 9 months group care plus overlay BH services ($78K)

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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

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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)

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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

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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!

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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.

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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.

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Next Steps

Working with Medicaid and its contract Managed Care Organizations 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 of Together Facing the Challenge curriculum for all therapeutic foster parents,

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