Alliance for Child Welfare
Excellence
The Power of Partnership
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.
2
Mental Health
Screening and Referral
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 Social and Health Services
Children’s Administration
Funded by the US Department of Health and
Human Services, Administration for Children and
Families, Children’s Bureau, Grant #90C01103
Thank you to collaborators:
• Michael Tyers
• Dae Shogren
• LaRessa Fourre
3
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?
• What does mental health look like?
• How do we know when unmet mental health needs are present?
• What do we do about it?
4
Where does Mental Health Fit
into Your Caseload?
Safety
Permanency
Wellbeing
5
National Prevalence of Mental Health
for Children and Youth
30.0%
25.0%
21.5%
20.0%
Alumni
General Population
15.3%
15.0%
11.9%
11.4%
10.6%
9.4%
8.9%
10.0%
5.1%
4.5%
3.6%
5.0%
3.6%
3.7%
2.9%
2.0%
0.5%
0.4%
0.0%
Post
Traumatic
Stress
Disorder
Major
Depressive
Episode
Modified
Social Phobia
Panic
Disorder
Generalized
Anxiety
Disorder
Alcohol
Dependence
Drug
Dependence
Bulimia
Casey Alumni Study (2003)
6
Children and Youth in Washington State
In FY11, 52% of Children (Ages 3 - 17) that were Flagged for a Potential Mental
Health Concern on the Child Health and Education Tracking (CHET):
80%
63%
70%
55%
60%
50%
40%
24%
30%
20%
10%
0%
Received a Public MH Service in
the Same Year
Diagnosed with a Mental Illness
in their Lifetime
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Perscribed Psychotropic
Medication
Small Group Activity
What are the implications for an untreated mental health need for a
child or youth?
8
Mental Health Needs and Permanency
Placement
Changes
Externalizing
Behaviors
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
9
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?
• What does mental health look like?
• How do we know when unmet mental health needs are present?
• What do we do about it?
10
Catch the Smoke before the Fire
11
Child Development
• Clingy and upset when
caregiver leaves
• Aggressive and hostile
towards others
• Bullies other children
• Is fearful with familiar
adults or too friendly
with strangers
• Returning to an earlier
& mastered
developmental level
• Bed wetting and/or
encopresis
Pre-Adolescent and Pre-Adulthood
• Regularly cries or
hard to soothe
• Overly fearful
• Trouble expressing
emotions
• Little or no reaction
when familiar people
enter or leave the
room
• Returning to an
earlier & mastered
developmental level
Pre-School – School Age
Birth - Toddlers
Developmental Causes for Concern
• Feels hopeless or
unable to make things
better
• Withdrawn from
family or friends
• Violent or abusive
• Alcohol or drug use
• Difficulty managing
emotions in a healthy
way
• Fire setting
• Bed wetting and/or
encopresis
Night terrors, unable to sleep, obsessive, overly vigilant, over-sexualized behaviors
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Common Mental Health and Behavior
Challenges
Trauma
Re-experiencing, Avoidance, Hyperarousal
Externalizing
“Acting Out
Behaviors”
Internalizing “Feelings
or Emotional”
Behaviors
Fighting, rule
Depression, anxiety
breaking, not
listening, anger
outbursts
(including
responses to
trauma)
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Attention
Challenges
Trouble paying
attention, acting
impulsively
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?
• What does mental health look like?
• How do we know when unmet mental health
needs are present?
• What do we do about it?
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Where do I Look? In the Case File or in
FamLink?
Referral
Investigation
or Non
Dependency
Cases
Safety Plans
General observations or conversations
Reports or information from previous treatment providers
Previous questionnaires, assessments (e.g., GAIN-SS)
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) and other
screening tools
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CHET Screening Tools about Mental Health:
Ages and Stages Questionnaire – Social Emotional (ASQ-SE)
 Age of child: 3 months – 66 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)
 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
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Review the CHET
• 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.)
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CHET Report Interpretation
PSC-17
– Internalizing score of 5
– Externalizing score of 7
– Attention score of 7
– Total Score of 15
ASQ-SE
– Score of 70
Scores equal to or above the cutoff: need a mental health referral
SCARED
– Anxiety score of 3
– PTSD score of 6
GAIN-SS
– **Score of 2 on total screener;
between 3-5 on sub screeners
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
** CA-specific cut-off
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Ongoing Mental Health Screening
Live in July 2014
 New screening unit will re-screen newly placed children and youth
every 6 months
• Similar to CHET process
 Ongoing Mental Health Screener will use the ASQ-SE, PSC-17 and
the SCARED
• Triage with social service specialists around child/youth needs
 Screening information can be used to assess change in wellbeing
and treatment progress
• Screeners will make recommendations for social service
specialists
• Screeners will upload recommendations into FamLink
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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?
• What does mental health look like?
• How do we know when unmet mental health needs are present?
• What do we do about it?
20
Assessing Mental Health
Treatment Options
Thousands
of different
programs
and services
available…
Many do not
have evidence
that they
work…
Some may
actually do
harm…
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However,
there are
ones that
have been
proven to
work!
How is Evidence Based Defined?
Best Evidence
 Generally Refers to a Continuum of Standards
 Best evidence: Replicated in Real World Settings
 BUT, this is very rare
 Many programs say they are evidence-based
 There are helpful resources available
No Evidence
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Boiling Down EBPs
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 DBT components
For children and youth, most evidence based interventions
require work with the parent, caregiver, and child!
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CBT: Topics Covered During CBT
Interventions
• 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.”)
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CBT: Qualities of CBT Interventions
• 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
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CBT: Qualities Inconsistent with CBT or
other EBP Interventions
• 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
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Externalizing “Acting Out”
Behavior Challenges
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 not the most important ingredient
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Externalizing “Acting Out” Behavior
Challenges – EBP’s
Example:
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.
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Internalizing “Feelings or
Emotional” Challenges
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
29
Internalizing “Feelings or Emotional”
Challenges – EBP’s
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
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Attention Challenges (ADHD)
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)
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Parenting – EBP’s
Example:
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.
Do you notice how the parenting EBP’s are
very similar to the externalizing EBP’s?
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I am an Advocate for MH Treatments for
Children and Youth … Now What?
Things to Consider:
1.
Specific mental health or behavior health need/s
2.
EBPs available in the area
3.
4.
•
Consider child or youth’s age
•
Family preferences (e.g., group v individual)
•
Who delivers this service?
For children birth to age 3,
Department of Early
Learning’s Early Support for
Infants and Toddlers (ESIT)
offers great resources, visit :
http://www.del.wa.gov/dev
elopment/esit/
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
33
The Role of Mental Health Professionals
Counselor
Psychiatrist
• RSN
• Fee-for-Service
• CA
Primary Care
Provider
• RSN
• Fee-for-Service, as
appropriate
• CA
Psychologist
• RSN
• Fee-for-Service, as
appropriate
• CA
• Health Care Auth.
Child
Welfare
Evidence Based Treatments
34
Other (e.g.,
Neuropsychologist)
• Fee-for-Service
• Managed Care Org.
• CA
When an EBP is Not Available …
1. Refer to community mental health agency for
comprehensive mental health evaluation
2. Work with the agency or assigned therapist
around the child or youth’s needs
3. Be an informed consumer
• Do they offer CBT or BT?
35
CA EBP Directory
http://ca.dshs.wa.gov/intranet/ebp/index.asp
36
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
 What if the assessment of service needs is different than
what the court is ordering?
37
Washington Antipsychotic Medication Usage
Compared to the other 9-states, WA had the lower percentage of
foster children and youth using antipsychotics medication
Foster children and youth are more likely to be on multiple meds and to
receive doses that exceed recommendations
Antipsychotic
Foster Care
Status
Mental Health Drug
WA
9-State
Average
WA
9-State
Average
Foster Care
6.2%
14.0%
20.8%
26.6%
Non-Foster Care
1.0%
1.8%
6.0%
7.4%
Medicaid Medical Directors Learning Network – Antipsychotic
Medication Use in Medicaid Children and Adolescents (2009)
38
Five Questions to Ask about Psychotropic
Medication Usage
1. What problem or symptom is the child prescribed psychiatric
medication(s) for?
2. What are the intended effects of the medication?
3. Is there an evidence-based psychosocial intervention for the
child and their caregivers (foster and/or biological), in addition to
the psychiatric medicines?
4. How is this treatment plan helping the child and caregiver?
5. How are side effects monitored medically?
Bench card?
39
Psychotropic Medications Policy
CA 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)
•
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)
•
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
40
Possible Red Flags
• 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 Regional Medical
Consultant or call Fostering Well-Being at 1-800-422-3263
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Safety Net
Children’s Administration Regional Medical Consultants
Region 1
Region 2
Region 3
R1 North
Don Ashley
(509)524-4952
ashled@dshs.wa.gov
R2 North
Frances Chalmers
(360)429-2999
chalmf@dshs.wa.gov
R3 North
Michelle Terry
(253)983-6200
terrym@dshs.wa.gov
R1 South
Roy Simms
(509)454-6913
simmsrj@dshs.wa.gov
R2 South
Rebecca Wiester
(206)680-9786
wiestrt@dshs.wa.gov
R3 South
Vacant
(doctors are covering
until filled)
42
Medications across the buckets
Externalizing Internalizing
FIRST CHOICE:
Psychosocial
interventions
FIRST CHOICE:
Psychosocial
interventions
Very limited evidence for Medications can be
using medication to
effective
manage aggression –
Medications should be
Always seek
paired with psychosocial
consultation!
interventions
(preferably CBT)
RED FLAG: Under 6yo
Attention
FIRST CHOICE:
Psychosocial
interventions +
medication
Medications can be very
effective
Some psychosocial
treatments can be
beneficial, but therapy
with medication is the
most beneficial.
Adult Mental Health
•
•
•
Prevalence
Adult Mental Health & Child Development
Adult Mental Health & It’s Relationship to Abuse & Neglect
•
Parents with Developmental Disabilities
44
Parents involved in Child Welfare in Washington State
56% of parents met criteria for one or more mental health disorders
70%
60%
52%
46%
50%
40%
29%
26%
30%
17%
20%
9%
10%
0%
Any mood disorder
Major depressive
disorder / episode
Any anxiety
Bipolar
Panic disorder
PTSD
Marcenko, Newby, Lee, Courtney, and Brennan,
November 2009: Evaluation of WA SBC Practice Mode
45
Adult Causes for Concern
Things to Look Out for
Experiences,
Circumstances, &
Attitudes
Mental Health
Conditions
• Maternal depression
• Substance use and/or
abuse
• Social isolation
• Domestic violence
• Attitudes about parenting
practices, child rearing,
developmental
expectations
• Serious Mental Illness (SMI)
• Post Traumatic Stress (PTS)
or unresolved trauma
symptoms
46
Adult Mental Health Resources
A Changing Landscape
Social Service Specialist
• Need access to insurance to access services  supporting parents in applying for
healthcare coverage through the Affordable Care Act (www.wahealthplanfinder.org)
Evidence Based Treatment Options for Adults
• Limited Selection – landscape is changing
• Cognitive Behavioral Treatments
Evidence Based Parenting Programs
• Improving parent-child relationship first can lower mild/moderate depression
• May reduce risk for substance use relapse
Other Support Resources
• Mental Health Professionals
• Housing
• Supported Employment
• Case Management
• Peer Services & Supports
• Hospitalization
Inventory of Evidence-Based, Research Based, and Promising Practices
http://www.wsipp.wa.gov/Reports/538
47
Parents’ Mental Health Needs Can
Impact the Children, Too
48
Parents with Developmental Disabilities
SHB 2616
• This bill requires:
– CA Social Service Specialists can contact DDA to determine if the
parent is eligible for DDA services
– If parent is eligible the CA Social Service Specialist must make
reasonable efforts to consult with DDA in order to create an
appropriate plan for a parent with a developmental disability
who is eligible for DDA services and whose child has been
removed from his/her care.
– Case plan must be tailored and take into account a parent’s
disability, and DSHS must determine the appropriate method to
offer services based on parent’s disability
49
Small Group Activity
What other adult behavioral health
indicators should you take into account
when case planning?
50
What is Trauma?
Acute Trauma
• Exposure to a single traumatic events that is limited in time (e.g. a
natural disaster, death of a loved one)
Chronic Trauma
• Repeated exposure to traumatic events (chronic physical or sexual abuse,
chronic neglect, domestic violence, etc.)
Complex Trauma
• Describes both chronic trauma and the immediate and long-term impact
of exposure
51
Reactions to Traumatic Stress
Physical
Emotional
52
Reactions to Traumatic Stress
Physical
Emotional
•
•
•
•
•
•
•
•
•
Terror
Intense Fear
Horror
Helplessness
Avoidance or
repeated telling of
story
• Disorganized or
agitated behavior
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Rapid heart rate
Trembling
Dizziness
Loss of bladder or
bowel movements
Child or Youth Responses to Trauma
• Regressive behaviors
• Clingy, unwilling to
separate from familiar
adults
• Resist leaving or
afraid to go to places
• Significant changes in
eating/sleeping habits
• Complain of physical
aches and pains
• Bedwetting
• Attention-seeking
behaviors
54
Pre-Adolescent and Pre-Adulthood
• Difficulty coping
with loss
• Unable to cope,
manage emotions
• Quickly
dysregulated when
talking about the
‘event’ (i.e. quickly
shift activities –
become more
active, engage in
nurturing play,
show signs of
aggression, etc.)
Pre-School – School Age
Birth - Toddlers
Causes for Concern
• Place more importance
on peer groups and has
abrupt changes of
relationships
• Rebel against authority
• Feel immune to
physical danger
• Isolation and reluctant
to talk about feelings
• Have flashbacks,
nightmares, emotional
numbing
• Express shame about
feeling afraid
Adverse Childhood Experiences (ACEs)
55
Prior
Psychological
Problems
Little or no
social support
after the event
Perceived Life
Threat During
the Event
Feeling terror,
helplessness,
or extreme
fear
Prior Trauma
History
Increased
Risk for
Clinically
Significant
Trauma
Impact
56
Chronic
Traumatic
Events
Child and Youth
Reactions to Traumatic Stress
Although
… Not all children and youth who experience
traumatic events develop symptoms of Post
Traumatic Stress Disorder (PTSD)
• Kolko, et. al (2010) found among children in the
child welfare system, the prevalence of PTS
symptoms only 11.7%
57
Suicidal Thinking and Self-Harm
In Washington:
• Average of two youth (ages 10 – 24) die by suicide each week
• In 2011: 15% of 6th graders, 17% of 8th graders, 19% of 10th graders, and
17% of seniors in high school report seriously considering suicide
• Native youth die from suicide at a higher rate than any other population in
Washington as well as nationally
• Youth suicides out numbers youth homicides
Nationally (WA does not specifically track suicide stats on LGBTQ and transgender
populations)
 More than 30% of LGBTQ youth report at least one suicide attempt within
the last year
 More than 50% of Transgender youth will have at least one suicide
attempt by their 20th birthday
58
Suicidal
Thinking
and Self-Harm
Know the Warning
Signs
Previous suicide
attempt
Lack of
connection to
family or friends
Recent suicide
attempt by a
friend or family
member
Takes
unnecessary
risks or
impulsive
behavior
Preoccupation
with death
Strong wish to
die
Current talk
about suicide, or
making a suicide
plan
Accessible
firearm access
Severe drop in
school
performance
Significant
change in eating
or sleeping
patterns
Withdraws from
friends and/or
social activities
Giving away
prized
possessions
Serious
depression,
moodiness,
expressions of
hopelessness
59
Increased
alcohol and/or
other drug use
Suicidal thinking and Self-Harm
If you suspect that a child or youth is suicidal or at risk
for self-harm, ask the question:
Asking the question does not cause suicide
“Are you thinking about suicide?”
“Have you thought about how you are going to do it?”
“Do you have the means to go through with your plan?”
Getting the child or youth help:





Crisis phone hotline: See Regional Support Network (RSN) list
National hotline for LGBTQ: 1-866-4U TREVOR
School counselor, teacher, coach
Therapist or counselor
Emergency room or 911
Check out the web for more information:
Youth Suicide Prevention Program (www.YSPP.org)
60
Special Thanks
Children's Administration
(CA)
Barb Putnam and
Dae Shogren
Behavioral Health Service
Integration Administration
(BHSIA)
Lin Payton, LaRessa Fourre and
Jessica Bayne
Administration for Children,
Youth and Families (ACYF)
Joyce Pfennig
DSHS Research and Data
Analysis (RDA)
Barbara Lucenko
Children,
Youth, and
Families
University of
Washington (UW)
Sue Kerns, Mike Pullmann,
Sarah Holland, Andrea
Negrete and Eric Trupin
Alumni and Veteran
Parents
Jeanette Barnes and
Passion to Action
Harborview Center
for Sexual Assault
and Traumatic Stress
Lucy Berliner
Naomi Perry
Laura Merchant
61
Health Care Authority
(HCA)
Kari Mohr
Department of Health
(DOH)
Ellen Silverman