|
In the past few years, significant attention
has been given to the growing number of children who suffer needlessly
because their emotional, behavioral, and developmental needs are not being
met. All of us are urged to take seriously the task of preventing mental
health or substance abuse problems and providing services and supports
for treating mental illness or substance abuse in children.
The Surgeon General’s Report on Children’s
Mental Health and the United Nations Convention on the Rights of the Child
have emphasized that treatment should be considered a basic right for
children and families that suffer from a mental health or substance abuse
problem. President Bush issued an executive order, the New Freedom Initiative
(NFI) of June 18th, 2001, to remove barriers to community living for persons
with disabilities, including children with severe emotional disturbances.
NFI highlights the fact that there is no “wrong door” for
accessing services and creating opportunity for children to receive community-based
services within their local service systems. The president’s announced
plan to establish a National Commission on Mental Health will further
support addressing the emotional/mental health needs of children.
Children served by the foster care system are coping
with the events that precipitated their coming into care and enduring
the grief and trauma that accompany the loss of a family. Currently, more
than 500,000 children reside in foster care in the United States, and
85% of them are estimated to have an emotional disorder and/or substance
abuse problem. The American Academy of Child and Adolescent Psychiatry
(AACAP) and the Child Welfare League of America (CWLA) began an initiative
in March 2001 to improve the design, delivery, and outcomes of the mental
health and substance abuse services provided to children in foster care
and their families. AACAP and CWLA have been joined by more than 30 consumer
and professional organizations, which have contributed their expertise
and resources to this initiative.
The seriousness, intensity, prevalence, and urgency
of the unmet needs of these children and their families substantiates
our commitment to this initiative. Drawing on the values and principles
already developed through such efforts as the systems of care, which focused
on service delivery to children with serious emotional disturbances, the
values and principles delineated in this document will guide efforts to
improve policies and practices in the systems that serve children in foster
care and their families. We believe such values and principles will drive
practice in addressing the mental health and substance abuse needs of
children and their families. This will lead to other reforms in how local
communities and formal systems intersect on mental health, substance abuse,
and child welfare issues to ensure the well-being of children in foster
care and their families.
Our mutual interest is the emotional/mental health
of children and their families. We must develop innovative and evidence-based
assessment tools to identify children’s emotional and/or behavioral
problems as early as possible and to ensure that all children and their
families have access to and receive evidence-based, effective, mental
health and substance abuse prevention and treatment services and supports.
It is our professional responsibility to provide the most timely, appropriate,
and effective prevention/treatment services and supports to children and
their families to ensure the best outcomes.
To this end, we support and advocate for providing mental health and substance
abuse prevention strategies, assessments, treatments, services, and supports
designed for children in the foster care system and their families that
abide by the following five VALUES:
- Child-focused mental health and substance abuse
services and supports
- Family-driven mental health and substance abuse
services and supports
- Integration, collaboration, and coordination of
community-based mental health and substance abuse services and supports
with the foster care system
- Culturally competent, relevant, and strength-based
services and supports provided by knowledgeable, skilled service providers
who understand the cultural diversity of the community.
- Timely, effective, evidence-based, outcome-driven
mental health and substance abuse services and supports
Further discussion of the values appears in the appendix.
The principles outlined here are infused
by the core values mentioned above and provide greater detail for how
they are to be implemented.
Service Coordination and Case/Care Management
- Coordination among mental health, substance abuse,
physical health, developmental disability, legal, educational, and child
welfare services is essential.
- Children in foster care deserve services that are
designed, assessed, and delivered as part of their foster care services
plan.
- System coordination can ensure the most appropriate
use of limited resources and eliminate fragmentation experienced with
different funding streams for the needed services and supports.
- Many children and youth in foster care have co-occurring
mental health and substance abuse issues. Service coordination ensures
that their substance abuse and mental health services and supports are
provided concurrently.
- Coordination must include services children and
family members are receiving.
- Information must be shared on a regular basis among
organizations providing services and support to the child and family.
Barriers must be eliminated while complying with the confidentiality
requirements in HIPAA. This information should follow the child from
placement to placement.
Prevention and Early Identification
- Prevention and early identification programs and
supports for potential mental health and substance abuse issues are
vital to children in the foster care system and their families.
- Children from birth to age 3 are of particular
concern, given they are a significant percentage of the population of
children in foster care. Prevention and early intervention programs
should be targeted to them.
- Assessments for children entering the foster care
system should include screening for potential mental health and substance
abuse issues. Children should be reassessed for mental health and substance
abuse problems at specific intervals (minimally, EPSDT timeframes) so
prevention and treatment services can be provided as early as possible.
A referral should be made for a mental health and substance abuse assessment
by a trained professional.
Planned and Coordinated Transitions
Among Agencies and Providers and Between Children, Families, and Adult
Systems
- Children and
families suffer significant negative effects when transitions and discharges
are not successful. Therefore, coordination and effective planning are
necessary whenever children are involved in changing providers and/or
agencies, returning home, changing levels of care, changing placements,
transitioning to self-sufficiency, or being transferred to another service
system.
- Youth making the transition to self-sufficiency
may need services provided by the adult system, such as mental health,
substance abuse, housing, financial, health, dental, educational, and/or
employment assistance. Effective coordination must take place between
child and adult serving systems.
- Each child leaving the system must have a developmentally
appropriate transition and/or discharge plan. Planning must provide
skills that allow young people to transition to adulthood and provide
for their own permanency, safety, and well-being.
- Transition can significantly affect the child and
family. It is important that the child’s needs and wishes take
precedence over the system’s needs whenever possible. If a child
experiences more than two placements, the child welfare system should
have a process in place to review the reasons and ensure attachment
issues and the child’s mental health and substance abuse needs
are being considered.
- To minimize the negative effect of turnover in
workers, training should be provided to workers on the affect of removal
from home and/or transitions on children and their ability to form attachments,
effective interventions for dealing with attachment trauma, and signs
that a child should be referred for mental health and substance abuse
treatment.
Human Rights and Responsibilities
Regarding Protection and Advocacy
- All children in foster care have the right
to express their views through their words and behavior to the extent
that is developmentally appropriate or be represented by an adult who
offers the child’s perspective on the following:
- Access to quality mental health and substance
abuse services and supports.
- Which mental health and substance abuse services
assist them based on their strengths and needs.
- The development, monitoring, and revision of
their mental health and substance abuse treatment plan, which is
in keeping with their permanency and family service plan.
- What mental health and substance abuse services
and supports work for them.
- Refusal of mental health and substance abuse
services and supports unless their refusal would put them at risk
of harm.
- Provision of services and supports in the least
intrusive environment possible.
- Their constitutional rights when placed in
foster care.
- The affect of placement decisions on their
mental health.
- When very young or developmentally immature,
consideration of the effect of placement decisions on their mental
health.
- Frequent, ongoing contact with siblings and
other family members when the family cannot be maintained as a single
unit.
- All families with children in foster care
(except when parental rights are terminated or other legal decisions
take precedence) have the right to:
- Participate in the mental health and substance
abuse treatment services and supports that will assist them and
their child based on their strengths and needs.
- Participate in the development, monitoring,
and revision of their child’s mental health and substance
abuse treatment plan.
- Decide which mental health and substance abuse
services and supports work for them.
- Refuse mental health and substance abuse services
and supports, when their refusal does not put their child at risk
of harm.
- Have access to quality mental health and substance
abuse services and supports.
- Be provided services and supports in the least
intrusive environment possible.
- Retain their constitutional rights when their
child is placed in foster care.
- Through a release of information form, emancipated
youth and family members can provide consent on who gets information
about them.
- Children and their families have the right to be
treated in compliance with federal, state, and local policies and standards.
- Children and their families have the right to seek
advocacy support.
- Children and their families have the right to raise
concerns about the mental health and substance abuse services and supports
that they receive without retribution. All agencies should have a defined
process for how such concerns can be addressed.
- Children and their families have the right to receive
services that are culturally competent and to choose providers who value
their language, culture, and beliefs.
- Children and their families have the right to access
the courts to address concerns about the mental health and substance
abuse services they are receiving or believe they should be receiving.
Nondiscrimination in Access to Services for
Children in Care
- There should be no discrimination on the basis of
race, religion, ethnicity, language, gender, age, sexual orientation,
marital status, or disability.
- Providers should deliver services and supports
in compliance with the Americans with Disabilities Act.
- Public and private providers must ensure services
are accessible without discrimination, including interpreters if needed.
A Comprehensive and Accessible Array of Services
- Given the complexity of serving children and families,
it is crucial to have a comprehensive array of services. This includes
traditional, faith-based, nontraditional, formal, and informal supports
and services.
- This service array should be appropriate to address
treatment needs of children and families.
- Services chosen from the array should be age and
developmentally appropriate.
· This service array should support children and their families
in the community if possible.
- This service array should take into account the
ongoing developing strengths of children and their families.
Individualized Service Planning
- Service planning to address the mental health
and substance abuse needs of children should be individualized and include
the following:
- Focus on the strengths, desires, values, and
goals of the child and family,
- Assessment of the specific needs of the child
and the services and supports the family requires to support a child
with these mental health and substance abuse needs,
- Measures to address issues of emotional distress
arising from transitions,
- Consistency between the child’s permanency
plan and the family service plan,
- Informal and formal mental health and substance
abuse services and supports, and
- Measurable goals identified by the child
and family.
- This individualized service plan should include
the continuation of treatment when the child is reunified with his or
her family. If a child is not receiving services or supports at the
time of reunification, it is important to initiate any treatment services
that are needed as part of the reintegration process.
- The individualized service plan should be developed
in partnership with the child and family and other professionals working
with them.
- The individualized service plan should be reviewed
and updated to reflect the progress of the child, with input from the
child and family when appropriate.
- The individualized service plan should include
the discharge and transition plans.
Services in the Least Intrusive Community-Based
Environment
- Service planning should focus on providing services
and supports for children and families at the appropriate level and
intensity and in the least intrusive environment to increase the child’s
functioning and physical stability.
- Every effort should be made to keep children in
their community whenever possible. Risk to the child takes precedence
over the placement that is least intrusive.
- There should be an easily accessed array of community-based
services that support children receiving treatment. This might be over
a widespread region, particularly in rural areas where it is not financially
feasible to have all services in each community.
- When services are being designed, family and community
input should be part of the process.
- When children need to be placed outside the home
community, it is essential that treatment be provided to maintain the
family connection.
Family Participation in All Aspects of Planning,
Service Delivery, and Evaluation
- The family should be part of the engagement process
at all levels of planning, service delivery, and evaluation.
- The family should be involved in activities involving
the child when possible.
- Families should be given the choice to participate
or not.
- Family choices should be considered in all planning
for the child outside of situations that put the child at risk of harm.
- Families should be treated with respect and provided
advocacy and representation.
Integrated Services with Coordinated Planning
Across the Child-Serving System
- Children in the foster care system with mental health
and substance abuse issues are often involved with multiple organizations
and systems. They require well-coordinated planning and integration
of services.
- To ensure the most effective service delivery,
services should be coordinated across the child-serving system.
- Often, children in the foster care system initially
access services through primary care. The EPSDT screening process should
facilitate coordination of services to meet needs.
- When funding streams cannot be combined, there
is greater potential for integrating services when planning is coordinated
across systems. Integrated planning makes better use of limited dollars
and reduces potential duplication of services while increasing the availability
of services and supports for the child and family.
- Consistency in planning across systems is important
to ensure the child and/or family does not hear conflicting messages
or has treatment approaches that are contraindicated. All systems must
work to mitigate the burden caused by uncoordinated planning between
agencies and families.
- The goal is one document in which the plans of various
child-serving systems are incorporated into the foster care system case
plan. The plan should be reasonable, useful, and respectful.
Child—Any child placed
in out-of-home care.
Child-focused—When both the
physical and emotional well-being of the child is central to all levels
of decisionmaking and a process is in place for resolving conflicts between
these two domains. The child’s own views are expressed, where possible,
directly through the child’s words and behaviors or, as required,
through an adult whose offers the child’s perspective along with
the viewpoint of members of the child’s family.
Child safety—A child is considered
safe when an analysis concludes that the child is not in immediate danger
of serious harm and no safety interventions are necessary.
Cultural competence—A
system is considered culturally competent when there is professional,
formalized competence throughout the system in policies, procedures, outreach,
advocacy efforts, and training. Cultural competence, sensitivity, and
relevance is demonstrated through the array of services, delivery, framework,
and recognition of the importance of community-based, informal support
networks such as churches, extended kinship networks, and social organizations.
Cultural competence is demonstrated when there are skilled staff who are
aware of cultural issues within the community and who understand the diversity
of the community.
Family—Families can include
birthparents, foster and adoptive parents, grandparents, as well as kinship
caregivers and others who have primary responsibility for providing love,
guidance, food, shelter, clothing, supervision, and protection for children
and adolescents. It is the extent of daily interaction with and responsibility
for a child, not a legal construct, that identifies a family member.
Family-driven—A system is family-driven
when the family is involved in all decisionmaking. Identification and
engagement of the family receiving services is required so the family’s
experiences and perspectives drive the planning and outcomes for the foster
child. This moves the system beyond being centered and focused on the
family to having service delivery be more family-driven.
Prevention and early intervention—
Primary prevention:
Efforts to avert mental health and substance abuse problems altogether.
For children, these efforts include interventions directed at parents
or professionals involved with children.
Secondary prevention: Efforts to detect mental health
and/or substance abuse problems in their early stages of development
and to apply techniques to reduce the severity and duration of incipient
problems.
Tertiary prevention: Attempts to arrest further deterioration
in individuals who already suffer from severe mental health and/or substance
abuse problems. Treatment is tertiary prevention.
System of care—A system of mental
health, substance abuse, social services, education, medical, physical
health, primary care, juvenile justice, and other organizations, and formal
and informal services that work with the family to meet the child’s
needs.
Substance Abuse—Refers to the
use of alcohol or illicit drugs and the misuse of prescription drugs.
Values Discussion Points
- Child-Focused Mental Health
and Substance Abuse Services and Supports
- Attachment issues are significant to the mental
health of children in all placement decisions. The trauma children
endure when moved from placement to placement is not conducive to
normal development. When placing children outside the home, it is
essential to help them create meaningful new attachments while maintaining
existing attachments if possible.
- Children’s views of how their mental
health will be affected by placement decisions should be represented
in all proceedings, in keeping with the age and maturity of the
child.
- The current child welfare system tends to focus
on the physical safety of the child while not adequately considering
the effect of removal on the child’s emotional/mental health.
- Practice guidelines must be established to
address not only safety issues but also children’s emotional,
mental, and behavioral health needs.
- Foster care providers need resources to address
the mental health and substance abuse needs of the children they
serve. Ensuring that services are delivered in a timely, appropriate
manner is necessary.
- The child and birthfamily should maintain contact
while the child is in care. Assessment decisions need to be made
to determine if the birthfamily can be in immediate and continuing
contact to decrease the severity of separation trauma. Whenever
possible, the birthparents and foster parents or other agency caregivers
should communicate with each other to maximize continuity and mutuality
in accomplishing therapeutic goals.
- Providing mental health intervention at the
time of the initial placement and while in care helps prevent attachment
disorders and/or the progression of already existing mental health
and substance abuse problems.
- Reunification with the family of origin
may not always be the best option for the child. Other options must
be considered to ensure the child’s well-being.
- Family-Driven Mental Health
and Substance Abuse Services and Supports
- For child welfare services, a family-driven
policy that does not compromise the child’s safety is necessary.
- The foster care system is currently focused
on the child. To really meet the child’s needs, it should
place greater emphasis on the family of origin. This family-centered
approach could result in a major change of mindset within the child
welfare system.
- The child welfare system is concerned with
safety, permanency, and well-being. Every child should have a safe
home as soon as possible, but not necessarily with the family of
origin.
- To every extent possible, the birth family
should be involved even when it is not the custodial family.
- Integration, Collaboration
and Coordination of Community-Based Mental Health and Substance Abuse
Services and Supports with the Foster Care System
- Best practices in mental and behavioral health
services and supports should be available to children in foster
care and their families.
- Mental and behavioral health care providers
must have a clear and defined role, driven by professional expertise
and values, in treating children and families.
- To ensure child safety and achieve quality
services and supports for children and families, it is crucial to
increase the input of community members and professionals.
- There may be differences in how states define
safety. How local communities participate in setting the community
standards further affects the differences in definition.
- The child’s comprehensive health assessment
must include the elements of the EPSDT screening and assessment,
such as physical, dental, substance abuse, mental health, and comorbidity
evaluations.
- Foster parents must be provided with effective
ways their child’s needs can be met.
- Culturally Competent, Relevant,
and Strengths-Based Services and Supports Provided by Knowledgeable,
Skilled Service Providers Who Understand the Cultural Diversity of the
Community
- Assessment tools and mental health and substance
abuse services and supports must be culturally competent, be culturally
sensitive, and take into account the strengths of children and families.
They should take into account the cultural status, economic status,
and diversity of the population being served.
- There should be culturally competent policies
and professional competence in procedures, outreach, advocacy, and
training throughout the service delivery system.
- To facilitate rapport and successful outcomes,
the team delivering services and supports to children and families
should, if possible, represent the diversity of the population.
- Timely, Effective, Evidence-Based, Outcome-Driven
Mental Health and Substance Abuse Services and Supports
- The trauma children experience when they are
placed in the foster care system must be taken into account when
assessing their needs and providing services and supports. An initial
mental health and substance abuse screening should be done within
24 hours of placement. The mental health and substance abuse screen
identifies children in urgent need of emergency services. This screening
assesses internalized and externalized levels of distress in the
child regarding separation from their family of origin. A triage
intervention to address the child’s feelings and help the
child cope should be provided as quickly as possible.
- All children in foster care and their families
must have a comprehensive mental health and substance abuse assessment
once the child is stabilized, minimally within the timeframes of
EPSDT. The assessments should always address the child’s attachment
issues and be done in a timely fashion, especially when there is
transition between placements.
- The child welfare system must take into account
the difference between a child having a mental disorder and/or substance
abuse problem and a child requiring mental health and substance
abuse intervention to prevent a future disorder. Currently, a mental
health and/or substance abuse assessment is often not done until
there is a crisis.
- Just as it is necessary
for periodic reviews to be done on individual case plans, it is
necessary for systems and providers to perform evidence-based, outcome-driven
reviews of results to demonstrate progress in achieving the goals
for children and families.
- To provide compassionate, relevant services,
it is essential to reach for and use feedback from children and
families about service effectiveness.
|
