1. Influence of Trauma on Service Use and Expenditures for Children with Emotional & Behavioral Challenges James T. Yoe, Ph.D. Rachel Posner, Ph.D. Cynthia McPherson, M.S.W. Maine Department of Health & Human Services Julia R. Burns, Ph.D. YWCA of Portland Maine 18 th Annual Research Conference: A System of Care for Children’s Mental Health: Expanding the Research Base March 6 – 9 2005 Tampa, Florida

2. What the Research Tells us:  It is estimated that over 3 million children and adolescents in the United States are exposed to serious traumatic events each year.  Studies on selected public service populations (Medicaid service recipients) have demonstrated high-rates (between 50% and 70%) of Post-Traumatic Stress Disorder in child/adolescent and adult service users (Macy, 2002, Kessler, 2000, Switzer, et al., 1999). Macy (2002) found PTSD rates among Medicaid enrollees to be highest among children 5-12 years (609.5 per 1000).  In Massachusetts, 82% of all children & youth receiving intensive residential treatment and inpatient care were found to have trauma histories (NTAC, 2003).  Child/Adolescent trauma survivors have been found to use significantly more acute mental health treatment services, including: inpatient hospitalization, crisis services, and residential treatment services at higher cost (Macy, 2002, Newmann, et al., 1998).  Children in foster care (high rate of trauma exposure) exhibit disproportionately high rates of acute and chronic medical and mental health conditions and use more mental health services at higher cost than children not in foster care (Halfon, et al., 2002; Landers & Mei Zhou, 2004).  Childhood trauma exposure has consistently been associated with a wide range of serious mental health & physical health disorders in adults (Schwartz & Perry, 1994; Dube, et al., 2003, Chapman, et al. 2004).  Despite the high prevalence of trauma exposure among public service populations, few studies have specifically evaluated the impact of trauma on public service use, treatment costs or on service outcomes for children/youth with serious emotional/behavioral challenges.

3. Study Purpose To investigate the relationship between trauma exposure and public service use and expenditures for children/youth with serious emotional/behavioral challenges who are recipients of Targeted Case Management Services in Maine.

4. Study Hypotheses Child and youth trauma survivors will:  Be more likely to use and will use more high-cost psychiatric inpatient, crisis stabilization, and residential treatment services;  Be more likely to use and will use more public mental health services and supports at higher expense;  Be more likely to use and will use more general health/medical services at higher expense; and  Exhibit less functional improvement as a result of services received.

5. Study Sample Selection Criteria  Sample of 492 children and adolescents enrolled in Targeted Case Management Services in FY 2000 and FY 2001  The study sample was divided into two groups: an identified trauma experience group (n= 227) and a non-trauma experience group (n=265)  All study participants were enrolled in Targeted Case Management Services for at least 12 months with functional/behavioral assessments completed at baseline, 6 months, and 12 months.  All study participants were active Medicaid Service recipients with at least some mental health service use during FY 2000 or FY 2001.

6. Study Criteria: Identification of Trauma Experience Trauma relevant diagnosis  Prolonged Post Traumatic Stress  Acute Reaction to Stress  Child Abuse  Child Maltreatment  Child Sexual Abuse or Child Welfare Involvement  Child Protective Services  Substitute Care Services

7. Study Data Sources and Measures Behavioral Health Treatment Service & Expenditure Measures: Medicaid Service Claims 2 year period-Annualized: FY 2000 – 2001  Psychiatric Inpatient Treatment  Residential/Group Treatment  Community Mental Health Treatment & Support Services  Behavioral Health Pharmacy Primary Health Treatment Service & Expenditure Measures: Medicaid Service Claims 2 year period-Annualized: FY 2000 – 2001  Primary Health (Physician/Clinic Visits)  Medical Test & Procedures  Emergency Department Services  Medical Inpatient Services  Health Pharmacy  Dental Care Functional/Behavioral Outcomes  Child & Adolescent Functional Assessment Scale (CAFAS)  Child & Adolescent Level of Care Utilization System (CALOCUS)

8. Study Sample Characteristics GenderTrauma Non-Trauma Females 32.6% 29.8% Males 67.4% 70.2% Age Under 10 Years 27.3% 17.7% 10 to 12 Years 24.2% 28.3% 13 to 15 Years 29.1% 22.6% 15 Years and Older 19.4% 31.3% Mean Age (Years)* 11.78 12.54 Diagnostic Category Adjusted Related Disorder 4.8% 3.4% Conduct/Opposition Disorders 20.7% 24.5% Anxiety Disorders (non-PTSD)** 0.9% 5.3% Post-Traumatic Stress Disorder 27.3% 0.0% ADHD/ADD ** 16.3% 27.5% Bipolar Illness/Affective Psychosis 13.7% 15.5% Depression 13.7% 18.1% Psychosis 1.3% 3.8% Substance Abuse 6.6% 7.9% Other 1.3% 1.9% P <.05 **P<.01

9. Comparison of Baseline Behavioral/Functional Profiles Between Trauma and Non-Trauma Groups: CALOCUS Subscales + + + + + Groups differ significantly, p<.05

10. Comparison of Mental Health Service Use Between Trauma and Non-Trauma Groups ** Odds Ratio significant, p<.01 * Odds Ratio significant, p<.05

11. Comparison of Mental Health Service Use Between Trauma & Non-Trauma Groups + + + + + + + Groups differ significantly at P <.05

12. Comparison of Primary Health Care Service Use Between Trauma & Non-Trauma Groups + Groups differ significantly at P <.05 + +

13. Comparison of Behavioral/Functional Change Between Baseline & 12 Months for Trauma and Non-Trauma Groups + + + Groups differ significantly, p<.05

14. Comparison of Behavioral/Functional Change in CAFAS Total Youth Scores Between Baseline & 12 Months for Trauma & Non-Trauma Groups Groups differ significantly, p<.05

15. Comparison of Behavioral/Functional Change Between Baseline & 12 Months for Trauma & Non-Trauma Groups Change in CALOCUS Composite Scores Groups differ significantly, p<.05

16. Statistical Approach To Cost Analysis  Construct average per child, two-year expenditure variables for each service category & total expenditures;  Construct per child service use variables for each service category. A child was counted as using a service if he/she used any amount of a particular service in either FY2000 or FY2001;  Used log-normal transformation to normalize service expenditure distributions;  Student T-Tests conducted on log-transformed variables to assess expenditure differences between Trauma and Non-Trauma groups.

17. Comparison of Mean Annual Per Child Mental Health Service Costs Between Trauma & Non-Trauma Groups **p<.01, *p<.05

18. Comparison of Mean Annual Per Child Primary Health Service Costs Between Trauma & Non-Trauma Groups **p<.01, *p<.05

19. Comparison of Median Treatment Expenditures Between Trauma & Non-Trauma Groups + Groups differ significantly at P <.05 + + +

20. Median Out-of-Home Behavioral Health Treatment Expenditures Between Trauma and Non-Trauma Groups + + + + + - Groups differ significantly, p<.05

21. Median Community-Based Mental Health Treatment Expenditures Between Trauma & Non-Trauma Groups + + + + + - Groups differ significantly, p<.05

22. Median Primary Health Treatment Expenditures Between Trauma & Non-Trauma Groups + + + + - Groups differ significantly, p<.05 +

23. Summary of Results : Child Descriptive and Behavioral/Functional Differences Children and youth trauma survivors:  Were significantly younger;  Were 1.62 times more likely to be rated at moderate to serious risk of harm (as measured by the CALOCUS);  Were less than ½ (Odds=.451) as likely to experience serious co- occurring (medical, substance use, or developmental) challenges (as measured by the CALOCUS) (likely due to younger age and higher substance use in non-trauma group);  Were 1.76 times more likely to experience higher-levels of environmental stress and 1.65 times more likely to have moderate to extreme fewer supports;  Were ½ (Odds=.563) as likely to experience serious challenges with substance use (as measured by CAFAS)  Had significantly greater challenges with parent/caregiver acceptance & engagement with service providers; Than children and youth without a trauma history

24. Summary of Results: Service Use, Expenditures and Outcomes Child and youth trauma survivors:  Were significantly more likely to use high-end mental health services, including: inpatient psychiatric hospitalization, residential/group treatment, and crisis intervention services at significantly higher cost;  Were 1.92 times more likely to use out-of-home treatment (Psych. Inpatient, Resid. Tx. Crisis Residential);  Were 1.55 times more likely to use Outpatient Mental Health treatment services  Were 1.75 times more likely to use Medication Management Services  Used more Targeted Case Management services at significant higher expense;  Used outpatient-clinical and medication management services at significantly higher cost;  Were 1.61 times more likely to use and used more emergency department services at higher cost;  Had 73% higher mental health service expenditures & 51% higher overall treatment expenditures;  Were significantly less likely to exhibit behavioral/functional stability or improvement over study period. Than children and youth without a trauma history

25. Study Limitations and Next Steps Study Limitations  Focus on high-end user sample of children in Targeted Case Management limits generalizability of findings beyond ;  Indirect means of trauma identification based on diagnosis and child welfare involvement likely under identifies trauma and does not allow for examination of the type and nature of traumatic experiences encountered by the Trauma group. Next Steps  Develop models to assess predictors of restrictive & high cost service use  Examine change in service use and expenditures for Trauma versus Non-Trauma groups over three years.

26. Study Conclusions  The results of this study, consistent with previous research, indicate that children/youth who experience trauma were significantly more likely to use public treatment services at significantly higher cost than children with out a trauma history. Exposure to trauma significantly increased a child’s likelihood of using costly and restrictive out-of-home treatment, including: Acute Psychiatric Inpatient Services, Residential/Group Treatment, and Residential Crisis Stabilization Services.  Despite the greater use of service system resources, child/youth trauma survivors were less likely to exhibit stability or improvement in behavioral/functional status over the study period.  These findings suggest that when service systems do not appropriately assess, identify, and effectively address the underlying trauma-related needs of these children and families, the result may be greater use of expensive and often ineffective services that are likely to be overwhelming to the child and family, lead to re-traumatizing experiences for the child, and may contribute to poor treatment outcomes.  Given the pervasiveness of traumatic experiences among children/youth receiving public mental health services and the potential long-term costs to individuals, service systems, and society, these findings underscore the importance of trauma screening and identification early in the treatment process and the need for establishing and testing more trauma-informed approaches to service delivery and treatment.

27. Contact Information James Yoe, Ph.D. Director of Quality Improvement Maine Department of Health & Human Services #11 State House Station, 2 nd Floor Marquardt Building Augusta, Maine 04333-0011 E-Mail: jay.yoe@maine.gov Telephone: (207) 287-8982