CONNECTING THE DOTS: Safety, Permanency, and Well-being Bryan Samuels, Executive Director Chapin Hall Center for Children University of Chicago

Illinois’ Child Welfare Population 1990 to 2003 51,000 20,848

Pathway to Poor Outcomes for Children and Youth Abusive or Neglectful Parenting Poor Outcomes Psychological Distress Poor Social Functioning, Disturbed Peer Relationships Maladaptive Coping Strategies Insecure Attachments & Emotional Dysregulation Pathway to Poor Outcomes for Children and Youth

Re-Defining Success: Focusing on Well-being Redesign performance-based contracting to emphasize well-being outcomes in addition to permanency. Implement new placement system to keep children in the same school they attended prior to substitute care. Implement comprehensive assessment. Re-design transitional living and independent living programs to prepare youth for transition to adulthood. Creat a child location unit that tracks all youth who run away. Introduce evidence-based services to address trauma. Establish a common outcome measures for residential treatment and group homes.

25% DECLINE IN CASELOADS 2002-2011 Data Source: Adoption and Foster Care Analysis and Reporting System, U.S. Department of Health and Human Services

COMPLEX TRAUMA AMONG CHILDREN ENTERING FOSTER CARE 4/11/2013 Greeson, JKP; et al. (2011). Complex trauma and mental health in children and adolescents placed in foster care: findings from the National Child Traumatic Stress Network. Child Welfare. 90(6):91.

CHALLENGES AMONG CHILDREN KNOWN TO CHILD WELFARE Dolan, M., Casanueva, C., Smith, K., & Ringeisen, H. (2011). NSCAW Child Well-Being Spotlight: Children Placed Outside the Home and Children Who Remain In-Home after a Maltreatment Investigation Have Similar and Extensive Service Needs. OPRE Report #2012-32, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

RELATIONAL SKILLS ARE BOUND UP IN SOCIAL-EMOTIONAL PROBLEMS

Safety & Permanency are Necessary but not Sufficient to Ensure Well-Being REUNIFICATION “Childr en who went home and stayed home had a four fold increas e in interna lizing behavi or proble ms from baseline to 18- month follow- up. Though the percent age of children with behavio r proble ms at 36- month follow- up decreas ed, still twice as many children met or exceede d clinical levels as compar ed to baseline ” (1). KINSHIP CARE “Kinshi p placeme nts were not predict ive of mental health outcom es regardle ss of the amount of time in kinship care. … [M]mult iple causes of mental health proble ms often occur previou s to placeme nt in care and may not be mediate d by the child’s foster care experie nce enough to show significa nt differen ces” (2). ADOPTION In assessm ents of children at 2, 4, and 8 years followin g adoptio n, “Adopt ed foster youth were more behavi orally impair ed than their non- FC counter parts, althoug h a striking number of non- FC youth displaye d behavio r proble ms as well” (3) Bellamy, J. (2008). Behavioral problems following reunification of children in long-term foster care. Children and Youth Services Review. 30:216. Fechter-Leggett, MO & O’Brien, K. (2010). The effects of kinship care on adult mental heath outcomes of alumni of foster care. Children and Youth Services Review. 32(2):206. Simmel, C.; et al. (2007). Adopted youths psychosocial functioning: A longitudinal perspective. Child and Family Social Work. 12(4):336.

Chaffee Programs Yield Poor Outcomes Chaffee Foster Care Independence Program Type Outcomes Measures Findings Tutoring and Mentoring Age percentile in reading and math, school grades, high school completion, highest grade completed, and school behavior problems No statistically significant difference on key outcomes Life Skills Training High school completion, current employment, earnings, net worth, economic hardship, receipt of financial assistance, residential instability, homelessness, delinquency, pregnancy, possession of personal documents, any bank account, and sense of preparedness in 18 areas of adult living Employment High school completion, college attendance, current employment, earnings, net worth, economic hardship, receipt of financial assistance, residential instability, homelessness, delinquency, pregnancy, possession of personal documents, any bank account, and sense of preparedness in 18 areas of adult living Intensive Case Management and Mentoring High school completion, college enrollment and persistence, current employment, employment past year, earnings, net worth, economic hardship, receipt of financial assistance, residential instability, homelessness, delinquency, pregnancy, possession of personal documents, any bank account, and sense of preparedness in 18 areas of adult living Higher rates of college attendance and persistence among treatment than control group youth but difference was largely explained by continued child welfare system involvement among youth in the treatment group Koball, Heather, et al. (2011). Synthesis of Research and Resources to Support At-Risk Youth, OPRE Report # OPRE 2011-22, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

AVERAGE LIFETIME COST OF MALTREATMENT IS $210,000 X. Fang et al., 2012

“There is no doubt that children in harm’s way should be removed from a dangerous situation. However, simply moving a child out of immediate danger does not in itself reverse or eliminate the way that he or she has learned to be fearful. The child’s memory retains those learned links, and such thoughts and memories are sufficient to elicit ongoing fear and make a child anxious.” National Scientific Council on the Developing Child (2010). Persistent Fear and Anxiety Can Affect Young Children’s Learning and Development: Working Paper No. 9. Retrieved fromwww.developingchild.harvard.edu (emphasis added) “Traditional child welfare approaches to maltreatment focus largely on physical injury, the relative risk of recurrent harm, and questions of child custody, in conjunction with a criminal justice orientation. In contrast, when viewed through a child development lens, the abuse or neglect of young children should be evaluated and treated as a matter of child health and development within the context of a family relationship crisis, which requires sophisticated expertise in both early childhood and adult mental health.”  National Scientific Council on the Developing Child (2004). Young Children Develop in an Environment of Relationships: Working Paper No. 1. Retrieved from www.developingchild.harvard.edu (emphasis added)

Emotional, and Social Capacities Are Inextricably Intertwined Within the Architecture of the Brain Maltreatment during early childhood can cause vital regions of the brain to develop improperly, leading to a variety of physical, emotional, cognitive, and mental health problems. Maltreatment results in difficulties regulating emotional reactions, rage, dissociation, somatization, changes in perception of self and others, and changes in understanding and interpreting events. Siegel, DJ. (2001). Toward an interpersonal neurobiology of the developing mind: Attachment relationships, “mindsight,” and neural integration. Infant Mental Health. 22(1-2):67. Terr, LC. (1991). Acute responses to external events and Posttraumatic stress disorders. In Lewis, M (Ed.). Child and adolescent psychiatry: a comprehensive textbook New Haven, CT: Williams & Wilkins. 13

Maltreatment & Complex Trauma Refers to children’s experiences of multiple traumatic events that occur within the caregiving system – the social environment that is supposed to be the source of safety and stability in a child’s life. Typically, complex trauma exposure refers to the simultaneous or sequential occurrences of child maltreatment—including emotional abuse and neglect, sexual abuse, physical abuse, and witnessing domestic violence—that are chronic and begin in early childhood. Moreover, the initial traumatic experiences (e.g., parental neglect and emotional abuse) and the resulting emotional dysregulation, loss of a safe base, loss of direction, and inability to detect or respond to danger cues, often lead to subsequent trauma exposure (e.g., physical and sexual abuse, or community violence).”

Impact of Trauma on Brain Development Traumatic Stress Hormones, chemicals, and cellular systems prepare for a tough life in an evil world BRAIN > “Brawn over brains” > Hyper vigilant > Hot temper > Edgy INDIVIDUAL Individual and species survive the worst conditions OUTCOME NEUTRAL START Hormones, chemicals, and cellular systems prepare for life in a benevolent world BRAIN > “Process over power” > Think things through > Relationship-oriented > Laid back INDIVIDUAL Individual and species live peacefully in good times; vulnerable in poor conditions OUTCOME Adapted from: Family Policy Council. (2007). The High Cost of Adverse Childhood Experiences (PPT). Olympia, WA: Author.

Toxic Stress in Home of Children Involved in Child Welfare

Toxic Stress in Home of Children Involved in Child Welfare

Early Experiences Alter Gene Expression Extensive scientific research has shown that the healthy development depends on how much and when certain genes are expressed in the cells of these systems. Research has shown that environmental factors and early experiences have the power to impact whether genes are turned "on" or "off"—essentially whether and when genes are activated to do certain tasks.

Toxic Stress Evident in Social & Emotional Problems of Maltreated Children Data Source: National Survey of Child and Adolescent Well-Being II (NSCAW II). NSCAW II is a Congressionally required study sponsored by the Office of Planning, Research and Evaluation, Administration for Children and Families (ACF), U.S. Department of Health and Human Services (DHHS). Risk of social-emotional problems was defined as scores in the clinical range on any of the following standardized measures: Internalizing, Externalizing or Total Problems scales of the Child Behavior Checklist (CBCL: administered for children 1.5 to 18 years old), Youth Self Report (YSR; administered to children 11 years old and older), or the Teacher Report From (TRF; administered for children 6 to 18 years old); the Child Depression Inventory (CDI; administered to children 7 years old and older); or the PTSD section Intrusive Experiences and Dissociation subscales of the Trauma Symptoms Checklist (administered to children 8 years old and older).

A FRAMEWORK FOR WELL-BEING The framework identifies four basic domains of well being: (a) cognitive functioning, (b) physical health and development, (c) behavioral/emotional functioning, and (d) social functioning. Within each domain, the characteristics of healthy functioning related directly to how children and youth navigate their daily lives: how they engage in relationships, cope with challenges, and handle responsibilities. Cognitive Functioning Physical Health and Development Environmental Supports Personal Characteristics Emotional/ Behavioral Functioning Social Functioning Developmental Stage 4/8/2013

Screening, Functional Assessment & Progress Monitoring “Functional assessment—assessment of multiple aspects of a child’s social-emotional functioning (Bracken, Keith, & Walker, 1998)—involves sets of measures that account for the major domains of well-being.” “Child welfare systems often use assessment as a point-in- time diagnostic activity to determine if a child has a particular set of symptoms or requires a specific intervention. Functional assessment, however, can be used to measure improvement in skill and competencies that contribute to well-being and allows for on-going monitoring of children’s progress towards functional outcomes.” “Rather than using a “one size fits all” assessment for children and youth in foster care, systems serving children receiving child welfare services should have an array of assessment tools available. This allows systems to appropriately evaluate functioning across the domains of social-emotional well-being for children across age groups (O’Brien, 2011) and accounting for the trauma- and mental health-related challenges faced by children and youth who have experienced abuse or neglect.” Valid and reliable mental and behavioral health and developmental screening and assessment tools should be used to understand the impact of maltreatment on vulnerable children and youth. TRAUMA SCREENING Child and Adolescent Needs and Strengths (CANS) Trauma Version Childhood Trauma Questionnaire (CTQ) Pediatric Emotional Distress Scale (PEDS) FUNCTIONAL ASSESSMENT Strengths and Difficulties Questionnaire (SDQ) Child Behavior Checklist (CBCL), the Social Skills Rating Scale (SSRS) Emotional Quotient Inventory Youth Version (EQ-i:YV) May 11, 2012 Two Days in May - Ohio

Time to Stop Counting Service “It is common for child welfare systems to gauge their success based on whether or not services are being delivered. One way to focus attention on well-being is to measure how young people are doing behaviorally, socially, and emotionally and track whether or not they are improving in these areas as they receive services” (ACYF-CB-IM-12-04). Measuring Services How many children received…? How many hours of training were delivered? What percent of children got…? Measuring Outcomes Are trauma symptoms reduced? Did services increase relationship skills? Do children have healthier coping strategies?

DE-SCALING WHAT DOESN’T WORK, SCALING UP WHAT DOES Generic Counseling Generic Independent Living Skills Training Parenting Classes Functional Assessment Evidence-Based/Informed Mental Health & Parenting Interventions Trauma Screening DE-SCALING WHAT DOESN’T WORK, SCALING UP WHAT DOES De-scaling what doesn’t work Investing in what does INEFFECTIVE APPROACHES RESEARCH-BASED APPROACHES

Pre- and post-tx sx, n=25, 3-6 yrs old INTERVENTIONS NEED TO BE STRONG ENOUGH TO MEET COMPLEX NEEDS OF CHILDREN/YOUTH Pre- and post-tx sx, n=25, 3-6 yrs old ** * ** * *p<.001, **p<.0001 Scheeringa, M. and Gonzales, R.. Clinical treatment approaches to trauma. Tulane University School of Medicine. (April 15, 2013 presentation to at the CWLA Neuroscience and Child Maltreatment Conference). 4/25/2013

Many Child Welfare Requirements Are Missed Opportunities to Promote Well-being maltreatment investigation and removal recruitment and retention of quality foster homes case plan development with involvement from birth and foster families monthly caseworker visits with child and foster parents processes of returning children to their biological families processes of adoption or subsidized guardianship maintaining connections to biological siblings addressing placement disruptions, dissolutions or (un)anticipated moves transitioning “aging out” youth to independent living or adult service systems case management and interface with other service systems (e.g., education, mental health, physical health)

Connecting the Dots To Well-being Focus on child & family behavior, skills competencies, outcomes Build capacity for more intensive EBP/RBIs Monitor progress for improved child/youth functioning Promoting Well-being Actively promote healthy relationships Change practice to address trauma Take developmental approaches

Reduced caseload ratios in public and private sectors form 20 cases per worker to 14 cases per worker. Decreased child welfare population declined from 23,500 to16,500 statewide. Reduced disproportionate representation of African American children in child welfare system declined from 69.3% to 60%. Decreased number of youth “on run” decreased by 40% and number of days “on run” decreased by 50%. Decreased late child protection investigations by 60%. Reduced distance between home of origin and foster care placement reduced from 20 miles to 7.8 using new school placement strategy. Reduced time in residential treatment by 20%.

RE-DEFINING SUCCESS: STATE OF ILLINIOS Reduced caseload ratios in public and private sectors form 20 cases per worker to 14 cases per worker. Reduced disproportionate representation of African American children in child welfare system declined from 69.3% to 60%. Decreased number of youth “on run” decreased by 40% and number of days “on run” decreased by 50%. Decreased late child protection investigations by 60%. Reduced distance between home of origin and foster care placement reduced from 20 miles to 7.8 using new school placement strategy. Reduced time in residential treatment by 20%. Decreased child welfare population declined from 23,500 to16,500 statewide.

QUESTIONS?

MATCHING POPULATIONS, OUTCOMES, AND APPROACHES: IV-E WAIVER EXAMPLES Children, 8-17 Children, 13-17 Children, 2-7 Screening & Assessment - UCLA PTSD Index - Strengths & Difficulties Questionnaire - Child & Adolescent Needs & Strengths - Trauma Symptoms Checklist for Young Children - Infant Toddler Emotional Assessment - CBCL EBIs Trauma-Focused Cognitive Behavioral Therapy Multisystemic Therapy Parent-Child Interaction Therapy Outcomes - Behavior problems - PTS symptoms - Depression - Delinquency/Drugs - Peer problems - Family cohesion - Conduct disorders - Parent distress - Parent-child interaction

Connecting the Dots of Promising Practices To promote emotional, social, cognitive, and physical development broadly, promising practices including a range of strength building strategies that: Reduce stress in children’s lives, both by addressing its source and helping them learn how to cope with it in the company of competent, calming adults; Foster social connection and open-ended creative play, supported by adults; Incorporate vigorous physical exercise into daily activities, which has been shown to positively affect stress levels, social skills, and brain development; Increase the complexity of skills step-by-step by finding each child’s “zone” of being challenged but not frustrated; and Include repeated practice of skills over time by setting up opportunities for children to learn in the presence of supportive mentors and peers.

Connecting Dots of Promising Practices Focus on Relationships—Children develop in an environment of relationships. This starts in the home and extends to caregivers, teachers, medical and human services professionals, foster parents, and peers. Children are more likely to build effective executive function skills if the important adults in their lives are able to: Support their efforts; Model the skills; Engage in activities in which they practice the skills; Provide a consistent, reliable presence that young children can trust; Guide them from complete dependence on adults to gradual independence; and Protect them from chaos, violence, and chronic adversity, because toxic stress caused by these environments disrupts the brain circuits required for executive functioning and triggers impulsive, “act-now-think-later” behavior.

Supportive, responsive relationships promote healing and recovery and reinforce growing social and emotional skills Nurturing environments provide security and promote positive outcomes Systems and policies promote and sustain screening, assessment, the use of evidence-based interventions, progress monitoring, and continuous quality improvement Assessment drives individualized treatment plan with evidence-based interventions Systematic approaches to teaching coping skills and social skills Intensive Intervention Targeted Social and Emotional Supports Stress Reducing and Developmentally Appropriate Environments Safe, Supportive, and Responsive Relationships Knowledgeable and Effective Workforce Healing and Recovery SOCIAL AND EMOTIONAL WELL-BEING FOR CHILDREN, YOUTH, AND FAMILIES Adapted from the Technical Assistance Center on Social Emotional Intervention for Children and the Center on the Social and Emotional Foundations for Early Learning 4/30/2013

PROMOTING WELL-BEING ACROSS THE U.S. Regional Partnership Grants to Increase Well-Being and Improve Permanency Outcomes for Children Affected by Substance Abuse Partnerships to Demonstrate the Effectiveness of Supportive Housing for Families in the Child Welfare System Permanency Innovations Initiative Title IV-E Child Welfare Demonstration Projects, Approved in FY 2012 Working with Children’s Bureau for Title IV-E Child Welfare Demonstration Projects, for FY 2013 6/3/2013

Common Concerns & Evidence-Based Interventions (1 of 2) Diagnosis/Concern/Activity Evidence-Based Interventions (Examples) Age Screening Activities Identification of Mental Health & Behavioral Health Issues SCREENING TOOLS Child & Adolescent Needs & Strengths—Trauma (CANS) Pediatric Symptom Checklist (PSC) Strengths and Difficulties Questionnaire (SDQ) Child Behavior Checklist (CBCL) 0-18 4-16 4-17 4-18 Most Common Mental Health Diagnoses for Children in Foster Care (bold red text indicates parent or caregiver component) Conduct Disorder/Oppositional Defiant Disorder Parent-Child Interaction Therapy (PCIT) Strengthening Families Program (SFP) Early Risers – Skills for Success Brief Strategic Family Therapy (BSFT) Multisystemic Therapy (MST) Familias Unidas Multidimensional Treatment Foster Care (MTFC) 2-7 3-16 6-12 6-17 9-17 12-17 Attention Deficit Hyperactivity Disorder Parent–Child Interaction Therapy (PCIT) Triple P Children’s Summer Treatment Program (STP) 0-16 Major Depression Adolescents Coping with Depression (CWD-A) Cognitive Behavioral Therapy (CBT) for Adolescent Depression Alternative for Families-Cognitive Behavioral Therapy (AF-CBT) 13-17 13-25

Common Concerns & Evidence-Based Interventions (2 of 2) Diagnosis/Concern/Activity Evidence-Based Interventions (Examples) Age Trauma Actionable Trauma Symptoms  Posttraumatic Stress Disorder Child-Parent Psychotherapy (CPP) Parent-Child Interaction Therapy (PCIT) Combined Parent-Child Cognitive Behavioral Therapy for Families at Risk for Child Physical Abuse (CPC-CBT) Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) Alternatives for Families/Abuse Focused Cognitive Behavioral Therapy (AF-CBT) Cognitive Behavioral Intervention for Trauma in Schools (CBITS) Trauma Affect Regulation: Guide for Education and Therapy (TARGET-A) Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS) Prolonged Exposure (PE) Therapy for Youth 18-25 0-6 2-17 3-17 4-55 5-17 6-12 10-55 13-21 18-25 Behavioral Concerns Internalizing/Externalizing Behaviors  Behavioral Problems and Relational Concerns Child Parent Psychotherapy (CPP) Promoting Alternative Thinking Strategies (PATHS) Incredible Years Triple P Parenting Wisely Nurturing Parenting Programs (NPP) Brief Strategic Family Therapy (BSFT) Fostering Healthy Futures (FHF) – mentoring + skills training Functional Family Therapy (FFT) 0-12 0-16 0-17 6-17 9-11 10-18