Alliance for Child Welfare Excellence

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.

Screening and Referral Training developed by:
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

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?

Where does Mental Health Fit into Your Caseload?
Wellbeing Permanency Safety

National Prevalence of Mental Health for Children and Youth

Children and Youth in Washington State
In FY11, 52% of Children (Ages ) that were Flagged for a Potential Mental Health Concern on the Child Health and Education Tracking (CHET):

Small Group Activity What are the implications for an untreated mental health need for a child or youth?

Mental Health Needs and Permanency
Externalizing Behaviors Placement Changes 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

Catch the Smoke before the Fire

Child Development Developmental Causes for Concern
Birth - Toddlers 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 Clingy and upset when caregiver leaves Aggressive and hostile towards others Bullies other children Is fearful with familiar adults or too friendly with strangers Bed wetting and/or encopresis Pre-Adolescent and Pre-Adulthood 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 Night terrors, unable to sleep, obsessive, overly vigilant, over-sexualized behaviors

Common Mental Health and Behavior Challenges
Trauma Re-experiencing, Avoidance, Hyperarousal Fighting, rule breaking, not listening, anger outbursts Depression, anxiety (including responses to trauma) Attention Challenges Trouble paying attention, acting impulsively Externalizing “Acting Out Behaviors” Internalizing “Feelings or Emotional” Behaviors Add bucket picture

Where do I Look? In the Case File or in FamLink?
Investigation or Non Dependency Cases Referral Safety Plans General observations or conversations Reports or information from previous treatment providers Previous questionnaires, assessments (e.g., GAIN-SS) Dependency Cases Safety Plans General observations, conversations, and Health and Safety visits Child Health and Education Tracking (CHET) and other screening tools

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

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.)

CHET Report Interpretation
PSC-17 SCARED Internalizing score of 5 Anxiety score of 3 Externalizing score of 7 PTSD score of 6 Attention score of 7 Total Score of 15 GAIN-SS ASQ-SE **Score of 2 on total screener; between 3-5 on sub screeners Score of 70 Scores equal to or above the cut-off: need a mental health referral 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

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

Assessing Mental Health Treatment Options
Thousands of different programs and services available… Some may actually do harm… Many do not have evidence that they work… However, there are ones that have been proven to work!

How is Evidence Based Defined?
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 Best Evidence No Evidence

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 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!

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.”)

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

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

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

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.

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

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

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)

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?

I am an Advocate for MH Treatments for Children and Youth … Now What?
For children birth to age 3, Department of Early Learning’s Early Support for Infants and Toddlers (ESIT) offers great resources, visit : Things to Consider: Specific mental health or behavior health need/s EBPs available in the area Consider child or youth’s age Family preferences (e.g., group v individual) Who delivers this service? 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

The Role of Mental Health Professionals
Child Welfare Psychologist RSN Fee-for-Service, as appropriate CA Psychiatrist Counselor Fee-for-Service Primary Care Provider Health Care Auth. Other (e.g., Neuropsychologist) Managed Care Org. Evidence Based Treatments

When an EBP is Not Available …
Refer to community mental health agency for comprehensive mental health evaluation Work with the agency or assigned therapist around the child or youth’s needs Be an informed consumer Do they offer CBT or BT?

CA EBP Directory

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?

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 Foster Care Status Antipsychotic Mental Health Drug 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)

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?

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 ) 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 ) For children that are legally free and in the permanent custody of the department, the SW may authorize the administration of psychotropic medications (Policy #: Standard) – SW should still obtain court authorization

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

Children’s Administration Regional Medical Consultants
Safety Net Children’s Administration Regional Medical Consultants Region 1 Region 2 Region 3 R1 North Don Ashley (509) R2 North Frances Chalmers (360) R3 North Michelle Terry (253) R1 South Roy Simms (509) R2 South Rebecca Wiester (206) R3 South Vacant (doctors are covering until filled)

Medications across the buckets
Externalizing Internalizing Attention FIRST CHOICE: Psychosocial interventions Very limited evidence for using medication to manage aggression – Always seek consultation! Medications can be effective Medications should be paired with psychosocial interventions (preferably CBT) RED FLAG: Under 6yo 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

Parents involved in Child Welfare in Washington State
56% of parents met criteria for one or more mental health disorders Marcenko, Newby, Lee, Courtney, and Brennan, November 2009: Evaluation of WA SBC Practice Mode

Adult Causes for Concern Things to Look Out for
Mental Health Conditions Maternal depression Substance use and/or abuse Serious Mental Illness (SMI) Post Traumatic Stress (PTS) or unresolved trauma symptoms Experiences, Circumstances, & Attitudes Social isolation Domestic violence Attitudes about parenting practices, child rearing, developmental expectations

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 ( 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

Parents’ Mental Health Needs Can Impact the Children, Too

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

Small Group Activity What other adult behavioral health indicators should you take into account when case planning?

What is Trauma? Acute Trauma Chronic Trauma Complex 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

Reactions to Traumatic Stress
Emotional Physical

Reactions to Traumatic Stress
Emotional Terror Intense Fear Horror Helplessness Avoidance or repeated telling of story Disorganized or agitated behavior Physical Rapid heart rate Trembling Dizziness Loss of bladder or bowel movements

Child or Youth Responses to Trauma
Causes for Concern Birth - Toddlers 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 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 Pre-Adolescent and Pre-Adulthood 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)

Increased Risk for Clinically Significant Trauma Impact
Feeling terror, helplessness, or extreme fear Perceived Life Threat During the Event Little or no social support after the event Prior Psychological Problems Prior Trauma History 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%

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

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 Increased alcohol and/or other drug use Suicidal Thinking and Self-Harm Know the Warning Signs

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: U TREVOR School counselor, teacher, coach Therapist or counselor Emergency room or 911 Check out the web for more information: Youth Suicide Prevention Program (

Special Thanks Children, Youth, and Families
Children's Administration (CA) Barb Putnam and Dae Shogren Behavioral Health Service Integration Administration (BHSIA) Lin Payton, LaRessa Fourre and Jessica Bayne University of Washington (UW) Sue Kerns, Mike Pullmann, Sarah Holland, Andrea Negrete and Eric Trupin Health Care Authority (HCA) Kari Mohr Department of Health (DOH) Ellen Silverman Harborview Center for Sexual Assault and Traumatic Stress Lucy Berliner Naomi Perry Laura Merchant Alumni and Veteran Parents Jeanette Barnes and Passion to Action DSHS Research and Data Analysis (RDA) Barbara Lucenko Administration for Children, Youth and Families (ACYF) Joyce Pfennig Children, Youth, and Families

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