1. Community-based Treatment Alternatives for Justice-involved Youth in Child Welfare Norín Dollard Kimberly McGrath Mary Armstrong John Robst Melissa Johnson James Gimbel Presented at the 2013 FADAA/FCCMH Annual Conference, August 8, 2013, Orlando, Florida

2. Louis de la Parte Florida Mental Health Institute Support This work is supported in part by the Florida Agency for Health Care Administration contract #MED134

3. Louis de la Parte Florida Mental Health Institute Why enhanced therapeutic foster care? Many interventions targeted to youth with justice involvement are not effective (Henggeler & Schoenwald, 2011). ♦Blueprints Initiative reviewed the evidence base for over 600 prevention and intervention programs ♦Of the few found effective, Multidimensional Treatment Foster Care was included Evidence for the presence of a group contagion effect with delinquent youth in group settings (Lee & Thompson, 2009)

4. Louis de la Parte Florida Mental Health Institute Why enhanced therapeutic foster care? Florida studies over the past five years suggest: ♦There are large proportions of youth entering Statewide Inpatient Psychiatric Programs (SIPP) (42%, n=195) and Therapeutic Group Care (TGC) (31%, n=86) with juvenile justice contacts in the six months prior to placement ♦The higher the proportion of justice-involved youth in SIPPs or TGC, the more likely youth treated in such will have higher rates of future criminal activity after discharge. ♦Youth treated in Specialized Therapeutic Foster Care have lower rates of delinquent activity after discharge.

5. Louis de la Parte Florida Mental Health Institute Florida context No practice model with evidence base for Specialized Therapeutic Foster Care Closure of youth commitment settings in Miami- Dade Statewide move towards adopting EBPs ♦ReDirections (AHCA – DJJ) and DCF ♦Georgetown Crossover Youth Practice Model

6. Louis de la Parte Florida Mental Health Institute Implementation of a pilot program Engagement of system partners at state and community level Commitment to identify evidence-based model that is cost feasible statewide within Florida’s publicly funded children’s system Review of evidence base for therapeutic foster care ♦Investigation of feasibility of Multidimensional Treatment Foster Care ♦Decision to use Together Facing the Challenge

7. Louis de la Parte Florida Mental Health Institute What is Together Facing the Challenge? Evidence-based model that includes training and coaching for treatment foster care supervisors and parents on: ♦Supportive and involved relationships between supervisors and treatment parents; ♦Effective use of behavior management strategies by treatment parents; and; ♦Supportive and involved relationships between treatment parents and youth Farmer, E. M., Burns, B. J., Wagner, H. R., Murray, M. M., & Southerland, D. G. (2010)

8. Louis de la Parte Florida Mental Health Institute What is Together Facing the Challenge? Foster parents are an active member of the treatment team and are held accountable for behavioral interventions. Allows therapists the opportunity to focus on core issues with their clients while still addressing behavioral concerns. Provides a structured and consistent framework for parents within a system which reduces differences between homes in the program. Provides clear, consistent and obtainable treatment goals for clients.

9. Louis de la Parte Florida Mental Health Institute Study purpose: To implement and evaluate a small pilot study (n=10) of Together Facing the Challenge ♦for feasibility in real world public sector settings, ♦fidelity to the supervision and teaching model, ♦longer term outcomes and costs.

10. Louis de la Parte Florida Mental Health Institute Research Questions 1.To what extent is the therapeutic foster care model implemented with fidelity? 2.How are youth outcomes for this pilot in comparison with outcomes for similar youth with similar JJ profiles, in Mental Health and JJ group care settings, and in RTCs in child welfare custody? 3.What are the program costs, and what is the cost- effectiveness of the pilot program in comparison with youth with similar JJ profiles, in Mental Health and JJ group care settings, and in RTCs in child welfare custody?

11. Louis de la Parte Florida Mental Health Institute Population Inclusion criteria ♦9-17 years old ♦History of juvenile justice involvement ♦Referred by Miami-Dade multidisciplinary child welfare team for appropriate placement ♦Meets criteria for Florida’s Specialized Therapeutic Foster Care according to Medicaid handbook ♦Is in the child welfare dependency system ♦Is enrolled in Medicaid ♦Assent and consent obtained, as well court authorization if applicable

12. Louis de la Parte Florida Mental Health Institute Population (continued) Exclusion criteria ♦Sex offenders (Felony sex offenses including kidnapping involving sex offenses, sexual assaults, sexual battery, lewd & lascivious, and other felony sex offenses ♦Violent offenders (Violent crime includes murder, forcible sex offenses, robbery, and aggravated assault) ♦Axis I diagnosis of substance abuse

13. Louis de la Parte Florida Mental Health Institute Data collection Fidelity data to ensure fidelity of implementation Data from Citrus, adult and youth justice, state mental health, and Medicaid management information systems Primary data are collected from youth and their caregivers at baseline, every three months while in treatment, discharge, and three and six months post-discharge

14. Louis de la Parte Florida Mental Health Institute Fidelity data Therapeutic Treatment Parents as Front-Line Treatment Providers - the caregiver’s ability to effectively implement the parenting skills and techniques presented during the training on the Together Facing the Challenge curriculum

15. Louis de la Parte Florida Mental Health Institute MIS data elements Age, race / ethnicity, gender, and diagnoses Completion of the program, run away behaviors, delinquent behaviors, permanency goal attainment, treatment plan goal attainment, academic outcomes (e.g., grades, suspensions, expulsions, referrals for behavior), response to treatment, positive interactions with adults and peers, urinalysis results, and Baker Act initiations

16. Louis de la Parte Florida Mental Health Institute Outcome data collected from Youth & Caregivers Peer associations: Delinquent peer associations are assessed using the Interaction with Antisocial Peers Scale (Youth Report) Wellness: Child Health Questionnaire - Provides indicators of physical wellness, psychosocial wellness and an overall wellness (Caregiver Report) Youth strengths: Behavioral and Emotional Rating Scale—Second Edition, Parent Rating Scale and Youth Rating Scale (Caregiver & Youth Report) ♦interpersonal strength, involvement with family, intrapersonal strength, school functioning, affective strength, and career strengths

17. Louis de la Parte Florida Mental Health Institute Data collected from Youth & Caregivers – Mental Health Issues Child Behavior Checklist & Youth Self- Report ♦Total Problem Behavior Score, Internalizing Behaviors and Externalizing Behaviors (Youth and Caregiver Report. ♦Narrow band syndromes including Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints, Social Problems, Thought Problems, Attention Problems, Rule-Breaking Behavior, and Aggressive Behavior Strengths and Difficulties Questionnaire (Caregiver Report) ♦One overall scale and Four scales – Emotional Symptoms, Conduct Problems, Hyperactivity Scale, Peer Problems, and Prosocial Scale.

18. Louis de la Parte Florida Mental Health Institute Preliminary Findings Youth Demographics (n = 9) ♦44% Male ♦89% Black or African American ♦11% Hispanic / Latino ♦14.6 Years of age at baseline (range 13-17)

19. Louis de la Parte Florida Mental Health Institute Therapeutic Treatment Parents as Front-Line Treatment Providers

20. Louis de la Parte Florida Mental Health Institute Therapeutic Treatment Parents as Front-Line Treatment Providers

21. Louis de la Parte Florida Mental Health Institute Youth Strengths at Baseline Strength subscale a BERS2C Average Score (n=7) BERS 2Y Average Score (n=9) Interpersonal Strength 10.147.44 Family Involvement 9.337.44 Intrapersonal Strength 8.678.44 School Functioning 5.837.33 Affective Strength 9.178.22 Career Strength 10.1710.44 Strength Index b 8485 [a] Strength subscales on the BERS–2C range from 1 to 16, and on the BERS–2Y from 1 to 18. Average scores on both instruments range between 8 and 12. Higher scores indicate greater strength. [b] Strength Indexes for both BERS–2C and BERS–2Y range from 38 to 161, with an average index between 90 and 110. A higher index indicates greater overall strengths.

22. Louis de la Parte Florida Mental Health Institute Strengths and Difficulties Questionnaire Total Difficulties Score = Average 22.6 (n=7) ‘Normal’ 0 ‘Borderline’ 14.3% ‘In need of further assessment’ 85.7% Most challenging areas (% ‘borderline or abnormal’) ♦Conduct Problems 42.9% ♦Hyperactivity 42.9% ♦Peer Problems 42.9% ♦Emotional Symptoms 14.3% ♦Prosocial 14.3%

23. Louis de la Parte Florida Mental Health Institute Problem Behaviors & Symptoms Average ScoreCBCL (n=6)YSR (n=9) Internalizing T- Score 60.2 (range 44-71)43.8 (range 32-58) Externalizing T- Score 62.5 (range 40-73)55.3 (range 42-67) Total Problem T- Score 64.5 (range 52-75)46.9 (range 32-61) Borderline clinical range 60-63, clinical range 64 and higher

24. Louis de la Parte Florida Mental Health Institute Child and Youth Physical Well- being – Caregiver’s impression of overall health N = 7

25. Louis de la Parte Florida Mental Health Institute Impact on family life (CHQ) N = 6-7

26. Louis de la Parte Florida Mental Health Institute Association with Antisocial Peers Thinking about your four best friends. In the past year how many of your best friends have been…. N = 8

27. Louis de la Parte Florida Mental Health Institute Challenges to implementation Acquiring administrative or executive support and understanding within your agency of the implementation process is essential. Transitioning staff from “Business as usual” to implementation of new techniques and procedures can be challenging! Be prepared to face resistance to change from your foster parents –especially experienced or “expert” parents. Foster parents may feel as though they are being critiqued or evaluated unfairly during the implementation process.

28. Louis de la Parte Florida Mental Health Institute Challenges to implementation Successful implementation requires constant training and education for system partners (i.e judicial system, CBC providers, GAL) regarding the program requirements and the treatment process. Incentives and rewards for participation in the evaluation process help keep clients and parents engaged throughout the treatment process.

29. Louis de la Parte Florida Mental Health Institute Strengths & Successes This program provides an opportunity for intensive treatment services in the community for a population of clients that typically would not be served at this level of care. We are now integrated into the system of care in Dade county and we have a waiting list. Foster parents and staff are receptive to expanding the program. Case example of a successful client: D.L.

30. Louis de la Parte Florida Mental Health Institute Next steps Working with AHCA to modify discharge criteria for STFC pilot programs to allow children the opportunity to benefit from one year of treatment services. Engaging in intensive foster parent recruitment efforts to facilitate program expansion. Agreement from the FL Department of Juvenile Justice to share in the program costs If the outcomes are positive, work with system partners to move towards statewide implementation

31. Louis de la Parte Florida Mental Health Institute Questions?