Best-Practice Framework for Addressing the Mental Health and Substance Abuse Needs of Children and their Families.
January 21, 2003
I. Statement of Need
This document is the first step in outlining a framework for developing best practices to address the mental health and substance use/abuse needs of children in the child welfare and juvenile justice systems.
Emotional disorders are identified as the most serious unmet health problem of children in care--some studies estimate as many as 70% of child welfare children in placement have serious emotional disturbance.* Mental, emotional, and behavioral disorders may be associated with preplacement abuse and neglect, as well as the trauma and stress caused by being placed, along with the impermanence or inappropriateness of placement intervention or practices. Mental, emotional, and behavioral disorders may also contribute to failed and multiple placements and place demands on the mental health and substance abuse system for services and supports that are lacking in the child welfare system.
All children with mental, emotional, developmental, or behavioral health problems have the right to unbiased and comprehensive child mental health and substance use/abuse screening and assessment, treatment services, and supports. Frequently, however, these services are not provided. The child welfare, juvenile justice, and education systems currently use differing and often conflicting theories and methods to work toward conflicting, poorly defined, or myopic goals. The prevalence of mental health and substance use/abuse problems in children in these systems, and the variability of services, treatment, and supports provided by these systems, compel the development of one set of best practices that delineate the mental health and substance abuse services that should be provided in the child welfare system. This best-practice framework is an attempt to begin to define a set of theories, methods, and goals that child welfare systems can use so all children receive fair, appropriate, and accurate screening, assessment, treatment, and supports.
II. Overarching Principles for A Best-Practices Framework
Best practices for child welfare populations with mental health or substance use/abuse problems are guided by overarching principles that are consistent with a wellness model, core child welfare values, professional social work ethics, AACAP/CWLA's Values and Principles, and legal mandates. Child welfare efforts must promote positive mental health and decrease substance use. Seamless, integrated efforts must reinforce child and family strengths, use a developmental perspective, emphasize the appropriate involvement of children and families at all levels, encourage collaboration and coordination of community-based services and supports, educate the community that the promotion of good mental health and the decrease of substance use is everyone's concern, and destigmatize mental health and substance use/abuse problems.
Best practices ensure that children and families served by the child welfare system have access to quality services, practices, and programs that are culturally competent, relevant, child-focused, family-driven, effective, evidence-based, and outcome-driven. Early identification of risk factors, and policies and programs that focus on wellness by preventing problems from occurring altogether or preventing the escalation of problems, are hallmarks of best practices.
Providing mental health and substance abuse services when needed will help service providers
- promote good mental health, healthy child and family development, and decreased substance use;
- prevent the escalation of problems;
- protect children, families, and communities from harm;
- preserve family stability;
- ensure permanency and support for children as they grow into young adults; and
- place and treat children in a manner that nurtures positive mental health and substance use/abuse outcomes.
Early identification and intervention services will prevent the escalation of mental health and substance abuse problems and lead to overall improved outcomes for children, their families, and the community. In this context, prevention efforts by the child welfare system are characterized by
For children in out-of-home care, service providers need to recognize that the disruption of normally expected child development puts these children at greater risk for stress and trauma caused by separation, loss, and grief. To mitigate disruption and trauma, service providers must pay increased attention to attachment issues from the time of the initial placement, the importance of sustained relationships, and the input of the child and their family when making decisions for children who are separated from families and communities and placed in out-of-home care settings. To prevent emerging attachment issues, assessments should occur at regular intervals while the child is in out-of-home care or when moving to a new placement, including the child's permanent placement.
- programs and services that promote positive mental health and substance use prevention;
- an effective assessment process for early identification of factors that may lead to mental health and substance use/abuse problems;
- programs and services designed to prevent the escalation of mental health and substance use/abuse problems;
- easy access to appropriate screening, assessment, services, and intervention, beginning at birth; and
- family support services.
Timely and accurate screening, assessment, treatment planning, therapeutic interventions, and/or placement interventions all help ensure the safety of children, families, and communities. Child, family, and community safety are primary concerns. When out-of-home care is indicated, placement should be in the least restrictive, most normative environment appropriate to the child's needs, including attachment, development, and safety. The family's input and involvement are essential unless prohibited by court mandate. The child's input and involvement is also essential.
Strengthening of Family
Stabilizing and preserving family relationships must be a primary focus of treatment intervention to prevent the unnecessary or inappropriate separation of children from their families. The families or foster families of children with mental health and substance use/abuse problems must be full and active participants in all aspects of the planning and delivery of services. Additionally, children and families (unless otherwise indicated for safety reasons) should be the primary drivers of their service planning. Support services such as parenting education, family therapy, foster parent involvement with the family of origin, and education about mental health and substance use/abuse and child development issues can help facilitate family stability.
A family is the best place for a child to form significant attachments and grow into adulthood. We recognize, however, that this ideal situation is not always possible. Children with mental health and substance use/abuse problems are entitled to stable, nurturing relationships intended to last a lifetime; out-of-home placement does not preclude this right. Permanency affords children the opportunity to develop a lasting relationship with at least one unconditional, committed adult. Mental health and substance abuse services that focus on attachment issues are necessary to ensure that permanency plans for children are successful. As children with mental health and substance use/abuse problems grow up, permanency and support helps them grow into functional adults and facilitates a smooth transition to the adult mental health and substance use/abuse service system if necessary and appropriate.
Treatment and Supports
Children with mental health and substance use/abuse problems should have access to a comprehensive array of assessment, treatment, and support services that address their physical, emotional, social, and educational needs. Child welfare agencies need to ensure that children with mental health and substance use/abuse problems receive individualized services and supports in accordance with the unique needs and potential of each child and his or her family.
When out-of-home placement is indicated, children should receive services and supports in the least restrictive, most normative environment that is clinically and developmentally appropriate. Children with mental health and substance use/abuse problems, and their families, should receive services and supports that are integrated, with linkages between various agencies and across the multiple systems responsible for serving the child and family for both in-home and out-of-home care. Children with mental health and substance use/abuse problems in the child welfare system should receive case management services to ensure that multiple services are delivered in a coordinated, therapeutic manner that allows children and families to move easily within the system of services in accordance with their changing needs.
III. Best Practices Related to Clinical Assessment and Intervention
Screening and Assessment
All child welfare children should receive mental health and substance use/abuse assessments at the beginning of services and at regular intervals as necessary while in care. A standardized, comprehensive best-practice screening and assessment protocol, used by all systems to identify at-risk children and accurately assess their mental health and substance use/abuse needs, will ensure a consistent, appropriate approach across multiple systems that should result in better child and family outcomes.
An initial mental health and substance use/abuse screening should be conducted within 24 hours of a child being placed in out-of-home care. The mental health and substance use/abuse screening is intended to identify children in urgent need of emergency mental health and substance abuse services, including youth whose behavior may pose a danger to themselves or others. The screening process should assess the internalized and externalized levels of distress the child is experiencing regarding the separation and identify and support the child's strengths and successful coping strategies. Ideally the screening should take place as part of a child's health examination upon entry into care and be conducted by a health professional with expertise in the developmental and mental health and substance use/abuse needs of children in foster care. At a minimum, the individual conducting the screen should be appropriately trained on the screening protocol, with onsite supervision or readily accessible mental health and substance use/abuse consultation.
Children entering out-of-home care, and their families, should receive a comprehensive mental health and substance use/abuse assessment within 60 days of placements, or sooner, based on the severity of the child's needs as identified in the screening process. Assessments should then be conducted at regular intervals to identify emerging mental health and substance use/abuse needs. This comprehensive assessment should use developmentally appropriate techniques and tools, be conducted in a comfortable and accessible setting, and address the child and family's strengths and needs. Assessments should be conducted by qualified mental health and substance use/abuse providers and include the active involvement of a child or adolescent psychiatrist. Unless otherwise indicated for reasons of safety, the child and his or her family (including foster parents when the child is in out-of-home care) should be directly involved with procedures and planning and be partners to all assessments, treatment, and support services.
Individualized mental health or substance abuse treatment planning that takes into account the strengths and needs of each child in the context of family and community, and the strengths and needs of families to effectively deal with their children's emotional/mental health and substance use/abuse needs, is essential. Within this context, clinical protocols should guide treatment planning to ensure children and families receive appropriate child-focused, family-driven, culturally sensitive and competent treatment services throughout the time they are served, and to ensure they benefit in meaningful, measurable ways from the services they receive.
Best-practice protocols for treatment planning must identify and address such stressors as poverty, lack of housing, lack of transportation, lack of linkages to the adult mental health and substance use/abuse service system, and problems in school that will affect the child and family's ability to engage in and benefit from treatment. Best-practice protocols should ensure that child and family's mental health and substance use/abuse problems are not compounded by the way they access and receive services and supports within and across systems in the community. Best-practice protocols for treatment planning include the use of informal and formal support services.
IV. Best Practices Related to System Performance Indicators
The child-serving system is responsible for ensuring that mental health and substance abuse services are accessible in the child welfare system, and best practices define the minimum requirements relative to access. For example, what should be the geographic distance or travel time from the client's home to the location of service? How much time should elapse from first contact to intake to initiation of services? What should the provider or clinician do to ensure linguistic needs are met? What should be done to ensure access to culturally competent services with staff who reflect the diversity of the community served? How can children and families access the system? What are the enrollment and disenrollment criteria? Does the system allow for nonlinear, intermittent use of services, or provide checkups for children and families who may move in and out of the system?
The increased use of innovative technology, including teleconferencing and videoconferencing; transportation accommodations; traditional and nontraditional, faith-based, community, school and home-based services; and informal and formal support services, can enhance child and family access to services and supports.
Best practices ensure that, while they are in the system, children with mental health and substance use/abuse problems, and their families, receive services appropriate to their ages, developmental needs, and stage in the family life cycle. Children and families should not be under- or overserved, and services and supports should be based on a wellness model. Among other things, best practices related to appropriateness should describe
- how case management and service coordination occurs;
- the process for utilization management (UM), and the clinical protocols that guide UM throughout an episode of care;
- the level of involvement of the child and family in treatment planning, selecting services, supports, and planning for the design and delivery of services;
- the manner in which services are concluded or transitioned;
- how adolescents who age out of the child welfare system are transitioned to the adult mental health and substance use/abuse service systems if necessary and appropriate; and
- requirements regarding the cultural competence and cultural diversity of providers of care.
Best practices should define accreditation requirements for agencies, as well as the requirements for the credentials, training, supervision, and professional development of the staff needed to deliver effective, evidence-based, culturally competent screening, assessment, treatment, and support services. Opportunities for professional, academic, and agency-based inservice training should be afforded to all child-serving agency staff, families, and other partners to continuously enhance the delivery of services and system performance.
Best practices regarding assessment of the quality of system performance require research-based data. Best practices clearly describe the desired outcomes, indicators, and methods used to monitor, track, and report system performance.
Client Rights, Involvement, and Satisfaction
Best practices must protect the rights of all children and their families, maximize their involvement, and strive to improve their satisfaction. Children with mental health and substance use/abuse problems, and their families, have a right to culturally competent treatment and supports based on a committed, systemwide "no reject, no eject" policy. Children with mental health and substance use/abuse problems, and their families, should be fully informed about treatment options and their rights and have access to complaint, grievance, and appeals procedures that protect their rights. Children with mental health and substance use/abuse problems, and their families, are entitled to services regardless of race, religion, national origin, gender, physical disability, sexual orientation, or other characteristics. Best practices should ensure
- children and families are included as active participants in all phases of treatment planning, identification of services and supports, and service delivery, based on their strengths and needs;
- their satisfaction is regularly assessed using sound research methods; and
- data are used to continuously improve services.
Children with mental health and substance use/abuse problems, and their families, must have access to culturally competent services and providers that are sensitive and responsive to cultural differences and special needs. Staff and service providers should reflect, be aware of, and understand the cultural diversity of the community and population they serve.
The professional ethics and effective advocacy efforts of service providers should promote and protect the legal and ethical rights of children with mental health and substance use/abuse problems, and their families. Advocacy efforts should strive to ensure that children with mental health and substance use/abuse problems, and their families, receive services regardless of race, religion, national origin, gender, physical disability, sexual orientation, or other characteristics. Access to mental health and substance abuse services should be an entitlement for those children and families who need them. Advocacy is necessary to achieve equal access.
The system of care must be able to document the value of the therapeutic services provided, as well as the cost and effectiveness of prevention services. Professional accountability demands that program evaluation, based on best-practice principles, be conducted to ensure that resources expended result in measurably improved outcomes for children, families, and communities.
* Benoit, M.B. (1995). Foster care. In. B.J. Sadock & H.I. Kaplan (Eds.), Comprehensive Textbook of Psychiatry. (6th ed.). Philadelphia: Lippincott Williams & Wilkins
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