AACAP/CWLA Values and Principles for Mental Health and Substance Abuse Services and Supports for Children in Foster Care
In the past few years, significant attention has been given to the growing number of children who suffer needlessly because their emotional, behavioral, and developmental needs are not being met. All of us are urged to take seriously the task of preventing mental health or substance abuse problems and providing services and supports for treating mental illness or substance abuse in children.
The Surgeon General's Report on Children's Mental Health and the United Nations Convention on the Rights of the Child have emphasized that treatment should be considered a basic right for children and families who suffer from a mental health or substance abuse problem. President George W. Bush issued an executive order, the New Freedom Initiative (NFI) of June 18, 2001, to remove barriers to community living for persons with disabilities, including children with severe emotional disturbances. NFI highlights the fact that there is no "wrong door" for accessing services and creating opportunity for children to receive community-based services within their local service systems. The president's announced plan to establish a National Commission on Mental Health will further support addressing the emotional/mental health needs of children.
Children served by the foster care system are coping with the events that precipitated their coming into care and enduring the grief and trauma that accompany the loss of a family. Currently, more than 500,000 children reside in foster care in the United States, and 85% of them are estimated to have an emotional disorder and/or substance abuse problem. The American Academy of Child and Adolescent Psychiatry (AACAP) and the Child Welfare League of America (CWLA) began an initiative in March 2001 to improve the design, delivery, and outcomes of the mental health and substance abuse services provided to children in foster care and their families. More than 30 consumer and professional organizations have joined AACAP and CWLA, contributing their expertise and resources to this initiative.
The seriousness, intensity, prevalence, and urgency of the unmet needs of these children and their families substantiates our commitment to this initiative. Drawing on the values and principles already developed through such efforts as the systems of care, which focused on service delivery to children with serious emotional disturbances, the values and principles delineated in this document will guide efforts to improve policies and practices in the systems that serve children in foster care and their families. We believe such values and principles will drive practice in addressing the mental health and substance abuse needs of children and their families. This will lead to other reforms in how local communities and formal systems intersect on mental health, substance abuse, and child welfare issues to ensure the well-being of children in foster care and their families.
Our mutual interest is the emotional/mental health of children and their families. We must develop innovative and evidence-based assessment tools to identify children's emotional and/or behavioral problems as early as possible and to ensure all children and their families have access to and receive evidence-based, effective, mental health and substance abuse prevention and treatment services and supports. It is our professional responsibility to provide the most timely, appropriate, and effective prevention/treatment services and supports to children and their families to ensure the best outcomes.
To this end, we support and advocate for providing mental health and substance abuse prevention strategies, assessments, treatments, services, and supports designed for children in the foster care system, and their families, that abide by the following five values:
Further discussion of the values appears in the appendix.
- Child-focused mental health and substance abuse services and supports.
- Family-driven mental health and substance abuse services and supports.
- Integration, collaboration, and coordination of community-based mental health and substance abuse services and supports with the foster care system.
- Culturally competent, relevant, and strength-based services and supports provided by knowledgeable, skilled service providers who understand the cultural diversity of the community.
- Timely, effective, evidence-based, outcome-driven mental health and substance abuse services and supports.
Principles Generated by the Values
The principles outlined here are infused by the core values mentioned above and provide greater detail for how they are to be implemented.
Service Coordination and Case/Care Management
Prevention and Early Identification
- Coordination among mental health, substance abuse, physical health, developmental disability, legal, educational, and child welfare services is essential.
- Children in foster care deserve services that are designed, assessed, and delivered as part of their foster care services plan.
- System coordination can ensure the most appropriate use of limited resources and eliminate fragmentation experienced with different funding streams for the needed services and supports.
- Many children and youth in foster care have co-occurring mental health and substance abuse issues. Service coordination ensures that their substance abuse and mental health services and supports are provided concurrently.
- Coordination must include services children and family members are receiving.
- Information must be shared on a regular basis among organizations providing services and support to the child and family. Barriers must be eliminated while complying with the confidentiality requirements in the Health Insurance Portability and Accessibility Act. This information should follow the child from placement to placement.
Planned and Coordinated Transitions Among Agencies and Providers and Between Children, Families, and Adult Systems
- Prevention and early identification programs and supports for potential mental health and substance abuse issues are vital to children in the foster care system and their families.
- Children from birth to age 3 are of particular concern, given they are a significant percentage of the population of children in foster care. Prevention and early intervention programs should be targeted to them.
- Assessments for children entering the foster care system should include screening for potential mental health and substance abuse issues. Children should be reassessed for mental health and substance abuse problems at specific intervals (minimally, timeframes contained in the Early and Periodic Screening, Diagnosis, and Treatment Program [EPSDT]) so prevention and treatment services can be provided as early as possible. A referral should be made for a mental health and substance abuse assessment by a trained professional.
Human Rights and Responsibilities Regarding Protection and Advocacy
- Children and families suffer significant negative effects when transitions and discharges are not successful; therefore, coordination and effective planning are necessary whenever children are involved in changing providers and/or agencies, returning home, changing levels of care, changing placements, transitioning to self-sufficiency, or being transferred to another service system.
- Youth making the transition to self-sufficiency may need services provided by the adult system, such as mental health, substance abuse, housing, financial, health, dental, educational, and/or employment assistance. Effective coordination must take place between child- and adult-serving systems.
- Each child leaving the system must have a developmentally appropriate transition and/or discharge plan. Planning must provide skills that allow young people to transition to adulthood and provide for their own permanency, safety, and well-being.
- Transition can significantly affect the child and family. It is important that the child's needs and wishes take precedence over the system's needs whenever possible. If a child experiences more than two placements, the child welfare system should have a process in place to review the reasons and ensure attachment issues and the child's mental health and substance abuse needs are being considered.
- To minimize the negative effect of turnover in workers, training should be provided to workers on the effect of removal from home and/or transitions on children and their ability to form attachments, effective interventions for dealing with attachment trauma, and signs that a child should be referred for mental health and substance abuse treatment.
Nondiscrimination in Access to Services for Children in Care
- All children in foster care have the right to express their views through their words and behavior, to the extent that is developmentally appropriate, or be represented by an adult who offers the child's perspective on the following:
- Access to quality mental health and substance abuse services and supports.
- Which mental health and substance abuse services assist them, based on their strengths and needs.
- The development, monitoring, and revision of their mental health and substance abuse treatment plan, which is in keeping with their permanency and family service plan.
- Which mental health and substance abuse services and supports work for them.
- Refusal of mental health and substance abuse services and supports, unless their refusal would put them at risk of harm.
- Provision of services and supports in the least intrusive environment possible.
- Their constitutional rights when placed in foster care.
- The affect of placement decisions on their mental health.
- When very young or developmentally immature, consideration of the effect of placement decisions on their mental health.
- Frequent, ongoing contact with siblings and other family members when the family cannot be maintained as a single unit.
- All families with children in foster care (except when parental rights are terminated or other legal decisions take precedence) have the right to:
- Participate in the mental health and substance abuse treatment services and supports that will assist them and their child, based on their strengths and needs.
- Participate in the development, monitoring, and revision of their child's mental health and substance abuse treatment plan.
- Decide which mental health and substance abuse services and supports work for them.
- Refuse mental health and substance abuse services and supports when their refusal does not put their child at risk of harm.
- Have access to quality mental health and substance abuse services and supports.
- Be provided services and supports in the least intrusive environment possible.
- Retain their constitutional rights when their child is placed in foster care.
- Through a release of information form, emancipated youth and family members can provide consent on who gets information about them.
- Children and their families have the right to be treated in compliance with federal, state, and local policies and standards.
- Children and their families have the right to seek advocacy support.
- Children and their families have the right to raise concerns about the mental health and substance abuse services and supports that they receive without retribution. All agencies should have a defined process for how such concerns can be addressed.
- Children and their families have the right to receive services that are culturally competent and to choose providers who value their language, culture, and beliefs.
- Children and their families have the right to access the courts to address concerns about the mental health and substance abuse services they are receiving or believe they should be receiving.
A Comprehensive and Accessible Array of Services
- There should be no discrimination on the basis of race, religion, ethnicity, language, gender, age, sexual orientation, marital status, or disability.
- Providers should deliver services and supports in compliance with the Americans with Disabilities Act.
- Public and private providers must ensure services are accessible without discrimination, including interpreters if needed.
Individualized Service Planning
- Given the complexity of serving children and families, it is crucial to have a comprehensive array of services. This includes traditional, faith-based, nontraditional, formal, and informal supports and services.
- This service array should be appropriate to address treatment needs of children and families.
- Services chosen from the array should be age and developmentally appropriate.
- This service array should support children and their families in the community if possible.
- This service array should take into account the ongoing developing strengths of children and their families.
Services in the Least Intrusive Community-Based Environment
- Service planning to address the mental health and substance abuse needs of children should be individualized and include the following:
- focus on the strengths, desires, values, and goals of the child and family;
- assessment of the specific needs of the child and the services and supports the family requires to support a child with these mental health and substance abuse needs;
- measures to address issues of emotional distress arising from transitions;
- consistency between the child's permanency plan and the family service plan;
- informal and formal mental health and substance abuse services and supports; and
- measurable goals identified by the child and family.
- This individualized service plan should include the continuation of treatment when the child is reunified with his or her family. If a child is not receiving services or supports at the time of reunification, it is important to initiate any treatment services that are needed as part of the reintegration process.
- The individualized service plan should be developed in partnership with the child and family and other professionals working with them.
- The individualized service plan should be reviewed and updated to reflect the progress of the child, with input from the child and family when appropriate.
- The individualized service plan should include the discharge and transition plans.
Family Participation in All Aspects of Planning, Service Delivery, and Evaluation
- Service planning should focus on providing services and supports for children and families at the appropriate level and intensity and in the least intrusive environment to increase the child's functioning and physical stability.
- Every effort should be made to keep children in their community whenever possible. Risk to the child takes precedence over the placement that is least intrusive.
- There should be an easily accessed array of community-based services that support children receiving treatment. This might be over a widespread region, particularly in rural areas where it is not financially feasible to have all services in each community.
- When services are being designed, family and community input should be part of the process.
- When children need to be placed outside the home community, it is essential that treatment be provided to maintain the family connection.
Integrated Services with Coordinated Planning Across the Child-Serving System
- The family should be part of the engagement process at all levels of planning, service delivery, and evaluation.
- The family should be involved in activities involving the child when possible.
- Families should be given the choice to participate or not.
- Family choices should be considered in all planning for the child outside of situations that put the child at risk of harm.
- Families should be treated with respect and provided advocacy and representation.
- Children in the foster care system with mental health and substance abuse issues are often involved with multiple organizations and systems. They require well-coordinated planning and integration of services.
- To ensure the most effective service delivery, services should be coordinated across the child-serving system.
- Often, children in the foster care system initially access services through primary care. The EPSDT screening process should facilitate coordination of services to meet needs.
- When funding streams cannot be combined, there is greater potential for integrating services when planning is coordinated across systems. Integrated planning makes better use of limited dollars and reduces potential duplication of services while increasing the availability of services and supports for the child and family.
- Consistency in planning across systems is important to ensure the child and/or family does not hear conflicting messages or has treatment approaches that are contraindicated. All systems must work to mitigate the burden caused by uncoordinated planning between agencies and families.
- The goal is one document in which the plans of various child-serving systems are incorporated into the foster care system case plan. The plan should be reasonable, useful, and respectful.
Glossary of Terms
Child. Any child placed in out-of-home care.
Child-focused. A system is child-focused when both the physical and emotional well-being of the child is central to all levels of decisionmaking, and a process is in place for resolving conflicts between these two domains. The child's own views are expressed, where possible, directly through the child's words and behaviors or, as required, through an adult whose offers the child's perspective along with the viewpoint of members of the child's family.
Child safety. A child is considered safe when an analysis concludes that the child is not in immediate danger of serious harm and no safety interventions are necessary.
Cultural competence. A system is considered culturally competent when there is professional, formalized competence throughout the system in policies, procedures, outreach, advocacy efforts, and training. Cultural competence, sensitivity, and relevance is demonstrated through the array of services, delivery, framework, and recognition of the importance of community-based, informal support networks, such as churches, extended kinship networks, and social organizations. Cultural competence is demonstrated when there are skilled staff who are aware of cultural issues within the community and who understand the diversity of the community.
Family. Families can include birthparents, foster and adoptive parents, grandparents, as well as kinship caregivers and others who have primary responsibility for providing love, guidance, food, shelter, clothing, supervision, and protection for children and adolescents. It is the extent of daily interaction with and responsibility for a child, not a legal construct, that identifies a family member.
Family-driven. A system is family-driven when the family is involved in all decisionmaking. Identification and engagement of the family receiving services is required so the family's experiences and perspectives drive the planning and outcomes for the foster child. This moves the system beyond being centered and focused on the family to having service delivery be more family-driven.
Prevention and early intervention
Substance abuse. Refers to the use of alcohol or illicit drugs and the misuse of prescription drugs.
- Primary prevention. Efforts to avert mental health and substance abuse problems altogether. For children, these efforts include interventions directed at parents or professionals involved with children.
- Secondary prevention. Efforts to detect mental health and/or substance abuse problems in their early stages of development and to apply techniques to reduce the severity and duration of incipient problems.
- Tertiary prevention. Attempts to arrest further deterioration in individuals who already suffer from severe mental health and/or substance abuse problems. Treatment is tertiary prevention.
System of care. A system of mental health, substance abuse, social services, education, medical, physical health, primary care, juvenile justice, and other organizations, and formal and informal services that work with the family to meet the child's needs.
Values Discussion Points
- Child-Focused Mental Health and Substance Abuse Services and Supports
- Attachment issues are significant to the mental health of children in all placement decisions. The trauma children endure when moved from placement to placement is not conducive to normal development. When placing children outside the home, it is essential to help them create meaningful new attachments while maintaining existing attachments if possible.
- Children's views of how their mental health will be affected by placement decisions should be represented in all proceedings, in keeping with the age and maturity of the child.
- The current child welfare system tends to focus on the physical safety of the child while not adequately considering the effect of removal on the child's emotional/mental health.
- Practice guidelines must be established to address not only safety issues but also children's emotional, mental, and behavioral health needs.
- Foster care providers need resources to address the mental health and substance abuse needs of the children they serve. Ensuring that services are delivered in a timely, appropriate manner is necessary.
- The child and birthfamily should maintain contact while the child is in care. Assessment decisions need to be made to determine if the birthfamily can be in immediate and continuing contact to decrease the severity of separation trauma. Whenever possible, the birthparents and foster parents or other agency caregivers should communicate with each other to maximize continuity and mutuality in accomplishing therapeutic goals.
- Providing mental health intervention at the time of the initial placement and while in care helps prevent attachment disorders and/or the progression of already existing mental health and substance abuse problems.
- Reunification with the family of origin may not always be the best option for the child. Other options must be considered to ensure the child's well-being.
- Family-Driven Mental Health and Substance Abuse Services and Supports
- For child welfare services, a family-driven policy that does not compromise the child's safety is necessary.
- The foster care system is currently focused on the child. To really meet the child's needs, it should place greater emphasis on the family of origin. This family-centered approach could result in a major change of mindset within the child welfare system.
- The child welfare system is concerned with safety, permanency, and well-being. Every child should have a safe home as soon as possible, but not necessarily with the family of origin.
- To every extent possible, the birthfamily should be involved, even when it is not the custodial family.
- Integration, Collaboration, and Coordination of Community-Based Mental Health and Substance Abuse Services and Supports with the Foster Care System
- Best practices in mental and behavioral health services and supports should be available to children in foster care and their families.
- Mental and behavioral health care providers must have a clear, defined role, driven by professional expertise and values, in treating children and families.
- To ensure child safety and achieve quality services and supports for children and families, it is crucial to increase the input of community members and professionals.
- There may be differences in how states define safety. How local communities participate in setting community standards further affects the differences in definition.
- The child's comprehensive health assessment must include the elements of the EPSDT screening and assessment, such as physical, dental, substance abuse, mental health, and comorbidity evaluations.
- Foster parents must be provided with effective ways their child's needs can be met.
- Culturally Competent, Relevant, and Strengths-Based Services and Supports, Provided by Knowledgeable, Skilled Service Providers Who Understand the Cultural Diversity of the Community
- Assessment tools and mental health and substance abuse services and supports must be culturally competent, be culturally sensitive, and take into account the strengths of children and families. They should take into account the cultural status, economic status, and diversity of the population being served.
- There should be culturally competent policies and professional competence in procedures, outreach, advocacy, and training throughout the service delivery system.
- To facilitate rapport and successful outcomes, the team delivering services and supports to children and families should, if possible, represent the diversity of the population.
- Timely, Effective, Evidence-Based, Outcome-Driven Mental Health and Substance Abuse Services and Supports
- The trauma children experience when they are placed in the foster care system must be taken into account when assessing their needs and providing services and supports. An initial mental health and substance abuse screening should be done within 24 hours of placement. The mental health and substance abuse screen identifies children in urgent need of emergency services. This screening assesses internalized and externalized levels of distress in the child regarding separation from their family of origin. A triage intervention to address the child's feelings and help the child cope should be provided as quickly as possible.
- All children in foster care, and their families, must have a comprehensive mental health and substance abuse assessment once the child is stabilized, minimally within the timeframes of EPSDT. The assessments should always address the child's attachment issues and be done in a timely fashion, especially when there is transition between placements.
- The child welfare system must take into account the difference between a child having a mental disorder and/or substance abuse problem and a child requiring mental health and substance abuse intervention to prevent a future disorder. Currently, a mental health and/or substance abuse assessment is often not done until there is a crisis.
- Just as it is necessary for periodic reviews to be done on individual case plans, it is necessary for systems and providers to perform evidence-based, outcome-driven reviews of results to demonstrate progress in achieving the goals for children and families.
- To provide compassionate, relevant services, it is essential to reach for and use feedback from children and families about service effectiveness.
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