Children's Voice May/June 2009

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Modeling a Continuum of Care

Boys Town's sites determine the right care for the right time to help families

Father Stephen Boes is executive director of Boys Town, a national child- and family-serving organization founded and based in Nebraska. He had a front-row seat to the state's crisis over its safe haven legislation last fall, and like others in the field, his concern keeps growing as the recession translates into cuts in social service programs nationwide. Cuts are the opposite of what struggling families need, according to Boes. "I don't know if the need is unlimited, but I bet you could quadruple the budget for child welfare and people would still drop kids off," he says. "I don't know if there's ever enough."

Father Steven Boes, executive director of Boys Town, with some of the children served at the founding site in Nebraska.

Boes advocates smart investment; Boys Town, which directly serves more than 51,000 boys and girls a year, has recently been focusing on making care more fiscally responsible. Spending money on front-end, preventive services will reduce the need for more expensive back-end interventions. To facilitate this shift, Boys Town has defined a continuum of care that is implemented in all of the organization's 13 sites, which are spread across 11 states.

The Boys Town continuum includes seven steps, all of which include four key components: education services, medical care, care coordination, and spiritual/religious support. The first step is child and family support services, which consists of outpatient child and family services, community education services and support, the Boys Town national hotline (800-448-3000), their Common Sense Parenting program, and website, The second step is in-home family services, with family-centered services, family preservation services, and aftercare services. Foster family services and treatment family services are the next two options, which include traditional foster care and treatment foster care or treatment family homes. An intermediate level after that is intervention and assessment services, which at Boys Town is characterized by a multilayered assessment and a short-term residential, intervention, and assessment home. Deeper levels of intervention care are broken down into two steps: specialized treatment group home services and intensive residential treatment center services.

The total environmental assessment is one of the major pieces Boys Town hopes to utilize better as part of its strategic plan. They evaluate body, mind, and spirit of the children they serve. (While Boys Town doesn't discriminate, the organization does have a historical link and ongoing connection to the Catholic Church-which includes naming a priest as executive director. Boes thinks this helps: "We have the courage to ask the faith question.") Their thoroughness pays off, in that they are able to provide a child with appropriate care directly after the assessment in more than four out of five cases. "With a greater than 80% success rate, we're able to pick the right level," Boes says.

Boys Town may get the ability to practice their assessments more often as many states reform their child welfare systems and move to privatization for some services. Dan Daly, Director of Youth Care, said that officials in the states where Boys Town operates will often bring them a child and a specific proposal for which program the child needs. Sometimes, this is a lower level of care than Boys Town would recommend. In the future, Boys Town hopes to get only general referrals, and decide what's in the child's best interests based on the assessment.

The seven-level continuum of child and family services is part of Boys Town's new strategic plan.

Daly and Boes agree this would be another type of smart investment: "Pennywise and dollar foolish, we think that often states make the wrong decision about levels of care based on money," Boes says. Even when an initial assessment underestimates the type of care a child should receive, it's easier to move him or her up within an established, coordinated system because it facilitates a quick move back down the spectrum. Too often it's a crisis that pushes children and youth into more intense services. "You don't want kids to fail up, and that has been the biggest problem in the United States," Boes says. "Kids have to prove they're sick enough."

Even if the Boys Town continuum is only a starting point, and is only used at the Boys Town locations, Boes wants to spread the concept of a coordinated system of care: "We want to change the way America cares for children and families."

The New Family Tree A recent story in The Boston Globe highlighted parents and child advocates who are trying to increase teachers' sensitivity to elementary school assignments that involve family and identity. Adopted children may not have baby pictures; those in closed adoptions don't know their birth parents, while those in open adoptions may find it hard to fit their full family in the basic "tree" structure. And adoption isn't the only type of blended family: single parents, stepparents, and gay parents are common today. Alternative assignments include a family orchard, with several trees, or a river with tributaries feeding into it.

Stopping the Suicide Trend

In Illinois, a 10-year-old and two 11-year-olds took their own lives in February, the Chicago Tribune reported. According to the BBC, calls to Belfast's ChildLine, which counsels suicidal youth, have tripled in the last five years. And recently in Ghana a 13-year-old prostitute tried to hang herself. Earlier this year the National Academies of Science released a report on progress and possibilities to prevent mental, emotional, and behavioral disorders in youth, which they say costs the United States $247 billion annually. More recently, the U.S. Preventive Services Task Force advised all youth ages 12 to 18 be screened for depression.

Greening Child CareChild care agencies are getting in on the greening trend in America with the Eco-Healthy Child Care program run by the Oregon Environmental Council. The program creates healthier environments in and around child care facilities by educating providers about how to maintain environmentally healthy settings and services, assisting in implementation of changes in practices and purchasing, and promoting endorsed facilities. Currently, over 950 child care facilities in 43 states, three Canadian provinces, and Puerto Rico have completed the 25-item checklist to reduce environmental health hazards. Steps are low- or no-cost. For more information, visit

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