Transcript Overview of Evidence-based Practices for Youth in Connecticut

Overview of Evidence-based Practices for
Youth in Connecticut
Robert P. Franks, Ph.D.
Director
Connecticut Center for Effective Practice (CCEP)
Child Health & Development Institute
Outline
I.
History & Description of the Connecticut Center for
Effective Practice
II.
Context for Best Practices: Positive Youth Development
III.
Rationale for Using Evidence-based Practices
IV.
History of Adoption and Implementation of Evidencebased Practices in Connecticut
V.
Current EBPs Being Utilized & Numbers of Youth Served
VI.
Lessons Learned from MST Implementation: Ongoing
MST Progress Report
History & Description of the Connecticut
Center for Effective Practice
History & Description of the Connecticut Center for
Effective Practice
Founded five years ago in response to identified need in
the State to have a mechanism for providing
information on best practices in child mental health
and to implement evidence-based practice on a large
scale.
First major project was working with DCF to implement
Multisystemic Therapy (MST) across the state.
Connecticut Center for Effective Practice
(CCEP)
Five active partners:
– Department of Children and Families (DCF)
– Court Support Services Divisions (CSSD)
– University of Connecticut Health Services (UCHC), Department of
Psychiatry
– Yale University School of Medicine
• Child Study Center
• The Consultation Center
– Child Health & Development Institute (CHDI)
Funding sources:
– State agencies, private foundations, grants
CCEP Vision and Mission
• The purpose of the Connecticut Center for Effective Practice
(CCEP) is to enhance Connecticut's capacity to improve the
effectiveness of treatment provided to all children with serious and
complex emotional, behavioral and addictive disorders through
development, training, dissemination, evaluation and expansion of
effective models of practice.
CCEP
A place to connect the dots…
Achieving Vision:
Engaging Stakeholders
Engage stakeholders in activities that promote systemic change
or act as catalyst for change across Connecticut at multiple
levels:
• Through work with state agencies who serve children
and families
• Through work with major academic institutions
• Through work with policy makers and legislators
• Through work with providers of services
• Through work with consumers (parents, caregivers and
children)
Achieving Vision:
Four Overarching Strategic Goals of CCEP
 Identification, adoption, and implementation of evidencebased and best practices
 Research, evaluation and quality assurance of new and
existing services
 Education and raising public awareness about evidencebased and best practices
 Development of infrastructure, systems and mechanisms
for implementation and sustainability
Context for Best Practices:
Positive Youth Development
Context for Best Practices:
Positive Youth Development
(Commission on Positive Youth Development, 2004)
• Focuses on youth’s talents, strengths, interests and
future potential
• Traditional models focus on deficits
• Criminal justice models focus on punishment over
prevention and rehabilitation
• Positive youth development recognizes adversities
• Builds on strengths and resiliencies
• Emphasizes ecological approach
Core Ideas of Positive Youth Development
• Adolescents can overcome adversity and thrive by
building on resiliencies and strengths
• Resiliency alone is not enough – Adolescents are not
impervious to unrelenting adversity
• Youth that thrive must have both positive individual
characteristics and positive characteristics of their
families, schools and communities
What are the characteristics
of programs that support
positive youth development?
(From meta-analysis published in 2005)
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Comprehensive, time-intensive
Earliest possible intervention
Timing is important
High structure is better
Fidelity to model is key to effectiveness
Characteristics of programs that support
positive youth development
6.
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Need adult involvement
Active, skills-oriented programs
Programs that target multiple systems
Programs that are sensitive to the individual’s
community and culture
10. Programs based on strong theoretical constructs
and proven effective by evidence
Rationale for Using Evidence-based Practices
Evidence-based practices are
arguably our best approach to
provide consistent, reliable,
effective interventions that
result in promoting positive
youth development.
Rationale for Using Evidence-based Practices
 Changing “landscape” of practice in mental health, juvenile
justice, social work
• Push for Accountability…”where is the data?”
• Increased quality and relevance of research
 Emergence of the concept “Best Practices”
• What is a best practice?
• More than…”what we already do”
• More than a theoretical approach
Rationale for Using Evidence-based Practices
 Systematic clinical intervention programs that are
integrative in nature (practice, research, theory)
And use systematic clinical protocols ”clinical maps”
• Manual driven
• Model congruent assessment procedures
• Focus on adherence and treatment fidelity
 Models that have strong science/research support
 Clinically responsive and individualized
to unique “outcome” needs of the client/family
to the unique “process” needs of the family
 Are able to guide practice with high expectation of success
with specific client problems
within specific community settings
Biases against Evidence-based Practices
“They are too rigid and cookbook”
“Doesn’t apply to real world kids with real world, multi-problem histories”
“Developed in some lab”
“Overly simplistic”
“Too difficult to implement in community setting”
“Just a band-aid and doesn’t address underlying issues and concerns”
“Another passing fad”
“My training and expertise are not valued”
Barriers to Implementation of Evidence-based
Practices in Connecticut
• Economic barriers
– Community-based and independent providers
“barely getting by”
– No mechanism for supporting supervision and training
necessary for implementing EBP’s in a fee-for-service
environment
– Providers do not see that up front investment will yield longer
term gains
– Turnover is high
– Medicaid and managed care do not routinely reimburse or
create incentives to deliver EBPs
Barriers to Implementation of Evidence-based
Practices in Connecticut
• Workforce Issues
– Older clinicians may not share theoretical perspective and see
EBPs as incompatible with their worldview
– Current clinicians may not receive adequate training and not
sufficiently prepared exiting graduate programs
– Turnover is high and clinicians are underpaid
– For some types of EBPs work can be intensive and not
“traditional”
– Difficulty finding appropriate supervision
Types of Evidence-based Practices
in Child Mental Health & Juvenile Justice
Outpatient Services/Community-based Services
– E.g., treatments for anxiety disorders, conduct disorders, child abuse
and trauma related disorders such as CBT and TF-CBT
School-based services
– E.g., Postive Action (PA) and Cognitive Behavioral Intervention for
Trauma in Schools (CBITS)
In-home Family-focused Services
– E.g., treatments for conduct and substance abuse problems such as
Multisystemic Therapy (MST), Functional Family Therapy (FFT) and
others
Foster Care Programs
– E.g., Multidimensional Treatment Foster Care (MTFC)
Residential or Inpatient Services
– E.g., Sanctuary Model
History of Adoption and Implementation of
Evidence-based Practices in Connecticut
Factors contributing to implementation
of EBPs in Connecticut
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Identification of need
Acknowledgement that existing services were not working well
Negative media attention
Available resources through grant funding
“Champions” within state government
Legislative and policy changes
Economic factors
Ease of implementation of model
Success of pilot programs
Connecticut’s History
of EBP Development
Legislative
DSS/DCF
Report
DCF
Program Review: 1997
Memorandum of Understanding: 1999
on Financing/Delivering Children’s Mental Health Services: 1999
developed first Multisystemic Therapy team: 1999
Connecticut
Blue
Community KidCare Legislation: 2000
Ribbon Mental Health Commission Report: 2000
Development
Connecticut
Statewide
of the Connecticut Center fro Effective Practice 2001
Policy and Economic Council (CPEC) Report: 2002
Implementation of MST and other EBPs: 2002 - present
CT’s Community KidCare’s Legislation
New and Expanded Service Continuum
“Enhancing the Traditional Service Model”
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Emergency Mobile Psychiatric Services
Care Coordination
Extended Day Treatment
Crisis Stabilization Beds
Therapeutic Mentors
Short-term Residential Treatment
Individualized Support Services
Intensive In-Home Services
Other Contextual Factors Leading
to Systems Change
• Legal action: Two major consent decrees for the Department of
Children and Families impacting child protection and juvenile justice
(Juan F and Emily J)
• Data: Statewide evaluation of juvenile justice programs that called
for systems change (CPEC Report, 2002)
• Media: Ongoing media coverage of problems at state’s Department
of Children & Families
Implementation of Evidence-based Practice
in Connecticut
1999 - Pilot Multisystemic Therapy (MST) Team in
Department of Children and Families
2001 - CT Center for Effective Practice formed to
disseminate MST across the state
2001 to Present - Dissemination of MST and other
in-home evidence-based practices for juvenile
justice youth
Implementation of Multisystemic Therapy:
WHY MST???
• Identified need to target “deep end” children who were accounting
for most of resources
• Acknowledgment that existing “business as usual” was not
working
• Much emphasis on juvenile justice population
• Policy focus on keeping children in their communities and
providing intensive in-home services through KidCare legislation
• Strong evidence-base
• Well-defined implementation and delivery system for MST
• Champions within the State
MST Growth in CT
30
25
20
PILOTS
CSSD
DCF
15
10
5
0
1999 2000 2001 2002 2003 2004 2005 2006
Growth of MST led to implementation
of a range of other evidence-based practices
for juvenile justice youth in Connecticut
Current Evidence-based Practices
Being Utilized in Connecticut
& Numbers of Youth Served
(2007)
Evidence-based Practices for Youth
in the JJ System in Connecticut
1) Multisystemic Therapy (MST)
2) Multidimensional Family Therapy (MDFT)
3) Functional Family Therapy (FFT)
4) Brief Strategic Family Therapy (BSFT)
5) Multidimensional Treatment Foster Care (MTFC)
6) Intensive In-home Child and Adolescent Psychiatric
Services (IICAPS)
Multisystemic Therapy (MST)
Program Overview:
Multisystemic Therapy (MST) is an intensive family- and communitybased treatment that addresses the multiple determinants of
serious antisocial behavior in juvenile offenders. The
multisystemic approach views individuals as being nested within
a complex network of interconnected systems that encompass
individual, family, and extrafamilial (peer, school, neighborhood)
factors. Intervention may be necessary in any one or a
combination of these systems.
Program Targets:
MST targets chronic, violent, or substance abusing juvenile
offenders at high risk of out-of-home placement and their families.
Multisystemic Therapy (MST)
Current Number of MST programs in Connecticut:
10 (DCF)
15 (CSSD)
Current Number of MST Specialty Teams:
3 (DCF)
Current Capacity for Children Served:
350 (DCF)
625 (CSSD)
975 Total Capacity
Multidimensional Family Therapy (MDFT)
Program Overview:
Multidimensional Family Therapy is an intensive in-home program. MDFT
focuses on several core areas of the teen's life simultaneously - parents,
schools, other family members and the community. The program also helps
the family understand the connections between drug use, criminal behavior
and mental health.
During treatment, skills are learned which enhance:
Positive peer relations; Healthy self-esteem; Connection to school and
community activities; Increased autonomy; Emotional connection to family
members
Parents and family members are also involved by learning and applying
skills which:
Improve the relationship with their child or sibling; Increase their knowledge
of successful parenting practices; Improve day-to-day and intimate
communication
Program Targets:
Adolescents ages 11-18 at risk for drug addiction.
Multidimensional Family Therapy (MDFT)
Current Number of MDFT Teams in Connecticut:
9 (DCF)
Current Number of MDFT Specialty Teams:
5 (DCF)
Current Capacity for Children Served:
395 (DCF)
395 Total Capacity
Functional Family Therapy (FFT)
Program Overview:
The FFT clinical model is identifies specific phases which organize
intervention in a coherent manner, thereby allowing clinicians to
maintain focus in the context of considerable family and individual
disruption. Each phase includes specific goals, assessment foci,
specific techniques of intervention, and therapist skills necessary
for success. Interventions focus on engagement/motivation,
behavior change and generalization of new behaviors and skills.
Program Targets:
Youth ages 10-18, and their families, whose problems range from
acting out to conduct disorder to alcohol/substance abuse.
Functional Family Therapy (FFT)
Current Number of FFT Teams in Connecticut:
4 (DCF)
Current Capacity for Children Served:
432 (DCF)
432 Total Capacity
Brief Strategic Family Therapy (BSFT)
Program Overview:
Brief Strategic Family Therapy (BSFT) is a problem-focused, and practical
approach to the elimination of substance abuse risk factors. It
successfully reduces problem behaviors in children and adolescents and
strengthens their families. BSFT provides families with tools to decrease
individual and family risk factors through focused interventions that
improve problematic family relations and skill building strategies that
strengthen families.
BSFT fosters parental leadership, appropriate parental involvement, mutual
support among parenting figures, family communication, problem
solving, clear rules and consequences, nurturing, and shared
responsibility for family problems. In addition, the program provides
specialized outreach strategies to bring families into therapy.
Program Targets:
Children and adolescents, 6 to 17 years with conduct problems;
associations with anti-social peers; substance use
and problematic family relations.
Brief Strategic Family Therapy (BSFT)
Current Number of BSFT Slots in Connecticut:
180 (CSSD)
Current Capacity for Children Served:
450 (CSSD)
450 Total Capacity
Multidimensional Treatment
Foster Care (MTFC)
Program Overview:
The goal of the MTFC program is to decrease problem behavior and to increase
developmentally appropriate normative and pro-social behavior in children and
adolescents who are in need of out-of-home placement. Youth come to MTFC via
referrals from the juvenile justice, foster care, and mental health systems.
MTFC treatment goals are accomplished by providing:
Close supervision; fair and consistent limits ; predictable consequences for rule
breaking ; a supportive relationship with at least one mentoring adult; and reduced
exposure to peers with similar problems.
The intervention is multifaceted and occurs in multiple settings. The
intervention components include:
Behavioral parent training and support for MTFC foster parents; family therapy for
biological parents (or other aftercare resources); skills training for youth;
supportive therapy for youth; school-based behavioral interventions and academic
support; and psychiatric consultation and medication management, when
needed.
Multidimensional Treatment
Foster Care (MTFC) -continued
Program Targets:
Children in the foster care system with multiple familial and
behavioral concerns.
Three forms of MTFC:
MTFC-P For preschool-aged children (3-5 years)
MTFC-L For latency-aged children (6-11 years)
MTFC-A For adolescents (12-18 years)
Multidimensional Treatment
Foster Care (MTFC)
Current Number of MTFC Teams in Connecticut:
3 (DCF)
Current Capacity for Children Served:
30 (DCF)
30 Total Capacity
Intensive In-home Child and Adolescent
Psychiatric Services (IICAPS)
Program Overview:
IICAPS is a Yale University model created to meet the
comprehensive needs of children with severe psychiatric
disorders. The program makes use of a consistent treatment
team to provide comprehensive assessments, case
management, individual and family treatment, and crisis
intervention. Intervention is informed by a synthesis of the
medical model, development psychopathology, systems theory,
and wraparound concepts.
Program Targets:
Children appropriate for IICAPS intervention may be returning
home from psychiatric hospitalization, at-risk for
institutionalization or hospitalization, or unable to benefit from
traditional outpatient treatment.
Intensive In-home Child and Adolescent
Psychiatric Services (IICAPS)
Current Number of IICAPS programs in Connecticut:
14 (DCF)
5 (CSSD)
Current Capacity for Children Served:
598 (DCF)
90 (CSSD)
688 Total Capacity
Evidence-based
Practice
# of Teams
# Children &
Adolescents Served
Annually
MST
10 (DCF)
319 (DCF)
625 (CSSD)
15 (CSSD)
MST Specialty Teams
MST- Problem Sexual
Behavior
MST-Building Stronger
Families
1 (DCF)
2 (DCF)
16 (DCF)
15 (DCF)
MDFT
9 (DCF)
270 (DCF)
MDFT Specialty Team
MDFT + Parental
Substance Abuse
5 (DCF)
125 (DCF)
FFT
4 (DCF)
350 (DCF)
BSFT
180 slots (CSSD)
450 (CSSD)
MTFC
3 (DCF)
30 (DCF)
IICAPS
14 (DCF)
5 (CSSD)
598 (DCF)
90 (CSSD)
Totals by Agency
DCF
CSSD
1723 (DCF)
1135 (CSSD)
Total by State
2858 total
Bottom Line:
Almost 2,900 children and adolescents
currently receive evidence-based practices
through DCF and CSSD annually in
Connecticut.
Lessons learned from
MST Implementation
Connecticut Evidence-Based Practices
System of Care Development
• Systems Changes
• Economic Changes
• Consumer Changes
• Practice Changes
• Quality Improvement
Lessons learned from
MST Implementation
Ongoing “Progress Report” being conducted by
Connecticut Center for Effective Practice
Examining quantitative outcomes of over 1,000 youth
receiving MST services through DCF and CSSD
Examining qualitative outcomes and implementation
factors for families, providers, agency staff, probation
officers, judges and others (over 30 focus groups).
Report with lessons learned available in July 2007.
Lessons learned from
MST Implementation
Preliminary results show positive outcomes and
reduction in recidivism
Ultimate Outcomes
Living at Home
Attending School
Not Arrested
N= 1,000
73.5%
76.1%
73.1%
Lessons Learned
 Must invest in Quality Assurance and Quality
Improvement of services
 Must build capacity, invest in ongoing training
of workforce, and provide ongoing technical
assistance to providers
 Fidelity to treatment models is key to
successful outcomes
 Outcomes data should be shared with parents
and stakeholders
Summary
• Evidence-based practices are best means of helping juvenile
justice youth.
• A range of evidence-base practices exist as alternatives to
detention/incarceration of youth in the justice system.
• These practices have demonstrated positive results nationally
(including in youth ages 16-18)
• Connecticut already has a range of excellent juvenile justice
services in place that can be expanded
• Ongoing need for training and technical support of providers,
attention to implementation and fidelity and ongoing evaluation
and quality assurance of programs.
QUESTIONS?
Bob Franks, Ph.D.
Director
Connecticut Center for Effective Practice
(CCEP)
[email protected]