Good afternoon, Senator DeWine, members of the District of Columbia Subcommittee and staff. I am Martha B. Knisley, Director of the DC Department of Mental Health. Thank you for this opportunity to share with you the status of the service delivery to children, youth and families in the DC foster care/child welfare system.
On behalf of all DMH employees, and District children, youth and families, our heartfelt appreciation for your vision and support to ensure evidence-based mental health services now are available to those with the greatest need.
Mayor Anthony Williams has devoted himself to a long-range effort to improve services to children in foster care, starting with his commitment to end the Department of Mental Health and Child and Family Services Agency receiverships that were in place when he took office.
He reasoned that the faster our two agencies came out of receivership, the faster we would be able to deliver necessary services to begin helping people improve their lives.
At Mayor Williams’ urging, our two agencies began meeting to develop a long-term plan wherein the DMH would begin to take responsibility for providing and arranging for mental health services for children under the supervision of the CFSA.
Because of this commitment and our joint efforts to identify how this cooperation could work to the benefit of children, youth and foster families, CFSA, the LaShawn Court Monitor and advocates identified mental health services as key areas for improvements in their deliberations with you and District leaders.
Hence, in the summer of 2003, we began meeting to carve out both a long-term plan that addresses the areas of most critical need for foster children, their foster parents and the children’s birth parents, where appropriate.
The $3.9 million provided in FY 2004, and $1.25 million in FY 2005 have spurred development of an array of services to meet those urgent needs that would not have happened this fast without your remarkable commitment to the nation’s capital and Mayor Williams’ foresight.
Building the System of Care
The District is committed to building a comprehensive, state-of-the-art system of care for mental health service that meets the needs of the children, youth, and families of the District.
When we speak of the fragility of children’s lives, especially those in the child welfare system, the foster care system or the juvenile justice system, we are talking about disruption of family, frequent change of residence and the resulting emotional trauma. Our role is to build resilience within these children, youth and families so they can go forward.
Studies profiling the mental health status of children involved in child welfare indicate that children in foster care are three to ten times more likely to have mental health problems than children on welfare. The trauma of separation, multiple placements, and transitions once children are involved in the foster care system often exacerbate mental health problems in children and families.
These issues are frequently compounded by a lack of appropriate, quality mental health services, by long waits for assessment and treatment, and by a system that has not been organized or funded to meet the particular needs of children, youth, and families that are experiencing a high level of stress. These factors further jeopardize children’s placement in permanent and loving homes.
The resources provided by the Committee have allowed us to take aggressive action to strengthen the accessibility, timeliness, and quality of mental health services to children and families to:
o Significantly expand our capacity for screening and assessments for children in foster care.
o Build an array of providers with the ability to provide timely, appropriate and even cutting edge mental health services to children in foster care, focusing on services that have been shown by research evidence to be successful.
o Significantly expand the treatment capacity of agencies and clinicians by increasing their knowledge and expertise in a wide array of service interventions.
HOW DMH IS MAKING A DIFFERENCE
Many children and youth in foster care are living with the emotional distress of uncertainty, violence and lack of control over their own lives. They are at greater risk of becoming part of the juvenile justice system; therefore, any delay in identifying and providing the mental health services and supports they need prolongs their suffering.
We have two goals:
1. Reduce the backlog of court-ordered evaluations of foster care children’s mental health needs.
2. Create a new infrastructure of evidence-based mental health services to be available to foster care children.
DMH moved quickly with CFSA and community partners to meet these goals.
DMH immediately increased its capacity for screening and assessments by:
- Contracting with 10 additional child forensic psychologists, including one who is a neuro-psychologist.
- Contracting with three additional Board Certified Child Psychiatrists.
- Hiring one additional social worker to assist in handling increased neglect referrals, serves as the Mayor’s Liaison Officer to the Family Court, and works with juvenile and domestic relations referrals.
The results included:
- Reduced wait time for psychiatric exams from three months to three weeks by the end of the FY 2004 fiscal year. Demand has increased and so has our wait time in the past two months. We will add resources to the extent possible to reduce the wait again to three weeks or less.
- Reduced wait time for psychological exams from two months to less than three weeks, but again we are experiencing a higher demand and will need to add resources to meet this need if the demand continues to rise.
- Established a supervisory clinical rotation with Children’s Hospital to train child psychiatrists in forensic child psychiatry, with two staff serving in pending faculty positions. The supervisory faculty psychiatrist also has received his board certification in addiction.
- Increased capacity to work with individuals representing diverse cultures and who speak languages other than English:
- One psychologist speaks Arabic.
- Two psychologists speak Spanish.
- One psychologist speaks French.
- One psychiatrist speaks Spanish.
- Meanwhile, the number of assessments conducted in FY 2004 represents a 44 percent over FY03 and has increased by 41 percent in the first five months of FY05 over the same time period in FY04.
Our second goal became a reality January 24, 2005 when our three new services – Multi-systemic Therapy, Intensive Home- and Community-Based Services, and Mobile Response and Stabilization Services – came on line.
While it is too early to begin calculating the effects of these services, nevertheless, having them in place furthers our effort to create a comprehensive network of services. I also want to point out that more than 82 percent of these funds or $2.8 million has been allocated for direct services to children, youth and families. I will describe these services briefly:
Across the country where Multi-Systemic Therapy (MST) has been implemented successfully, youth are half as likely to be re- arrested, and they have reductions in arrests for violent and substance-related crimes. Additionally, they have improved family relations. This service focuses on preventing older children and teens from entering residential treatment and allowing others to return from residential treatment to less restrictive, more family-like settings.
These funds allow for the treatment of 96 youths, ages 10 to 17, with complex behavioral issues, for upward of six months. Qualified, experienced therapists will visit the youth at least three times per week in the community where they live, whether at home, in foster homes, or in local group homes. Therapists will also be on call around the clock in case of emergencies involving their clients. This service will focus on preventing older children and teens from entering residential treatment and allowing others to return from residential treatment to less restrictive, more family-like settings. MST has admitted 27 consumers and two are awaiting assessments.
Intensive Home- and Community-Based Services (IHCBS) will allow for the in-home treatment of 72-90 youth and families during the first year. This provider already is working at maximum capacity with 36 youth. Qualified, experienced counselors will work with children with serious emotional disturbance and behavioral problems in their homes several times per week. This service is designed to help families resolve serious issues and prevent removal of children from the home.
Mobile Response and Stabilization Services (MRSS) will allow parents, foster and pre-adoptive parents, kinship caregivers, and group care providers to access emergency assistance from qualified professionals for children and youth, ages five to 21 years old, displaying extreme behavior but not requiring hospitalization. Professionals can stay on site to provide emergency response for up to 72 hours. On a case-by-case basis, they can also develop eight-week stabilization plans. This service is designed to help reduce placement disruptions for children and teens with emotional and behavioral issues.
Caregivers of children and youth involved with the District’s child welfare system can reach this service through DMH’s 24-hour Access HelpLine. While the capacity of these services is initially limited, they mark the beginning of a more comprehensive and nuanced approach to meeting the mental health needs of children, youth, and families within the local child welfare system.
How DMH is Expanding Clinical Capacity
DMH is significantly expanding the treatment capacity of agencies and clinicians by increasing their knowledge and expertise in a wide array of service interventions. The following training opportunities have been or are being offered:
- The National Council for Community Behavioral Healthcare (NCCBH) provided technical assistance to nine child serving agencies and provided community support training to twenty-six staff.
- The American Academy of Child and Adolescent Psychiatry provided CALOCUS training to child-serving agencies working with CFSA children.
- DMH has contracted with another provider to offer another 30 hours of community-support training to up to nine agencies and staff.
- DMH has contracted with National Association of State Mental Health Program Directors and National Child Trauma Stress Network to assess the treatment capacity of agencies to deliver quality services to youth who have experienced or who are experiencing trauma.
The Trauma Learning Collaborative Project
- DMH has allocated $228,515 of the congressional appropriation to support a Learning Collaborative Project focusing on the practice of evidence-based cognitive behavioral therapy for clinicians serving DC foster care children and youth.
- The major focus of the project is an in-depth training in Abuse Focused Cognitive Behavioral Therapy, a treatment model that has received support from several randomized clinical trails and has been adapted specifically for use with children in child protection and foster care systems.
- The project will be initiated this month with a baseline assessment that will use a combination of tools and oral interviews to identify current knowledge and use of evidence-based practices, current therapy procedures, and identify attitudes and potential barriers to adoption of evidence-based practices.
- Experts from the Center for Child and Family Health (CCFH) in Durham, North Carolina, a learning collaborative for maltreated and traumatized children and adolescents, will facilitate. CCFH is a collaborative undertaking by the University of North Carolina at Chapel Hill, North Carolina Central University, Duke University and Child and Parent Support Services, a nonprofit corporation, and has been designated as a community practice site in the Substance Abuse and Mental Health Service Administration (SAMHSA)-funded National Child Traumatic Stress Network, whose mission is to raise the standard of care and improve access to services for traumatized children, their families and communities throughout the United States. The National Association of State Mental Health Authorities (NASMHD) serves as DMH’s primary contractor for the project. NASMHPD will provide technical assistance to DMH concerning system change with respect to integration and replication of best practices.
- Learning sessions are scheduled at the Gallaudet University Kellogg Conference Center April 28-29, June 9-10 and August 12, 2005. Between sessions clinicians will receive regular consultation via conference calls with the training faculty. Each clinician will receive a toolkit that includes a treatment manual and resources related to the practice of best practices in trauma treatment.
- DMH has invited 57 child and youth-serving clinicians from the Department of Mental Health’s community system of care to participate in the project and clinical program administrators from Child and Family Services and the Department of Mental Health’s School Mental Health Program and CINGS System of Care Project will also participate.
- The project will culminate by the close of FY05 with a final report that will include an evaluation assessing program change (from the baseline) and recommendations for ongoing implementation of evidence-based practices across the DMH child and youth-serving system of care.
Projecting into the Future
DMH is committed to sustaining the gains made thus far. We are creating the means for providing the three services as part of our Mental Health Rehabilitation Services system, which will allow the three aforementioned services to be reimbursed in part by Medicaid. We are encouraged that the services we have put in place will reduce out of home treatment costs and will carefully monitor outcomes overtime.
We have two concerns however for the future. One is the level of need and whether the current level of resources and Medicaid reimbursement, which requires a 70% local match is sufficient to meet the service needs of foster care children and their families. Secondly we continue to see escalating requests for formal psychiatric and psychological assessments. We are monitoring this demand closely.
In conclusion, Sen. DeWine and Subcommittee members, I would like to again express my appreciation for your support. I will be happy to answer your questions.