CORE COMPONENT 1. ASSESSMENT AND PLACEMENT SERVICES FOR CHILDREN
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Placement stability is essential to the healthy adjustment and daily functioning of children and youth in foster care (Sudol, 2010). When children and youth are in stable placements while in foster care, they are able to experience the security and support they need to grow and develop in healthy ways, and they are more likely to find permanent families through reunification, adoption or legal guardianship (Sukol, 2010).
Despite the critical role of placement stability in children’s and youth’s healthy growth and development while in foster care, placement instability has continued to be a significant concern. A growing body of research has identified a number of child characteristics and conditions that are associated with placement disruptions and multiple foster care placements. Some of the factors are not subject to intervention. Studies, for example, show that children are more likely to experience placement instability when they are older when they enter foster care (Eggersten, 2008) and other studies have found that children in certain age groups are at greater risk of multiple placement moves (children ages 11 or older, Barth, et al., 2007; children ages 13 to 15, US Department of Health and Human Services, 2004).
Importantly, studies consistently document that children’s emotional and behavioral problems are linked to placement instability (Barber, Delfabbr, & Coper, 2001; Palmer, 1996; Smith, et al., 2001). One study found that the existence of a mental health problem doubled the likelihood of a child experiencing 3 or more foster care placements (Eggersten, 2008). Child depression, in particular has been associated with placement changes (Barth, et al., 2007), and children with externalizing behaviors such as oppositional behavior, fighting and stealing experience a greater number of foster care placements than children without these behaviors (Leathers, 2006; Nissim, 1996). Among the specific problematic behaviors that have been identified as problems resulting in placement instability are a lack of social skills, lying, arguing, having tantrums, running away, and behaving badly in order to be sent away (Nissim, 1996). James (2004) found that children’s behavior problems were the second most common reason for a foster care placement change, after systems- or policy-reasons such as movement from a short term shelter. These problems are subject to identification and intervention.
Some studies have focused on the reasons that children in foster care move and their later experiences in foster care:
- A California study found that children removed from their parents’ custody for physical or sexual abuse were 25 percent more likely to experience placement instability (defined in the study as children who experienced 3 or more moves after their first year in care) compared to children who entered foster care because of neglect (Webster, Barth & Needell, 2000).
- Another study found that entering foster care because of emotional abuse increased the risk of behaviorally-related placement changes by 48 percent (James, 2004).
- A Utah study found that children referred to the public child welfare agency because of delinquent behavior were nearly twice as likely to experience 3 or more placements while in foster care (Eggersten, 2008).
Studies also show that disruptive, aggressive child behaviors are a strong predictor of placement disruption and one of the most common reasons that caregivers request that a child be removed from the home (University of Minnesota School of Social Work, 2008). In a large study of placement disruption, unmet behavioral health needs were by far the biggest cause for placement moves (Harnett, et al., 1999).
Research consistently has shown that children who have multiple placements while in foster care use more mental health services (Rubin, et al., 2004). Recent studies have found that children’s needs for mental health services are heightened based on a number of placement-related factors: the duration of time between placement changes, the type of placement a child receives (kinship care versus non-kinship services), whether the child bounces in and out of foster care from home; and the restrictiveness of the foster care services in which the child is placed (in-home versus a residential treatment center) (Rubin, et al., 2004).
| Key Issues |
In order to effectively promote placement stability when children have emotional and behavioral issues, three key issues must be addressed:
Key Issue #1: Assessments of children’s emotional and behavioral needs and problems
Key Issue #2. Therapeutic interventions for children and youth
Key Issue #3. Wraparound and case management services |
| Key Issue #1: Assessments of children’s emotional and behavioral needs and problems |
Assessment forms the foundation of effective practice with children and families. Through careful and thorough screening, child welfare workers can ensure that children receive the most appropriate agency response. Initial and ongoing assessments of children’s emotional and behavioral status are essential to making careful first placements and maintaining placement stability. The California Evidence Based Clearinghouse has identified a number of evidence-based assessment tools that child welfare agencies can use or can request that other professionals use to assess children’s emotional and behavioral needs when they enter placement or during the course of a child’s stay in foster care:
Behavioral and Emotional Rating Scale (2nd Edition): Youth Rating Scale (BERS-2)
The BERS-2is a measure of strengths and competencies for children covering the domains of Interpersonal Strength, Family Involvement, Intrapersonal Strength, School Functioning and Affective Strength. There is also a 5-item Career Strength subscale for older youth. Scores can be used to identify target areas for interventions, set goals for educational, mental health and social work treatment plans and monitor progress towards goals. The BERS-2 may be completed as a self-report, or by parents, teachers or other professionals.
Target Population: Children between the ages of 5 to 18 years with emotional or behavioral disorders. The BERS-2 manual and all three rating scale forms are available for a fee from Pro-Ed. The Spanish version is available for a fee from Pro-Ed.
Child and Adolescent Needs and Strengths- Mental Health (CANS-MH).
The CANS-MH is a comprehensive assessment of psychological and social factors for use in treatment planning. Domains assessed include general symptomology, risk behaviors, developmental functioning, personal/interpersonal functioning, and family functioning. The CANS-MH is intended to support case planning and evaluation of service systems.
Target Population: Children and adolescents with mental, emotional, or behavioral problems.
The measure can be obtained free of charge from the Praed Foundation but training and certification are required by the publisher, Praed Foundation, to use it.
The Child Behavior Checklist (CBCL)
The CBCL obtains reports from parents, other close relatives, and/or guardians regarding children's competencies and behavioral/emotional problems. Parents provide information for 20 competence items covering their child's activities, social relations, and school performance. The CBCL/6-18 has 118 items that describe specific behavioral and emotional problems, plus two open-ended items for reporting additional problems. Parents rate their child for how true each item is now or within the past 6 months using the following scale: 0 = not true (as far as you know); 1 = somewhat or sometimes true; 2 = very true or often true.
Target Population: Children between the ages of 6 and 18. A version of the CBCL is also available for children ages 1 ½ to 5 years of age.
The CBCL, accompanying manual, and scoring materials may be purchased through the Achenbach System of Empirically Based Assessment (ASEBA)
The Eyberg Child Behavior Inventory (ECBI)
The ECBIis a parent rating scale assessing child behavior problems. It includes an Intensity Scale, which measures the frequency of each problem behavior and a Problem Scale which reflects parent's tolerance of the behaviors and the distress caused. The ECBIis intended to assess both the type of behavior problems and the degree to which parent finds them problematic.
Target Population: Children between the ages of 2 and 16.
The ECBIand accompanying manual and scoring materials may be purchased from PAR Inc.
Mental Health Screening Tool (MHST 0-5)
The MHST (0-5) is a brief screening tools designed to identify those children younger than five years old most urgently in need of more thorough mental health screening or assessment. It is designed for use by those who do not have expertise in the area of childhood mental health but have contact with children in this age group, particularly children in foster care.
Pediatric Symptom Checklist-17 (PSC-17)
The PSC-17 is used to screen for childhood emotional and behavioral problems including attention, externalizing, and internalizing problems.
Target Population: Children between the ages of 4 -18 years.
The PSC-17 can be obtained free from Massachusetts General Hospital.
Strengths and Difficulties Questionnaire (SDQ)
Purpose: The SDQ is a screening measure for early detection of behavioral problems and strengths in children and adolescents. Topics addressed by SDQ subscales include emotional symptoms, conduct problems, hyperactivity/inattention, ADHD, peer relationship problems, and pro-social behavior. The SDQ is designed to include both positively and negatively worded items.
Target Population: Children between the ages of 4 to 16.
PDF versions of the questionnaire may be obtained for free from SDQ Info . Photocopying and use of the questionnaire is permitted free of charge, but the SDQ's copyright is held by YouthinMind and may not be modified or distributed electronically without permission.
Assessment of Youth and Foster Family Relationships
An additional assessment tool that can be used is the Belonging and Emotional Security Tool (BEST) developed by Casey Family Services. This tool was developed recognizing that for some youth in foster care, the closest family or family-like relationships are with the foster parents with whom they have lived for extended periods of time. The BEST is a tool that social workers can use to explore young people’s sense of emotional security with their foster parents and foster parents’ sense of claiming and attachment with the young person in their care. The BEST tool can assist in promoting placement stability by clarifying the nature and quality of the relationship between a young person and his or her foster parents.
| Key Issue #2. Therapeutic interventions for children and youth |
Because many children and youth in foster care have emotional and behavioral challenges that can lead to placement instability, therapeutic interventions that assist them in self-regulating and dealing with the impact of trauma in their lives are essential. Interventions that help parents and foster parents understand and appropriately respond to the behaviors of children and youth who have experienced maltreatment are also important.
In this section, we highlight two types of interventions that can address children’s emotional and behavioral challenges:
- Evidence-based therapeutic interventions for children and youth in foster care
- Evidence-based therapeutic parenting interventions
Evidence-Based Therapeutic Interventions for Children and Youth in Foster Care.
Several therapeutic interventions have been developed to address the needs of children and youth in foster care and promote greater placement stability. The following interventions have been reviewed by the California Evidence Based Clearinghouse on Child Welfare.
Multidimensional Treatment Foster Care - Adolescents (MTFC-A): A model of treatment foster care for children 12-18 years old with severe emotional and behavioral disorders and/or severe delinquency. MTFC-A aims to create opportunities for youths to successfully live in families rather than in group or institutional settings, and to simultaneously prepare their parents (or other long-term placement) to provide youth with effective parenting. Four key elements of treatment are (1) providing youths with a consistent reinforcing environment where he or she is mentored and encouraged to develop academic and positive living skills, (2) providing daily structure with clear expectations and limits, with well-specified consequences delivered in a teaching-oriented manner, (3) providing close supervision of youths' whereabouts, and (4) helping youth to avoid deviant peer associations while providing them with the support and assistance needed to establish pro-social peer relationships. MFTC-A also has versions for preschoolers and children. MFTC-P (for preschoolers) is rated separately on this website. MTFC-C (for children) has not been tested separately, but has the same elements as MFTC-Aexcept it includes materials more developmentally appropriate for younger children.
Target Population: Boys and girls, 12-18 years old with severe delinquency and/or severe emotional and behavioral disorders. These youth were in need of out-of-home placement and could not be adequately served in lower levels of care.
Multidimensional Treatment Foster Care for Preschoolers (MTFC-P): A treatment foster care model specifically tailored to the needs of 3 to 6-year-old foster children. MTFC-P is effective at promoting secure attachments in foster care and facilitating successful permanent placements.MTFC-P is delivered through a treatment team approach in which foster parents receive training and ongoing consultation and support; children receive individual skills training and participate in a therapeutic playgroup; and birth parents (or other permanent placement caregivers) receive family therapy. MTFC-Pemphasizes the use of concrete encouragement for pro-social behavior; consistent, non-abusive limit-setting to address disruptive behavior; and close supervision of the child. In addition, the MTFC-P intervention employs a developmental framework in which the challenges of foster preschoolers are viewed from the perspective of delayed maturation.
Target Population: Preschool foster children aged 3-6 years old who exhibit a high level of disruptive and anti-social behavior which cannot be maintained in regular foster care or who may be considered for residential treatment.
Multisystemic Therapy (MST)
An intensive family and community-based treatment for serious juvenile offenders with possible substance abuse issues and their families. The primary goals of MSTare to decrease youth criminal behavior and out-of-home placements. Critical features of MSTinclude: (a) integration of empirically based treatment approaches to address a comprehensive range of risk factors across family, peer, school, and community contexts; (b) promotion of behavior change in the youth's natural environment, with the overriding goal of empowering caregivers; and (c) rigorous quality assurance mechanisms that focus on achieving outcomes through maintaining treatment fidelity and developing strategies to overcome barriers to behavior change.
Target Population: Youth, 12 to 17 years old, with possible substance abuse issues who are at risk of out-of-home placement due to antisocial or delinquent behaviors and/or youth involved with the juvenile justice system.
Evidence-Based Therapeutic Parenting Interventions.
The following therapeutic parenting interventions – which can be used with foster parents and birth parents -- have been reviewed by the California Evidence Based Clearinghouse on Child Welfare.
Attachment and Biobehavioral Catch-up (ABC) A program that targets several key issues that have been identified as problematic among children who have experienced early maltreatment and/or disruptions in foster care. These young children often behave in ways that push caregivers away. The first intervention component helps caregivers to re-interpret children's behavioral signals so that they provide nurturance even when it is not elicited. Nurturance does not come naturally to many caregivers, but children who have experienced early adversity especially need nurturing care. Thus, the second intervention component helps caregivers provide nurturing care even if it does not come naturally. Third, many children who have experienced early adversity are dysregulated behaviorally and biologically. The third intervention component helps caregivers provide a responsive, predictable environment that enhances young children's behavioral and regulatory capabilities.
Target Population: Foster parents of infants
Parent-Child Interaction Therapy (PCIT) A programdeveloped for families with young children experiencing behavioral and emotional problems. Therapists coach parents during interactions with their child to teach new parenting skills. These skills are designed to strengthen the parent-child bond; decrease harsh and ineffective discipline control tactics; improve child social skills and cooperation; and reduce child negative or maladaptive behaviors. PCIT is an empirically supported treatment for child disruptive behavior and is a recommended treatment for physically abusive parents.
Target Population: Children ages 3-6 with behavior and parent-child relationship problems. May be conducted with parents, foster parents, or other caretakers. Adaptation available for physically abusive parents with children ages 4-12.
| Key Issue #3. Wraparound and case management services |
Wraparound services provide individualized, comprehensive, community-based services and supports to children and adolescents with serious emotional and/or behavioral disturbances. Intensive therapeutic wraparound services are often provided for children in more restrictive foster care placements. Wraparound services are based on a model of service that develops plans focusing on the individual strengths and needs of the child and members of the family. Plans center on the family, and are built upon the child's and family's unique strengths. The following interventions have been assessed by the California Evidence Based Clearinghouse on Child Welfare.
Wraparound A team-based planning process intended to provide individualized and coordinated family-driven care. Wraparound is designed to meet the complex needs of children who are involved with several child and family-serving systems (e.g. mental health, child welfare, juvenile justice, special education, etc.); who are at risk of placement in institutional settings; and who experience emotional, behavioral, or mental health difficulties. The Wraparound process requires that families, providers, and key members of the family’s social support network collaborate to build a creative plan that responds to the particular needs of the child and family. Team members then implement the plan and continue to meet regularly to monitor progress and make adjustments to the plan as necessary. The team continues its work until members reach a consensus that a formal Wraparoundprocess is no longer needed.
Target Population: Designed for children and youth with severe emotional, behavioral, or mental health difficulties and their families. Most often these are young people who are in, or at risk for, out of home, institutional, or restrictive placements; and who are involved in multiple child and family-serving systems (e.g. child welfare, mental health, juvenile justice, special education, etc.) Wraparound is widely implemented in each of these various settings; however, because the youth have multi-system involvement, wraparound participants have many similarities across settings.
The CORE (Case management, Outreach, Referral, and Education) A program that targets families with children (ages 0-19 years) in transition such as those who are living in homeless shelters, temporary or doubled-up housing situations, or in foster care situations. The purpose is to improve the stability and well-being for children and families by providing a wide range of wrap-around services to improve conditions that place children and families living in transition at-risk for health, social, psychological, and safety concerns. The CORE program helps families with: coordination of medical care for their children; identification of resources that will facilitate family function and stability including counseling; support with recovery from substance abuse; and referral and assistance with completing housing applications.
Target Population: Families and children (ages 0-19 years) in transition, such as those who are living in homeless shelters, temporary or doubled-up housing situations, or in foster care situations. The caregivers may be relative or non-relative, young or old.
Resources:
The National Wraparound Initiative
In 2004, stakeholders—including families, youth, providers, researchers, trainers, administrators and others—came together in a collaborative effort to better specify the wraparound practice model, compile specific strategies and tools, and disseminate information about how to implement wraparound in a way that can achieve positive outcomes for youth and families. The NWI now supports youth, families, and communities through work that emphasizes four primary functions:
The Children’s Bureau’s Improving Child Welfare Outcomes Through Systems of Care
demonstration initiative, the Technical Assistance and Evaluation Center (the Center) conducted a national cross-site evaluation of the demonstration program. The evaluation used a mixed methodological approach, which included a process and outcome component, to examine each grant community’s planning and implementation of its local Systems of Care initiative and the corresponding impact such work had on community collaboratives, agencies, and children and families. The resulting evaluation reports provide overviews of the planning, implementation, and outcomes of the Systems of Care demonstration initiative, and summarize the challenges, promising practices, and lessons learned.
Overview of the National Cross-Site Evaluation
Summarizes the initiative and its cross-site evaluation, presents key findings related to the implementation process and outcomes, and highlights lessons learned and conclusions.
Systems and Organizational Change Resulting from the Implementation of Systems of Care
Provides an in-depth analysis of the critical factors that influenced the Systems of Care initiative during the planning and implementation phases; highlights the outcomes at the systems, organizational, and individual levels; and identifies sustainable policies, structures, practices, and components expected to endure beyond the grant period
State and County Examples:
South Carolina: Children in foster care in South Carolina who have severe emotional, behavioral, or developmental disabilities and are determined ISCEDC (Interagency System for Caring for Emotionally Disturbed Children) eligible receive a range of treatment services such as therapy, intensive family services and community-based wraparound services.
Wraparound Oregon – Early Childhood – Multnomah County Education District:
Wraparound Oregon: Early Childhood brings families, professionals and community organizations together to provide services and supports to children (birth to eight) with significant social and emotional health needs. Through a facilitation process and bringing together family teams, Wraparound Oregon integrates family voice and choice, natural supports, strength-based, individualized and culturally competent practices. They have developed a handout on how Wraparound can help children in child welfare.
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