Gateway Assessments 22/04/2017 Gateway Assessments are an interagency programme of work between Child, Youth and Family, Health and Education. 1

Gateway Assessments - Overview 22/04/2017 Gateway Assessments - Overview Gateway Assessments are an interagency project between Child, Youth and Family, Health and Education. For children and young people known to Child, Youth and Family, their aim is to: identify health and education needs early ensure interagency agreement on how best to address needs facilitate access to appropriate services ensure children and young people get the support they need at home and at school. A Gateway Assessment is a comprehensive look at the health and wellbeing needs of a child or young person The assessment incorporates: a review of background health information of both the child and their parents a physical examination of the child or young person information from an education profile. The Education profile is a snapshot, not a full assessment, however it will note if a full assessment is required. information from the social worker. The Gateway Assessment report and the recommendations in the Interagency Service Agreement will: identify the health and education needs of children and young people Ensure there is interagency agreement on how best to address their needs Facilitate access to appropriate services for health, education and wellbeing Ensure that children and young people are getting the help they need at home and at school support children and young people to have improved life outcomes in the future. 2

Health and Education Assessments – the pilot project Involved 4 DHB’s and 16 Child, Youth and Family sites between 2008 and 2010. The pilot project was reviewed and a number of recommendations for improvement were suggested. The recommendations were taken on board and the pilot became Gateway Assessments. Budget bid of May 2011 provided funding for the pilot to be implemented throughout New Zealand. There are now 12 DHB’s and 37 Child, Youth and Family sites that have an operational Gateway Assessment clinic. Implementation will be complete by the end of 2012 In the lead up to the programme becoming a nation-wide service, a set of pilots occurred

Services for Children in Care 22/04/2017 Services for Children in Care Budget 2011 provided government funding for services to address the needs of children and young people in state care. The package includes: Gateway Assessments (health assessments and education profiles) mental health services for children and young people in care funding for early childhood education for children in care, aged 18 months to three years. Children in care are recognised globally as a highly vulnerable group with increased physical, mental and social health needs. There is clear evidence in international studies that children entering care have a high prevalence of acute and chronic health problems and developmental disabilities. Budget 2011 announced the Government’s commitment to addressing the health & education needs of children who come to the attention of Child, Youth and Family: Gateway assessments are a comprehensive health assessment and an educational profile (up to 4,200 children and young people per year) - $3.8 million a year mental health services for 175 children and young people with high/complex behavioural needs and 1,600 with mild to moderate emotional or behavioural problems - Building to $2.5 million per year over 3 years funding for early childhood education for all children in state care, aged 18 months to three years - Building to $2.5 million per year over 4 years 4

22/04/2017 Who are they for? Gateway Assessments are available to any child or young person who: is entering Child, Youth and Family care is already in Child, Youth and Family care is having a care and protection family group conference (FGC) Gateway Assessments are available to any child or young person who: is entering state care (about 2,200 children and young people per year) is already in care, and the social worker believes they would benefit from an assessment (about 500 per year) is preparing for, or has had, their Care and Protection family group conference and an assessment would help clarify and identify ways to address their health or education needs (about 1,500 per year). ** Youth Justice have their own health and education assessment process and we are working towards a single process. From July 2011 to March 2012, children and young people receiving Gateway Assessments included: 60 % Maori descent 13% Pacific Island descent 22% European descent 4% other ethnicities 18% are under the age of 2 years 20% are aged 3-5 years 40% are aged 6-12 years 21% are aged 13 and over 5

Gateway Assessments flow chart 22/04/2017 22/04/2017 Gateway Assessments flow chart Child Identified as likely to benefit from a Gateway Assessment Social Worker Engages with family and gains consents Refers for health assessment & education profile Provides information regarding child or young person’s history Urgent health appointment if required Teacher/Principal/ RTLB (School or Early Childhood Centre) Completes education profile Identifies issues affecting education ACC Social Worker Health (NHI) Well Child Provider Family Gateway Assessment Coordinator Collates information from CYF, Health & Education Collects existing health information Collects family health history Determines appropriate assessment Health Assessor Reviews history Undertakes comprehensive health assessment Writes health report and recommendations Health Referrals Immunisations Primary Care engagement Gateway Assessment Coordinator Drafts Interagency Services Agreement recommendations Coordinates Multi-disciplinary Clinical Meeting Follows-up on implementation of recommendations at 3 months CAMHS Primary Child MH Services Paediatric Services Adult AoD and MH Services Education Health Social Worker This is how the Gateway Assessment process works. The following slides describes the roles and responsibilities of everyone involved. Improving and supporting the child or young person’s health and wellbeing is the focus of the whole process. Children and young people and their families/whānau/caregivers are supported to be involved (where appropriate) all the way through the Gateway Assessment process. Social Worker Prepares information for use at care and protection FGC Completes child or young person’s plan Monitors agreed recommendations 6 6

Gateway Assessments - roles and responsibilities 22/04/2017 Gateway Assessments - roles and responsibilities Gateway Assessments are an interagency programme of work between Child, Youth and Family, Health and Education. 7

The Child, Youth and Family social worker 22/04/2017 The Child, Youth and Family social worker The social worker is responsible for: engaging with child, young person and their family and obtaining consents requesting the education profile and making the referral to the Gateway Assessment Coordinator ensuring the child or young person can attend the appointment and has the right support with them assisting with the development of the Interagency Services Agreement and participating in the multi-disciplinary clinical meeting discussing the completed report with the child or young person and family/ caregivers and developing the plan with the family ongoing monitoring and reviewing of the child or young person’s progress. The social workers role is to: Identify children and young people who are likely to benefit from a gateway assessment (children and yp coming into care, children in care who have high needs or to help clarify needs, high needs identified pre or port FGC) Attend appointment where practicable Record agreements in CYRAS Implement, monitor and review child or young persons plan Information required on referral to Gateway clinic Adverse life events – family violence, parental separation, loss of caregiver, abuse, neglect, injuries Health concerns or issues including hospital admissions Strengths and resiliencies of the child or young person Emotional and behavioural issues or concerns Education achievements and difficulties Care history and placements

The teacher/RTLB The teacher is responsible for: 22/04/2017 The teacher/RTLB The teacher is responsible for: completing the education profile and attaching any specialist education reports to the profile - this should be completed by someone who knows the child well where the child is entering care, liaising with the RTLB cluster manager* returning the completed Education Profile within seven days ensuring someone from the education sector attends the multi-disciplinary clinical meeting, as required reviewing and approving the education services suggested in the Interagency Services Agreement *As directed by the Ministry of Education, RTLB only work with children entering care between the ages of 5-14 The education profile will be sent by the social worker to the teacher/school/ RTLB Cluster Manager. Most parents/guardians are happy to provide consent and support their children to get the help they need at school. On the rare occasions guardians do not consent the social worker will still request the education profile and make it clear that consent was not gained. The teacher should still complete the profile and return it to the social worker, and not the Gateway Assessment Coordinator. The education profile should be completed by someone who knows the child well. Teachers need to talk to the social worker if they have any concerns about information being shared From June 2012 RTLB Cluster Managers will have oversight (supporting teachers) to ensure education profiles are completed for children in care Someone from Education will be invited to the Multi-disciplinary Clinical Meeting: this is likely to be the RTLB Cluster Manager, or someone from Group Special Education.

Gateway Assessment Coordinator 22/04/2017 Gateway Assessment Coordinator The Gateway Assessment Coordinator is responsible for: collecting existing health information about the child or young person from other agencies (e.g. ACC, Plunket) collecting the mental health and drug and alcohol history of the parents (if consent from the parent has been obtained) ensuring the education profile information is provided to the assessor drafting a health report after the health assessment has taken place for dissemination to the child/young person, their family, the caregiver and all of the involved professionals drafting the Interagency Services Agreement, in consultation with the social worker and teacher arranging multi-disciplinary clinical meetings a 3 month review of the services provided The Gateway Assessor needs to Ensure the Mental Health and Drug and Alcohol status of the parents, are known if consent is obtained from that parent. This involves contacting the mothers GP for their history, and administering or organising screening tools Collect existing health information for the child, or young person including : immunisation status, enrolment with primary health care, Hospital visits/admissions, mental health events, medical warnings, pharmacy and lab records, birth and family health history, any injuries or reports of abuse. This information will come from agencies such as GPs, DHBs, Plunket, ACC, CYF Ensuring the education profile information is used in the assessment Determine the most appropriate assessor for the child or young person, and book the assessment Coordinate the assessment with the social worker and the child and young person and their family/caregiver Facilitate the multi-disciplinary clinical meeting to clarify needs and agree appropriate services, and document agreement on an Interagency Services Agreement. Facilitate medical referrals and specialist assessments if required Work with the health assessor to create and maintain a clinical record of the information gained through the assessment process Ensure report and recommendations is returned to social worker in timely way, so this can be shared with child/young person and their family and other professionals involved in the case. Draft the Interagency Services Agreement (ISA) and circulate to the social worker, teacher and health assessor for their agreement Arrange Multi-disciplinary Clinical Meetings Maintain accurate records, and follow up on recommendations

Assessing health practitioner 22/04/2017 Assessing health practitioner The health assessor is responsible for: identifying the health needs of the child or young person, including mental health screening and writing a health report completing follow-up referrals for the follow, as required ensuring the child or young person has a primary care provider reviewing and endorsing the Interagency Services Agreement once drafted by the Gateway Assessment Coordinator attending a multi-disciplinary clinical meeting if there are concerns about the ISA that need clarification or resolving. The health assessment should be undertaken by health practitioners who have the skills and expertise required, which will vary depending on the age, health history and development of the child. They are mainly paediatricians, or youth health assessors overseen by a paediatrician. The health practitioner collects information about the health and wellness needs of the child, and formulates it into a report and recommendations for the child, their family, the social worker, the teacher and the health service, outlining interventions which could meet the child/young person’s needs. Referrals may include specialists, eg ear, nose and throat, audiology, endocrinologist etc. Where need be private information is sent to the social worker, and excluded from the information sent to others, for example, the teacher. They also act as an advocate for the child 11

22/04/2017 Timeframes Health and education information needs to be available in child focused time frames, so their needs can be addressed in a timely manner. The Gateway Assessment process therefore needs to be undertaken within the following timeframes: Social worker requests the education profile and Makes the referral for the health assessment Within 5 working days of identifying the need for an assessment Teacher attends RTLB led meeting (within 4 days) and completes the Education Profile Within 7 working days of request Health assessor Completes the health assessment Within 6 weeks of receiving referral (4 weeks for under 5 year olds) Gateway Assessment Coordinator Distributes health report and recommendations Within 10 working days of the assessment Drafts Interagency Services Agreement Arranges Multi-disciplinary Clinical Meeting This is the agreed time frames for each agency. Decisions about children's futures need to be made within well-defined timeframes. Six months is a long time in the life of a one year old. Children's lives cannot be put on hold while adults negotiate about what to do. Every task in the child's plan needs to have its own clear timeframe which is both realistic and achievable. Information needs to be discussed with the child or young person and their family/ caregivers. Where possible, information should be available in time for Family Group Conferences.

Examples of outcomes Condition Age of child Outcome Enlarged kidney 22/04/2017 Examples of outcomes Condition Age of child Outcome Enlarged kidney 3 months Referred for x-ray and specialist assessment. Major illness identified. Undergoing treatment Jaundice with arching back 4 months Referred to specialist paediatric service. Major concern about permanent brain injury Tongue tie – feeding problems Surgery the following day. Excellent progress and now thriving Cleft palate 18 months Referred to plastic surgery for repair, speech progressing Club foot 2 years Orthopaedic surgery corrected deformity. Able to walk 12 months later Squint 3 years Eye surgery to correct muscle problems, coordination improved and building towers Disruptive behaviour 5 years Incredible Years Programme to help caregivers understand and manage behaviour positively – child now participating well at school Needle stick injury 11 years Investigated for HIV infection, Hepatitis Acute psychosis 14 years Referred for psychiatric assessment, now under specialist mental health care Epilepsy 15 years Commenced treatment. Able to progress well at school once treatment established Identifying and addressing the needs of children and young people coming into care is a priority. This gives us the best opportunity to enhance their chances of achieving at school, being healthy, and growing up in a supportive family These are some examples of the referrals and subsequent treatments that have been carried out as a result of the gateway assessments. 13

Primary mental health services - interventions 22/04/2017 Primary mental health services - interventions Gateway Assessments are an interagency programme of work between Child, Youth and Family, Health and Education. 14

New CYF Funded Mental Health Services 22/04/2017 New CYF Funded Mental Health Services We have new funding for mental health services to meet the needs of children and young people identified through Gateway Assessment. Extension of Intensive Clinical Support Services Complex mental health and behaviour 175 young people per year Average cost of $14,300 Evidence-based, family focused services New primary services Mild to Moderate mental health = emotional and behavioural needs 1,600 children per year Average $1,550 per child Evidence-based family focused services Starting very soon Acute ICSS CAMHS We know the mental health concerns (including emotional and behavioural issues), are very common for children engaged in child protection services. Most of the children Child, Youth and Family engage with will have a mental health concern – but until now effective treatment options have often not been available. We are addressing this with new money announced in the budget 2011. The new services are: 1. Primary child mental health services will be endorsed evidence based interventions to address mild to moderate emotional or behavioural needs for children and young people that: warrant intervention to maintain stability in living arrangements, or to address issues that are otherwise likely to escalate, but whose needs are not severe enough to meet the criteria for access to Child and Adolescent Mental Health Service (CAMHS). It is rolling out now in the areas with the Gateway Assessments already in place 2. Intensive clinical support services are for children and young people with high and complex mental health needs. The new CYF funded services are not intended to replace or duplicate services already funded through the Ministry of Health. We still want our children and young people to access Ministry of Health funded services and will be issuing guidance to make sure this happens. Primary Child Mental Health Service Universal services 15

Primary services – CYF will fund evidence based interventions 22/04/2017 Primary services – CYF will fund evidence based interventions Group Names of evidence based interventions Infants (aged 0-4) Watch, Wait and Wonder™ Primary Mental Health Services 0-17 year olds Parent Child Interaction Therapy Trauma and Abuse focused Cognitive Behavioural Therapy Primary care or level 4 and 5 Triple P Incredible Years Children & young people (aged 3 or older) We want children and young people to have access to interventions that have an evidence based - as we know this works. Each intervention’s evidence based is specific to a particular age group and set of presenting issues. With a few exceptions, effective mental health interventions for children and young people have the adults in the child or young people’s life as the central point of intervention. For this reason, it is key that social workers engage with the adults in the child or young person’s life. Through this engagement, you are central to making these clinical interventions work. There are other evidence based interventions that have not been included (mostly due to cost considerations) but which are available in some areas. For example “Treatment Foster Care” in Auckland. The list of interventions is not exclusive, rather they are the ones we have identified to date that have an evidence base. We will consider funding others as long as they have research attached to demonstrate that they work. Young People Intensive Mental Health Services 10-17 year olds Functional Family Therapy Multi-systemic Therapy These rely on good social worker engagement & case management 16

What the interventions do 22/04/2017 What the interventions do ≈ 8 sessions for caregiver & infant with therapist 2 parts to sessions, 1st half infant led, 2nd half focuses on the parent’s observations Infant: improvement in attachment; cognitive development, and emotional regulation Parent: improvement in parenting confidence, depression, & reduced parenting stress. aimed at reducing challenging behaviours and promoting social competence at home and school caregivers attend about 14 weekly group sessions view & discuss videos showing caregivers interacting in appropriate & inappropriate ways reinforced with role playing, rehearsal, phone calls and home work. Watch, Wait and Wonder ™ Incredible Years We want to give you a short summary of what happens in each of these interventions - so they are more than just a name. You can contact us for more information about any of these interventions. Each intervention has an evidence based specific to particular sets of your clients needs and circumstances. Watch, Wait and Wonder Traditionally about 8 - 12 weekly sessions. Dyadic – meaning that is involves the caregiver and infant with a trained therapist. Two parts to sessions 1st half is infant led with the parent asked to follow their child’s activities 2nd half focuses on the parent’s observations, at first developing this capacity, then as the intervention progresses what those observations may tell them about what their child is feeling, thinking, communicating and later the child’s experience in the relationship. The aim of the intervention for the infant is a significant improvement in attachment relationship with parent or caregiver - particularly disorganised to organised attachment pattern; cognitive development, and emotional regulation And for the parent or caregivers, a significant improvement in parenting confidence, depression, and reduced parenting stress. Incredible years Currently available in many areas– it is most effective for children aged 3-8. Its aim is to reduce challenging behaviours and promote social competence at home and school. It is not suitable for children who are severely developmentally delayed, psychotic or autistic. Internationally a wide variety of Incredible Years programmes are available, including some which have been adapted to foster caregivers. web link is http://www.incredibleyears.com/ Speaking notes end Additional information on Watch Wait and Wonder The manualised and researched intervention is dyadic [caregiver / infant, toddler, preschooler] and most often this will be with the child’s primary caregiver, generally their mother. The infant is directly involved and sessions are split – - For half the session the parent is asked to get down on the floor with their infant, observe the activities that their infant introduces, and to interact only when the infant indicates they want the parent to interact. - During the second half of the session the parent is asked to talk about what they have observed about their infant’s activity and their own experience during the session. The infant uses play and activity to master difficulties in relation to their parent [for example the toddler with a sleeping or eating problem is highly likely to focus on those toys that relate to those relational difficulties despite other toys being beside them on the floor] Parents are supported to observe and know their infant and they develop confidence in their capacity to resolve difficulties in the relationship. Although some parents talk about their early relationships with their own parents, this is not necessary for the therapy to be effective. Aims and expected outcomes of Watch, Wait and Wonder are grounded in attachment theory; the most extensively developed and empirically supported theory of infant-caregiver relationships. Indications for Watch, Wait and Wonder™ Assessment suggests the presenting problems of the infant reflects relationship difficulties Problems in adaptation - eating, sleeping. Problems with self-regulation – difficulties soothing, unsettled, clinging, over / under activity. Parent’s complaints – don’t understand, not bonded with, don’t know how to play with, feel child is in control. A risk or allegation of abuse. Now applied to a range of infants and young children with relational, behavioural, regulatory and developmental difficulties. Contra-indications for Watch, Wait and Wonder™ The other parent is unable to support or is actively hostile about the therapy. Parents/caregivers need to have some capacity to focus in the session or on the infant. Clinical judgement is required when. A parent/caregiver is preoccupied with severe external stress – impending death, illness, marital conflict. Parent’s mental health – experience supports attending to this first / concurrently and careful assessment No absolutes – strengthening the tie with the infant and confidence in parenting may help deal with couple problems or improve parental depression and the intervention can run concurrently with other interventions/services like couple’s counselling and adult mental health. Extra Information: Duration and Frequency of Sessions. Traditionally offer 8 sessions, weekly. In a 2⁰ and 3⁰ setting begin with at least 12 or make it clear that 8 sessions is a point of review and the likelihood is that this will be approximately half way through the intervention. Some finish earlier, some request further sessions. Extended Sessions needed for - Parents who were severely abused and fear they may repeat the abuse - Infants with Failure to Thrive - Parents with severe psychopathology [personality disorder] - Parents with unresolved mourning. References: Muir E., Lojkasek M. And Cohen N. [1999] Watch, Wait, and Wonder: A Manual Describing a Dyadic Infant-led Approach to Problems in Infancy and Early Childhood The Hincks-Dellcrest Centre and The Hincks-Dellcrest Institute Cohen N., Muir E., Lojkasek M., Muir R., Parker C., Barwick M. and Brown M. [1999] Watch, Wait, and Wonder: Testing the effectiveness of a new approach to mother-infant psychotherapy Infant Mental Health Journal; 20, 429-451 Cohen N., Muir E., Lojkasek M., Muir R. and Parker C. [2002] Six-month follow-up of two mother-infant psychotherapies: Convergence of therapeutic outcomes. Infant Mental Health Journal; 23, 4, 361-380. Bakermans –Kranenburg M., van IJzendoorn & Juffer (2005) Review and meta-analysis of disorganised infant attachment and preventative interventions Infant Mental Health Journal; 26, 3, 191-216 17

What the interventions do 22/04/2017 What the interventions do combines information with skills training and support teaches caregivers to apply parenting skills targets behaviours at home and in community several different delivery formats available. Triple P (Primary level and Levels 4 & 5) understanding the negative effects of abuse  daily positive interactions (child directed interaction- parents/caregivers learn non directive play skills) and promoting child compliance (parents/caregivers learn to direct the child’s play) live coaching either, in the room, one-way mirror, or the “bug in the ear” system. Parent-Child Interaction Therapy Triple P combines information sessions with skills training and support and teaches caregivers to apply parenting skills more effectively. It targets behaviours at home and in the community. Triple P is most effective with children aged 3-12. It is available in some areas of New Zealand already. - web link for more information is http://www33.triplep.net/ Parent Child Interaction Therapy helps parents to understand the negative effects of abuse and is a treatment for young children whose conduct is disordered (especially those aged 3-7 years). It places emphasis on improving the quality of the parent-child relationship and changing parent-child interaction patterns. Parents are taught specific skills to establish a nurturing relationship with their child while increasing their child’s pro-social behaviour and decreasing negative behaviour. Currently our Auckland based Specialist Services Unit has developed expertise in providing this intervention. - web link for more information is http://pcit.phhp.ufl.edu/ 18

What the interventions do 22/04/2017 What the interventions do goal-orientated systematic procedure to address challenging emotions, behaviour’s and cognitions 8-12 sessions which can be face to face or computer based. Cognitive Behaviour Therapy (CBT) for child and non-abusive caregiver teaches techniques to manage the emotional response to trauma training on parenting, personal safety and relationship skills. Trauma Focused CBT (sexual abuse) targets perpetrator and child's behavioural/emotional adjustment psychological education, coping skills, discussion, developing social support plans and developing communication skills. Cognitive Behaviour Therapy – can be used for a wide range of issues, especially anxiety disorders and depression. It aims to address challenging emotions, behaviours and thoughts. There has been a recent study done in Auckland using a successful computer based CBT with teenagers with depression. http://apt.rcpsych.org/content/7/3/224.full Trauma Focused CBT – Designed to respond to sexual abuse to reduce both maladaptive beliefs and thoughts and reduce Post Traumatic Stress Disorder, it can be used for a wide age range of needs. http://www.childwelfare.gov/pubs/trauma/ Abuse Focused CBT – It promotes the expression of pro-social behaviour and discourages coercive, aggressive or violent behaviour in both parents and children. It achieves this by using; psychological education, training, coping skills discussion, developing social support plans, and developing communications skills. It is usually used for school age children. It may not be appropriate for families where abuse is not acknowledged, especially where criminal proceedings may follow. http://www.childwelfare.gov/pubs/cognitive/ Abuse Focused CBT (physical abuse) 19

22/04/2017 More information You will find more information about these initiatives on the Child, Youth and Family website www.cyf.govt.nz You can also contact your local Child, Youth and Family site if you have specific enquiries about how this might affect you.