The Mission of DSHS The Department of Social and Health Services will improve the safety and health of individuals, families and communities by providing leadership and establishing and participating in partnerships. Because Mind Matters Screening and Assessment Panel Discussion August 27-28, 2012 Denise Revels Robinson, MSW, Assistant Secretary, Children’s Administration Department of Social and Health Services Barb Putnam MSW, Supervisor, Well-Being Unit Children’s Administration

Children’s Administration Service Structure State administered public child welfare system. Children’s Administration serves children and families in their communities through three regional offices and 45 field offices and by partnering with 26 federally recognized American Indian tribes.

Service Delivery Activities In Fiscal Year 2011 There are approximately 1.55 million children in Washington1 1.55 million children1 in Washington Children’s Administration received 77,882 reports alleging possible child abuse in State Fiscal Year 20112 Of those referrals, 37,992 were screened in for investigation. (35,772 did not meet the legal criteria for abuse, neglect, or abandonment or were referred to Alternative Services) 2 Children exiting care2 2,658 children (51%) went home 1,514 children (29%) were adopted 513 children (10%) placed in guardianships 414 (8%) reached age of majority. On June 30, 2011, there were 9,987 children in the care of Children’s Administration2 Of those, 8,966 were in out-of-home care such as foster care or group homes. (1,021 were state dependent but living at home.)2 Of those children placed in out-of home care, 3,147 lived with relatives. (Approximately 10% of relative caregivers are licensed.)2 6,507 children exited care2 www.Census.Gov ; 2.FamLink

Safety is at the forefront of every aspect of our work We endeavor to safely: Maintain children in their own homes preventing out-of-home placement Serve and support children with relatives or in temporary licensed out-of-home placement Return children home as quickly as possible Secure permanent homes for children who cannot return home Decrease over-representation of children of color in the public child welfare system

Values, Guiding Principles and Priorities Safety, permanency, and well-being are sought for all children and families regardless of race, ethnicity, or place of residence. Child safety, permanency, and well-being are the shared responsibility of parents and foster parents, caregivers, tribes, service providers, and community members. Practice improvement is data driven and outcomes are communicated transparently both within the Administration and publically. Efforts to reduce racial disproportionality are embedded into all aspects of our work. Supervisors are supported toward competency, accountability, and professional development.

Children’s Administration Programs and Services Public child welfare for Washington state Child abuse intake and investigation Services to support children and families Foster care and relative placement Adoption and post-adoptive services Adolescent Services Foster family home and facility licensing

Specialized Services and Programs Fostering Well Being Care Coordination services for complex health, dental and mental health concerns including psychotropic medications. Regional Medical Consultants Six part time Pediatricians out-stationed in regional offices are available to support case worker needs in the field. Foster Care Assessment Program assessment for children/youth languishing in care and have behavioral difficulties.

Screening Initial Health Screens Child Health and Education Track

Initial Health Screens Purpose: Intent is to help identify and manage a child’s urgent medical problems that may be overlooked in the transition from their home into out of home placement with a caregiver. Physician physical screening that occurs within the first 72 hours to five days of a child or youth initially coming into care.

Activities of the Initial Health Screen Health Screen is a well child exam that consists of a quick review of the child’s current health status that includes: Height, weight and growth Blood pressure and other vital signs Immunizations Health status Complete physical exam Referrals to other specialists if needed

Capacity Building State Medicaid partners created a billing code a specialized form and protocols for the physician use. Initially physicians needed extensive communication and training regarding the purpose and billing procedures. Worked extensively at the regional level to identify local qualified medical providers. Currently physicians are fully engaged in the process.

Child Health and Education Tracking (CHET) Legislatively mandated in 2000 to develop comprehensive screening capability in child welfare. Approximately 80 trained staff and supervisors deployed throughout the regions who screen all children and youth. CA’s role is to comprehensively screen and when identified, refer to the experts for a comprehensive assessment. There is a compliment of processes, staffings and referrals based on results of the utilized screening tools.

CHET Program Goals Identifies the long term well-being needs of children and youth in care. Solicits information from people who have known the child/youth for 30 days or longer. Is a “snapshot” of the child/youth at the beginning of the child’s placement. Provides a baseline for on-going monitoring. CHET screens are completed within the first 30 days of placement. Children who are expected remain in care longer than 30 days must be have a health, mental health and education screen completed w/in 30 days of placement. The CHET is completed only when the child is initially placed into out-of-home care. A new CHET may be completed if the child returns home and returns to foster care after a 12 month period. Social workers are responsible for the on-going monitoring of the child’s well-being as they continue in out-of-home care. The CHET Program assesses approx. 300 to 400 children per month for children ages birth to 18 years old. CHET Screeners are specially trained CA staff (SW 3) and located in CA offices around the state.

Who are the Screeners? Dedicated social workers who are and trained to administer screening tools. Not case carrying, except in small offices. Have an interest in the wellbeing needs of children coming into care. Have an understanding of child welfare and the movement /responsibilities within the system. Have an understanding of resources in their local communities.

Domains AREAS OF FOCUS: CHET screens children in five domains: Physical Health Social/Emotional Education Developmental Connection to family, community, peers, and other significant relationships The Physical Health component of the CHET screen is met via an EPSDT completed within 30 days of placement. In addition to the EPSDT exam, CHET screeners ensure the child sees a dentist within 30 days of placement. CHET screeners are required to attend Shared Planning Meetings to share the results within 60 days of placement to assist social workers in the development of case plans.

Tools The Screener administers the following standardized validated tools: Denver (birth to one month) Ages and Stages Questionnaire (ASQ) (1 month – 5 years) ASQ – Social Emotional (3 months – 5 ½ years) Mental Health: Pediatric Symptom Checklist – 17 (PSC-17) (ages 5 ½ -18) Global Assessment of Individual Needs – SS (13 – 18 years)

Pediatric Symptoms Checklist (PSC – 17) Developed as brief screen to identify possible psychosocial problems in pediatric settings for children 4-17 years. based on original 35-item PSC -- Leiner et al. 2007 Includes 17 items that fall into 3 domains Externalizing problems (7 items) Attention problems (5 items) Internalizing problems (5 items) Has clinical cutoff scores for each scale Based on recommendations from our University of Washington partners, we adopted the PSC-17 in 2009 and trained all of the CA CHET screeners in the new tool. Previously we had utilized the Child Behavior Check List (CBCL), which we found was not effort nor easy to get from teachers and caregivers. This is a much more nimble tool and our completed screening rates in mental health have significantly increased.

PSC-17 Sample Questions INSTRUCTIONS: Please read each question carefully and check off the box for the response that you believe is most true for your child during the past 6 MONTHS. # DOES YOUR CHILD (0) Never (1) Sometimes (2) Often 1 Fidget, is unable to sit still.  2 Act as if driven by motor 3 Daydream too much 4 Distract easily 5 Feel sad 6 Feel hopeless 7 Have trouble concentrating 8 Fight with other children. 9 Feel down on him/herself 10 Worry a lot 11 Seem to be having less fun 12 Not listen to rules 13 Not understand other people’s feelings 14 Tease others 15 Blame others for his/her troubles 16 Refuse to share 17 Take things that do not belong to him/her

PSC – 17 Results In Washington State fiscal year 2011, CHET Screeners administered the tool for 5,143 children and/or youth. Based on scores: 54% had “No Apparent Concerns”, and 46% had “Possible Mental Health Concerns” which resulted a referral for a comprehensive mental health assessment. The PSC – 17 provides results in 4 areas. Children can have “no apparent concerns” or “possible mental health concerns” identified through their in: Total Score Internalizing Behaviors – this is depression or anxiety related difficulties Externalizing Behaviors – this is acting out or behavioral difficulties Attention - this would include attention deficit disorder and a child/youth who is bouncing off the walls.

Post Implementation: What We Know Domains Possible Concerns Identified Internalizing 30% Externalizing 24% Attention 19% Total Score 46% Based on FY11 data, when we look at the scores of those children where a concern was indicated, this is the general break-out. There are more children and youth exhibiting concerns related to depression and anxiety than there are children and youth who are acting out. Results are duplicative, children can have concerns in more than one domain.

Assessment: Mental Health Service Referrals If the child/youth scores are at the cut-off point, the child is referred to the Regional Support Network (RSN) for a comprehensive mental health evaluation. Additionally, at any point while the child is in out-of-home care if there is an identified mental health concern, he or she is referred to mental health services. Referrals made on scores or reported concerns. The Regional Support Networks are Washington States publicly funded mental health system. It is a managed mental health care system that is organized regionally into 13 Regional Support Networks. These networks contract with community mental health providers and are responsible for the full array of outpatient and inpatient mental health services for adults and children.

Additional Resources Evidenced Based Programs: Intensive Family Preservation Services – Homebuilders Project SafeCare Functional Family Therapy Incredible Years Parent Child Interactive Therapy Multidimensional Treatment Foster Care Promoting First Relations Wraparound These are Evidenced Based Programs that are available through the child welfare system for families that are identified at the front door and need services. These support parental capacity to safely keep their children at home. Two additional EBP’s: Functional Adaptation Skills Training (FAST) and Project KEEP

Challenges We continue to need: A full array of Evidenced Based treatments that address the specialized trauma and other mental health needs of foster children and youth in the publicly funded mental health system, especially for 0-5 children. Barrier free access to mental health services. Training and better understanding in mental health of the unique needs of children and youth in foster care.

Next Steps Currently examining tools that are trauma screens. Anticipate implementing a trauma screen in the next year within the CHET process for those children and youth entering care. We also have recently applied for the ACF grant regarding screening, assessment and evidenced based treatments for child and youth in the child welfare system. We are also involved in a System of Care Infrastructure Building grant that may add additional resources to for the most complex mental health related children and youth that are crossing systems.