1. HEALTH SCIENCES CENTER There’s No Place Like Home Mary Evans, PhD, RN, FAAN

2. HEALTH SCIENCES CENTER COLLEGE OF NURSING Some Things We Know Estimated that 1 in 5 children has a mental health disorder 5% of these children have a serious emotional disturbance Estimated 20% not receiving care Issues of access and retention in services Those who stay in service longer do better

3. HEALTH SCIENCES CENTER COLLEGE OF NURSING More Things We Know Most children spend much of their time in schools & schools have become de facto mental health system Many interventions shown to be efficacious in controlled trials fail to be effective in less controlled settings This has led to new models of developing evidence based practices that begin & end with the setting where the service will be delivered (real world settings)

4. HEALTH SCIENCES CENTER COLLEGE OF NURSING In-Home Services These settings include the child’s home, school and community The foundations of these interventions are in systems theory and social ecological theory that view individuals as being influenced by and influencing multiple environments or systems, so interventions must occur in child’s natural ecology

5. HEALTH SCIENCES CENTER COLLEGE OF NURSING Multisystemic Therapy Multisystemic Therapy (MST) is probably the most widely known of these ecological interventions An evidence base has been established for MST in treatment of antisocial behavior and for youth in psychiatric crisis Currently a continuum of services is being developed based on MST principles

6. HEALTH SCIENCES CENTER COLLEGE OF NURSING Home-Based Crisis Intervention Another model of providing ecologically based services is Home Based Crisis Intervention (HBCI) Adapted from family preservation approaches to children in psychiatric crisis & their families Initially developed in Seattle for a child welfare population

7. HEALTH SCIENCES CENTER COLLEGE OF NURSING HBCI Model Counselor provides case management and therapeutic interventions (crisis de-escalation, parenting skills, family therapy) in home, school and community settings. Counselors work with 2 families at a time Intervention lasts 4-6 weeks with referral for longer term care

8. HEALTH SCIENCES CENTER COLLEGE OF NURSING What We Did Developed a randomized controlled trial to examine the outcomes associated with HBCI, an enhanced HBCI and a Crisis Case Management model Implemented these models at two sites in the Bronx Randomly assigned 300 children to one of the interventions on presentation to the emergency department of two hospitals

9. HEALTH SCIENCES CENTER COLLEGE OF NURSING Research Logic Model Child Characteristics Demographics Child Functioning Social Community Functioning Needs Self-Concept Level of Risk Family Characteristics Structure Demographics Parenting Skills Family Adaptability & Cohesion Needs Parenting Self-Efficacy Level of Acculturation Providing Characteristics Demographics Program Characteristics Individual Care Approach Respite Care Family Violence Cultural Competence Provider Behaviors Services Provided to Family Services Provided to Children Advocacy Activities Linkages System Outcomes Costs # Admissions to Restrictive Setting # Days in Restrictive Settings # ER Presentations Child Outcomes Child Functioning Satisfactions with Services Family Outcomes Family Adaptability & Cohesion Satisfaction with Services Provider Outcomes Job Satisfaction Turnover Child Self-Esteem Social Supports Parenting Skills & Self-Efficacy

10. HEALTH SCIENCES CENTER COLLEGE OF NURSING Comparison of Models Program AttributeHome-Based Crisis Intervention (HBCI) Enhanced Home-Based Crisis Intervention (HBCI+) Crisis Case Management (CCM) Program goalsResolve immediate crisis, teach skills, improve family relationships, link to needed services Same as HBCI with the added goal of providing long-term family support services Assess needs, provide concrete services, link child and link family to needed services Caseload per workerTwo families in crisis Four families in crisis, four families requiring “generic” case management services Respite careNo respite providedIn-home and out-of-home respite available Staff trainingHBCI trainingHBCI training plus training in cultural competence and in working with violence in families Intensive Case Management and Crisis Intervention training Flexible service dollarsSome flexible service dollars available through nongrant sources An average of $100 per family available to meet individualized needs An average of $150 per family available to meet individualized needs Psychiatric servicesPsychiatrist available to provide assessment and treatment services within the home Psychiatrist consultation available to crisis case managers and to families for medication review

11. HEALTH SCIENCES CENTER COLLEGE OF NURSING Characteristics of Children & Families Table 1. Characteristics of Children Served (N=238) AgeAverage 12.03 years Range 4-17 years Gender (%)53 Boys, 47 Girls Race/ethnicity (%)59 Hispanic 34 African-American 6 White or other Clinical diagnosis (%)37 Disruptive behavior 21 Adjustment disorders 17 Mood disorders 11 Psychotic disorders Functional impairment (%)71 In the areas of self-care, social relationships, cognition, self- direction, or motor functioning Dangerous behavior (%)81 Yes to self or others Special education (%)50 In placements for the emotionally disturbed Prior mental health treatment (%) 43 Yes Prior mental health hospitalization (%) 8 Yes Table 2. Characteristics of Families Served by the Project Household composition (%)70 Single parent 30 Two parents Age of maternal caregiverMean age 39 years Median age 36 years Range 22-83 years Caregiver’s education (%)46 < High school 26 High school Marital status (%)27 Never married 24 Married 34 Divorced or separated Race/ethnicity (%)58 Hispanic 30 African-American 8 White or other Number of children (%)18 One 27 Two 26 Three 30 Four or more Employment status (%)21 Working Income sources (%)34 Welfare 60 Medicaid Income level (%)43 < $10,000 24 $10,000 to 20,000

12. HEALTH SCIENCES CENTER COLLEGE OF NURSING Measurement Child functioning & symptoms (CAFAS, CBCL) Family functioning (FACES) Self-esteem (Piers-Harris) Parenting self-efficacy (Boothroyd & Evans) Parent child relationship skills (Magura & Moses) Social support (Inventory of Socially Supported Behs.) Satisfaction with services & fidelity assessment Out of home placements Costs

13. HEALTH SCIENCES CENTER COLLEGE OF NURSING Outcomes Significant Differences in Mean Scores from admission to discharge (4-6 weeks) These differences were fragile and not maintained at the 6-month follow-up period

14. HEALTH SCIENCES CENTER COLLEGE OF NURSING Were the interventions effective when measured at discharge? Significant Differences in Mean Scores Admission to Discharge CCMHBCIHBCI+ FACES – Adaptability + + + Piers-Harris Children’s Self Concept + + + Parental Self Efficacy Assessment + + + CBCL – Social Competence + + + FACES – Cohesion * + + Inventory of Social Supportive Behvs * * + Note: + indicates differences in mean scores significant at p <.05.

15. HEALTH SCIENCES CENTER COLLEGE OF NURSING Were any of the effects found at discharge maintained at follow up (six months post-discharge)? Significant Differences in Mean Scores Admission to Follow Up CCMHBCIHBCI+ FACES – Adaptability + + + Piers-Harris Children’s Self Concept + + + Parental Self Efficacy Assessment + + + CBCL – Social Competence + + + FACES – Cohesion * * * Inventory of Social Supportive Behvs * * * Note: + indicates differences in mean scores significant at p <.05.

16. HEALTH SCIENCES CENTER COLLEGE OF NURSING Case Study 15-year old boy Got into a fight with his mother and threatened to kill other family members. Brought to ER by police, diagnosed with conduct disorder, oppositional defiant disorder, and a wrist fracture. He was referred to Pediatrics for treatment of the fracture and to the study for intensive in-home services. A year later brought to the ER following a violent fight with his mother who was wielding a knife. He was referred for follow-up treatment with ER staff and a report was filed for suspected child abuse.

17. HEALTH SCIENCES CENTER COLLEGE OF NURSING Another Case Study 10-year old girl who moved to U.S. from Santo Domingo three years ago. Referred to HBCI when she intentionally burned herself. History of fire setting and command hallucinations, physical and sexual abuse Mother concerned for the welfare of her other children.

18. HEALTH SCIENCES CENTER COLLEGE OF NURSING Intervention Enrolled in HBCI for 43 days. Mother and daughter agreed to talk twice a week about feelings and were encouraged to do fun things together each week. Counselor taught child how to use feeling statements and trust building exercises. Linkages to medical and dental care, mental health clinic, intensive case management, tutoring, educational advocacy and housing.

19. HEALTH SCIENCES CENTER COLLEGE OF NURSING Outcome Child was able to talk about abuse she experienced in Santo Domingo. She did not harm herself or others during the intervention. Mother changed her parenting behaviors with less yelling and pointing out good behaviors.

20. HEALTH SCIENCES CENTER COLLEGE OF NURSING What We Learned Families could be recruited to the study Services could be provided safely in home and community settings All three interventions showed positive short term outcomes Enhanced HBCI produced best outcomes Outcomes are of relatively short duration indicating the need for longer term services

21. HEALTH SCIENCES CENTER COLLEGE OF NURSING More Learning Outcomes varied by clinical profile, e.g., children with adjustment disorders & suicidal tendencies showed declines in social competence from admission to discharge & those with psychotic disorders had declines in self-concept Multi-component, individualized interventions are difficult to evaluate and may call for identifying the primary goal of treatment for each child and family

22. HEALTH SCIENCES CENTER COLLEGE OF NURSING Next Steps New models of in-home care are being developed and must be evaluated Additional attention needs to be paid to the interactions of psychosocial interventions and medication Interventions must be designed to promote retention of the gains made in the initial program

23. HEALTH SCIENCES CENTER COLLEGE OF NURSING Funding This project was funded by the National Institute of Mental Health and the Center for Mental Health Services.

24. HEALTH SCIENCES CENTER COLLEGE OF NURSING For Additional Details Evans, M., Boothroyd, R., Armstrong, M., Greenbaum, P., Brown, E., & Kuppinger, A. (2003). An Experimental Study of the Effectiveness of Intensive In-Home Crisis Services for Children and Their Families: Program Outcomes. Journal of Emotional and Behavioral Disorders, 11(2), 92-102. Evans, M., & Boothroyd, R. (2002) A Comparison of Youth Referred to Psychiatric Emergency Services: Police Versus Other Sources. The Journal of the American Academy of Psychiatry and the Law, 30(1), 74-78. Evans, M., Boothroyd, R., Greenbaum, P., Brown, E., Armstrong, M. & Kuppinger, A. (2001) Outcomes Associated With Clinical Profiles of Children in Psychiatric Crisis Enrolled in Intensive, In-Home Interventions. Mental Health Sciences Research 3(1), 35-43. Boothroyd, R., Kuppinger, A., Evans, M., Armstrong, M., Radigan, M. (1998) Understanding Respite Care Use by Families of Children Receiving Short-Term, In-Home Psychiatric Emergency Services. Journal of Child and Family Studies, 7(3), 353-376. Evans, M., Boothroyd, R., & Armstrong, M. (1997) Development and Implementation of an Experimental Study of the Effectiveness of Intensive In-Home Crisis Services for Children and their Families. Journal of Emotional and Behavioral Disorders, 5(2), 93-105.