Children at the Interface of Child Mental Health and Child Welfare

1
Children at the Interface of Child Mental Health
and Child Welfare

• Michelle Caza
• John McLennan
• 10th Annual Qualitative Health Research
  Conference
• May 1, 2004
• Banff, Alberta

www-fhs.mcmaster.ca/cscr/integration mcaza_at_ucalgar
y.ca 403-220-2776
2
Study Overview

• The Integration Study is composed of several
  sub-projects.
• Interface service issues in the child welfare and
  mental health sectors and was driven by
• our partners interest
• the numerous references to interface issues in
  interviews with administrators and providers
• empirical literature

3
Canadian Data

• Child Function Problems (Trocmé et al., 2001)
• Behavioral problems, 24
• Depression or anxiety problems, 11
• Developmental delay, 8

4
American Data

• Child Function Problems (Garland et al., 2001)
• ADHD, 21
• Conduct Disorder, 16
• Oppositional Defiant Disorder, 14
• Major Depression Disorder, 5
• Separation Anxiety Disorder, 5

5
Service Utilization

• Rates of mental health service utilization are
• difficult to determine (Landsverk Garland,
  1999)
• greater for children in state care than in the
  community (Landsverk Garland, 1999)
• Substantial delays in receiving mental health
  treatment after onset of emotional problems
  (Trupin et al., 1993)

6
Service Utilization

• Children in foster care
• used mental health services at a rate of
  approximately 15 times greater than other
  children (Halfon Klee, 1991)
• 56 had used mental health services after
  entering state care (Landsverk Garland 1999)
• 14 were referred to mental health services
  (Glisson 1996)

7
Research Question

• What prevents children in the protection of the
  state from obtaining needed mental health
  services?

8
Methodology

• 11 interviews
• Research team used semi-structured interviews
• 5 discussion groups
• Research team directed discussion
• 1 workshop with 15 participants
• Research team facilitated discussion by
  presenting three topics for discussion
• Participants discussed one of the three topics in
  small groups
• Summary of the participants group discussion
  reviewed by participants

9
Analysis

• Grounded theory approach
• Initial analysis
• Identified codes
• Incorporated emerging themes into subsequent
  interviews
• Subsequent analysis
• Refined codes
• Develop model

10
A Preliminary Model
Lack of Services
Resource (Mis)Allocation
Communication Problems
Failures in Service Delivery
Poor Outcomes For Children
11
Lack of Services

• were constantly scratching our heads at how
  were going to help some kids who have real
  mental health problems
• provincial child welfare administrator

12
Lack of Services

• Weve seen so many kids that are in care for a
  year or two before they get any kind of mental
  health assessment, and we know that more than 80
  of them have mental health problems
• urban mental health provider

13
Lack of Services

• Nobody wants to take him for treatment. Treatment
  centers dont usually take kids unless they are
  12 or 13 years old.His needs are becoming
  higher, hes basically deteriorating in front of
  us and we cant stop it
• rural child welfare provider

14
Resource (Mis)Allocation

• I dont know why necessarily they access private
  mental health services and not us.Very few of
  them come to Mental Health first. They come to
  Mental Health through psychiatry second, third,
  fourth, fifth, sixth, down the line after theyve
  gone through a bunch of private stuff
• urban mental health provider
• I dont blame them for doing it, I dont think
  its a good use of money. I think if it was all
  in one pot together, it could be better utilized.
  Butthey have to have reports for courtsI mean
  they have to do it
• urban mental health administrator

15
Resource (Mis)Allocation

• There is an issue around, sort of this game that
  Mental Health and Child Welfare playsort of pass
  the hot potato. If the Mental Health clinic is
  and theyre all pretty much inundated with
  service demands and the child welfare worker has
  a child who also has a mental health issue, we
  know the child welfare worker can access private
  service provider to provide services to those
  children. So its a complicated game of between
  the therapist and the child welfare worker about
  who actually is to provide service.
  Unfortunately, what happens a lot of times, in my
  region anyway, is that sometimes nobody provides
  the services to the child because theyre still
  figuring out what to do with the child or the
  opposite happens in that the public clinician
  is providing services and a private contracted
  service is also providing service
• rural mental health provider

16
Resource (Mis)Allocation

• all types of models have been attempted, and not
  because of a change in mandate or a change in
  approach provincially. But local needs,
  particularly outside the major centers, whose
  available, whose living there to provide mental
  health services
• provincial child welfare administrator

17
Communication Problems

• Its a sort of definition and discipline issue,
  too, you know. Psychologists and psychiatrists
  coming from way over here and social workers from
  way over here. Like they may be talking about the
  same kid with the same presenting problems but
  they see him a little differently, and they see
  the solutions really differently. And quite often
  theyre looking at each other for the solution.
  They dont talk the same language
• provincial child welfare administrator

18
Communication Problems

• Child Welfare got involved because of a sexual
  abuse disclosure. So now, theyre child welfare
  sending him to me because maybe I can get the
  information out of him. Well, I dont go
  information hunting.Now if you get to talk to
  them, and explain it, its usually okay. But,
  sometimes they child welfare dont understand
  why we wont see certain people or why we cant
  do certain things
• rural mental health provider

19
Communication Problems

• I certainly think Mental Health, from their end,
  theyre very concerned about client
  confidentiality and, interestingly, what Ive
  heard happens is that Mental Health workers will
  call our workers asking for information, our
  workers are allowed to share the information and
  will do it, but they dont get that back from
  Mental Health workers. And sometimes they find
  that Mental Health workers, almost, because
  theyre advocating for their families, its like
  theyre working at cross-purposes sometimes
• rural child welfare administrator

20
Communication Problems

• privacy concerns prevent effective information
  sharing on the behalf of children
• provincial child welfare administrator

21
Barriers from Empirical Literature

• Inadequate or absent mental health services (Klee
  et al., 1997 Trupin et al., 1993)
• A lack of properly implemented and/or appropriate
  mechanisms to identify and refer children with
  mental health problems to services (Klee et al.,
  1997 Dale et al., 1999 Glisson et al., 2002)
• Lack of cooperation among providers (Trupin et
  al., 1993)

22
Summary

• System Characteristic
• Lack of services
• Resource (mis)allocation
• Communication problems

• System Failure
• Delays in treatment
• Fractionated services
• Delays in treatment
• Duplication of services
• Inhibits information sharing
• Contributes to misperceptions each sector has of
  the other sector

23
Current Initiatives

• Address the needs of children
• With multiple impairments, complex mental health
  and health issues and/or severe behavioural
  needs
• For whom all currently available resources have
  been utilized with limited success
• Who require fiscal and human resources that
  strain the capacity of any one ministry
• For whom there are questions about the safety of
  the child, youth, family, or public

24
Current Initiatives

• Components of interest
• Case management model
• Cross-ministry information sharing

25
Research Team

• John D. McLennan, MD, MPH, FRCP(C), Principal
  Investigator, University of Calgary, Calgary,
  Alberta
• Michael Boyle, MSW, PhD, McMaster University,
  Hamilton, Ontario
• Robin McWilliam, PhD, Vanderbilt University,
  Nashville, Tennessee
• D. R. Offord, MD, FRCP (C), McMaster University,
  Hamilton, Ontario
• Kent Rondeau, MBA, PhD, University of Alberta,
  Edmonton, Alberta
• Debbie Sheehan, BScN, MSW, City of Hamilton,
  Hamilton, Ontario
• Michelle Caza, MA, University of Calgary,
  Calgary, Alberta
• Ellie Deveau, BScN, McMaster University,
  Hamilton, Ontario

26
The Integration of Health and Social Services for
Young Children and their Families

• Funders
• Canadian Health Services Research Foundation
• Alberta Heritage Foundation for Medical Research
• Ontario Ministry of Health and Long-Term Care
• (Canadian Institutes of Health Research)

27
Selected Bibliography

• Dale G Jr, Kendall JC, Stein Schultz J. 1999. A
  proposal for universal medical and mental health
  screening for children entering foster care. In
  The Foster Care Crisis Translating Research into
  Policy and Practice, GD Dale and JC Kendall
  (editors). Lincoln, NB University of Nebraska
  Press, pps. 175 192.
• Garland AF, Hough RL, McCabe KM, Yeh M, Wood PA,
  Aarons GA. 2001. Prevalence of psychiatric
  disorders in youths across five sectors of care.
  Journal of the American Academy of Child and
  Adolescent Psychiatry 40 (4) 409 418.
• Glisson C. 1996. Judicial and service decisions
  for children entering state custody The limited
  role of mental health. Social Service Review
  June 257 281.
• Glisson C, Hemmelgarn A, Post JA. 2002. The
  shortform assessment for children An assessment
  and outcome measure for child welfare and
  juvenile justice. Research on Social Work
  Practice 12 (1) 82 106.
• Halfon N Klee L. 1991. Health and development
  services for children with multiple needs The
  child in foster care. Yale Law Policy Review 9
  (46) 71 96.
• Klee L, Kronstadt D, Zlotnick C. 1997. Foster
  cares youngest A preliminary report. American
  Journal of Orthopsychiatry 67 (2) 290 299.
• Landsverk JL Garland AF. 1999. Foster care and
  pathways to mental health services. In The Foster
  Care Crisis Translating Research into Policy and
  Practice, Curtis PA, Dale GD, Kendall JC
  (editors). Lincoln University of Nebraska Press
  in association with the Child Welfare League of
  America. Chapter 9 (pp 193 210).
• Trocmé NM, MacLaurin BJ, Fallon BA, Daciuk JF,
  Tourigny M, Billingsley DA. 2001. Canadian
  incidence study of reported child abuse and
  neglect Methodology. Canadian Journal of Public
  Health 92 (4) 259 263.
• Trupin EW, Tarico VS, Low BP, Jemelka R,
  McClellan J. 1993. Children on child protective
  service caseloads Prevalence and nature of
  serious emotional disturbance. Child Abuse
  Neglect 17 345 355.