System of Care Development

Overall System Development. The majority of sites made more progress in the development of their infrastructures than in the development of their service delivery systems. This is consistent with data collected from past years, and gives support to an assumption that the development of an infrastructure is needed to promote growth in service delivery.

Community Based Services. Sites generally made progress in offering services throughout their catchment areas. Most sites reported offering services in a range of settings, such as providing services in schools or homes.

Community Based Decision-Making. Overall, community needs were important factors in system development. Although almost half of the sites involved the community in the decision-making processes to some degree, only a few had active community representatives on their interagency structure or governing board.

Interagency Structure Participation. Virtually all sites included the required child-serving agencies on their interagency structures. However, the strength of the partnership and the degree of participation varied. All interagency structures had at least one family representative, although the decision-making authority given to these representatives varied widely.

Interagency Structure Authority. Only a few sites fully empowered the interagency structure to make management and budget decisions that influence all participating child-serving agencies. Many sites continue to struggle with the role of the interagency structure, and the roles of its participants. In response, many sites have reorganized their interagency structures over the past year.

Service Array. All sites reported using CMHS grant funds to expand their service arrays such that almost all sites were able to offer a full continuum of care. Some sites reported difficulties in recruiting enough qualified providers to offer adequate therapeutic foster care and respite services. Non-mental health service arrays, such as peer and parent support groups, are reported to be the most difficult to develop. Some sites expanded their service arrays by enlisting private providers already operating in the community, such as the YMCA and Boys and Girls Clubs.

Innovative Services. Many sites developed innovative and creative services, such as a vocational work program, an after-school art program, an independent living skills program, and a comprehensive sexual abuse treatment program. In some sites, flexible funds were used to pay for innovative services or classes designed to bolster the strengths and interests of children or meet the concrete needs of the family.

Case Management. All sites implemented variations of a case management system. In many sites all children and families in the system of care were assigned a case manager/service coordinator; in others a case manager was only assigned when a child was assessed to be at high risk of out-of-home placement.

Individualized Service Planning. Virtually all sites had an individualized service planning process that was designed to involve representatives from many agencies and the family. However, these processes had not resulted in every family receiving coordinated, individualized care. Some children received only traditional mental health services.

Family Centered. Almost all sites had an active family organization in the community, and all sites reported that they involved families in system management and in planning the care for their own families. However, the depth of family involvement varied significantly among sites.
Family Empowerment. Some systems of care were beginning to take steps to actively promote the development of family advocacy and empowerment. In some sites, system of care intake packages included information about a local family organization. Other strategies to empower families included creating resource libraries, creating computerized data bases of all families participating in the system of care, and offering on-line access to Internet information.

Cultural Competence. A few sites made significant attempts at improving cultural competence, although respondents in most sites recognized the need for continued improvement. Several sites created specific staff positions to identify cultural competence needs, or employed bilingual staff. Many families reported that the mental health case managers were sensitive to their backgrounds, respecting the family's beliefs and values.

Children and Families

Child Characteristics

Average Age: 12.7 years. 5% age 0-5 years; 29% age 6-11 years; 35% age 12-15 years; and 31% age 16 years and older
Sex: 62% male; 38% female
Race/Ethnicity: 54% Caucasian; 17% African American; 22% Hispanic; 7% other

Family Characteristics

Family Composition: 54% single parent homes; 24% two parent homes; 7% guardian; 11% ward of State; 5% other
Living Arrangements: 61% of children were reported to have lived in just one living arrangement during the previous 12 months; 39% were reported to have lived in two to eight different living arrangements.

Risk Factors

Poverty: Little is known about exactly how poverty affects mental health -- whether it precipitates the onset of mental health problems, lengthens the duration, or increases the potential for recurrence. Given these facts it is important to note that 63% of the respondents report incomes below the HHS Poverty Guidelines for 1996.
Poverty and Family Composition: Children living in single-parent homes and in poverty are disproportionately represented in the evaluation sample. Of children living in poverty, 73% were in mother-maintained households, 5% in father-maintained households, and 22% in two-parent households.
Child Risk Factors*: Of the respondent families, 68% identified at least one child risk factor for serious emotional disturbance: history of physical abuse (34%); previous psychiatric hospitalization (26%); history of running away (25%); and sexual abuse (24%) were the most frequently reported child risk factors.
Family Risk Factors*: Of the respondent families, 83% identified family risk factors, including family substance abuse, violence, and family history of mental illness. 21% reported two family risk factors, and another 40% reported three or more family risk factors.

*Each child and family risk factor was assessed independently of others; therefore, the reported percentages correspond to specific risk factors and should not be added across factors to reach 100%.

Referral Sources and Diagnosis

Referral Sources: 22% of the children were referred by a mental health agency; 21% were referred by a school; 17% were referred by a social service agency; 11% were referred through courts and correctional institutions; 16% were parent or self-referred. Thirteen percent did not specify a referral source.
Referral Sources by Racial/Ethnic Category: Of those who were self-referred, 71% are Caucasian; 15% are African American; and 3% are Hispanic. Of those referred by external sources, 50% are Caucasian; 25% are African American; and 10% are Hispanic.
Primary Diagnosis: Based on DSM-IV criteria, 35% were diagnosed with a conduct-related disorder; 27% with depressive disorders; 13% with attention deficit disorder; 7% with anxiety, 16% with other diagnoses such as substance use, eating, somatic, speech disorders, enuresis, phobia; and 2% with psychotic disorders.
Multiple Diagnoses: 30% of the children had two distinct diagnoses. For children diagnosed with conduct disorder, 33% had a secondary diagnosis of substance use disorder. Children diagnosed with a depressive disorder were most likely to have a secondary diagnosis of conduct disorder (23%) or substance use disorder (20%).

Education

Individualized Educational Plan (IEP): 36% SED designation; 17% other; 38% no IEP. Children in the primary grades were less likely to have an IEP than children in higher grade levels.
Educational Placement: 46% of the children were placed in regular classrooms; 32% were assisted with resource room and classroom aides; 20% were in self-contained special education classrooms; 2% formally dropped out of school. Of the children who were placed in special education classrooms at intake, within six months 13% were transferred to regular classrooms with some special education support.
Attendance: 73% of children attended school more than 75% of the time; 17% attended between 50% to 75% of the time; 10% attended less than half the time. There was a significant increase in the number of children who attended school regularly six months after intake.
Grades: 55% made average or above average school grades at intake; the percentage increased significantly to 62% at six months.
School Performance: Regular school attendance was associated with more favorable school performance.

Juvenile Justice

Contact with Youth Authorities: 15% of the children indicated some contacts with law enforcement at the time of intake. Of these, roughly half showed no subsequent contacts between intake and six months.
Adjudicated Convictions: 13% of the sample had one or more adjudicated misdemeanors; 6% reported an adjudicated felony conviction.

Clinical Outcome

Multiple Risk Factors: Children with multiple risk factors were more likely to have more problem behavior and poorer functioning.
Child Behavior Checklist: On average, children made significant improvement in all problem areas from intake to six months. Change scores for this analysis were based on the percentages of children participating at both intake and six months who scored above the 90th percentile on the CBCL.

CBCL	% Above Clinical Range at Intake	% Above Clinical Range at 6 Months	% Improvement
Total Problem Scale	72%	60%	12%
Internalizing	53%	42%	11%
Externalizing	69%	58%	11%

(CBCL--Internalizing: unhappy, sad, depressed; Externalizing: acts out, argues a lot)

Child and Adolescent Functional Assessment Scale: Children made significant improvement, on average, in behavior at school, in the community, and at home. Children who showed the greatest improvement in social functioning also showed the greatest improvement in school performance and had fewer contacts with law enforcement. Change scores for this analysis were based on the percentages of children participating at both intake and six months who scored above the cutoff for the moderate range on the CAFAS.

CAFAS	% Moderate or Severe Range at Intake	% Moderate or Severe Range at 6 Months	% Improvement
Home	60%	44%	16%
School	68%	52%	16%
Community	31%	22%	9%

(CAFAS--psychosocial domains: home/school/community; thinking; behavior toward others and self; moods and emotions; and substance use)

Satisfaction with Services

Most of the families were satisfied with the services their children had received, and they felt involved in their children's treatment program. Three quarters of the families rated service as good or excellent.
Over half of the families felt that they were always given a choice in decision making related to their child's treatment planning and care. The same proportion of families indicated that they were always asked for their ideas and opinions.
Another key indicator of family satisfaction was the high level of comfort families felt with their involvement in the system of care.
Over three quarters of families felt they would receive care unconditionally, and believed that the quality of their care would be high.

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