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2000 Annual Report to Congress on the Evaluation
of the Comprehensive Community Mental Health
Services for Children and Their Families Program
Back to Report
EXECUTIVE SUMMARY
Over the past three decades, increasing attention has been given to the needs of children and
adolescents with serious emotional disturbance. Beginning with the findings from the Joint
Commission on the Mental Health of Children (National Institute of Mental Health, 1969) and
substantiated by numerous subsequent studies, task forces, and reports, children with serious
emotional disturbance typically were found to be underserved or served inappropriately by a
fragmented mental health services system. In response to these findings, Federal leadership, along
with a growing family movement, began to emerge and create a new paradigm for serving the
estimated 4.5 to 6.3 million children in the United States who have a serious emotional disturbance
(Friedman, Katz-Leavy, Manderscheid, & Sondheimer, 1999). This paradigm shift has resulted in
a system-of-care approach, designed to help build comprehensive service systems that allow
children with emotional disturbance to receive a comprehensive array of integrated, community-based services.
The system-of-care approach is based on a philosophy built on three hallmark tenets: (a) mental
health service systems are driven by the needs and preferences of the child and family; (b) services
are community based with their management built on multi-agency collaborations; and (c) the
services offered, the agencies participating, and the programs generated to meet the mental health
needs of the children are responsive to the cultural context and other characteristics of the
populations being served.
To develop a system of care consistent with the theoretical approach described above, a community
must focus its service program activities at two distinct levels: (a) infrastructure to house, organize,
and manage the integrated program elements; and (b) service delivery to provide services, treatments,
and supports that are offered directly to children and families.1
The Center for Mental Health Services (CMHS) within the Substance Abuse and Mental Health
Services Administration (SAMHSA) has had the primary responsibility for translating this
framework into a program of services and supports that now exists in 67 grant communities around
the country. Beginning with a funding mechanism to support the creation of a service system
infrastructure called the Child and Adolescent Service System Program (CASSP) in 1986 and
culminating with the passage of the Children's and Communities Mental Health Services
Improvement Act in 1992, CMHS has championed the development of community-based, family-focused, and culturally competent systems of care. Funding for these systems of care is provided
through CMHS's Comprehensive Community Mental Health Services for Children and Their
Families Program.
This program, in its seventh year, provides grants to States, communities, territories, American
Indian tribes, and Alaskan Native communities to improve and expand their systems of care to meet
the needs of children and adolescents with serious emotional disturbance and their families. These
include children and youth with a serious emotional disturbance from birth to age 21 who currently
have, or at any time during the past year had, a mental, behavioral, or emotional disorder of sufficient
duration to meet diagnostic criteria specified in the Diagnostic and Statistical Manual for Mental
Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994), that resulted in
functional impairment that substantially interferes with or limits one or more major life activities.
Administered by CMHS's Child, Adolescent and Family Branch, funding for the initiative has grown
from an initial $5 million in its first year to the FY 2000 level of $83 million.
In addition to developing systems of care, the CMHS program is mandated by Congress to
demonstrate the effectiveness of these systems. The foremost method to demonstrate program
effectiveness is through evaluation. Beyond serving as a fiscal watchdog, evaluation—both of
specific grant community programs and of the combined effect of many systems of care—can inform
CMHS about what works best for whom, and under what conditions. As such, it helps guide new
directions for current grant communities and sets a benchmark for future generations of community-based systems of care. Government Performance and Results Act (GPRA) measures set for this
program include increases in collaboration among child-serving agencies, stability of children's
living arrangements and family satisfaction, decreases in the use of inpatient or residential services,
and improvement in child clinical and functional outcomes as indicators of program effectiveness.
Information about program performance on these measures is presented in detail throughout the
2000 Annual Report to Congress.
This report presents data accumulated through August 2000 from 67 grant communities funded in
1993, 1994, 1997, 1998, 1999, and 2000. Because the communities receiving their grants in 1999
had just begun data collection, this evaluation report focuses on the 45 grant communities that
established systems of care for approximately 42,221 children and families. Figure ES-1 illustrates
the funding phases and evaluation activities of the CMHS program.
This Executive Summary presents findings from four types of evaluation data, described as follows:
Outcomes data based on project site evaluations of a selected group of about 1,000 children from
communities funded in 1993 and 1994 assessed at intake, 6 months, 12 months, 24 months, and
annually thereafter for as long as they remained in the program. In addition, outcomes data based
on project site evaluations of a selected group of 100 to 250 children from communities funded
in 1997 and 1998 assessed at intake and 6 months, and every 6 months thereafter as long as they
remained in the evaluation. Outcomes measures applied in the evaluation included—but were
not limited to—an assessment of the child's clinical and social functioning, strengths,
educational performance, stability of living arrangements, delinquent activities and engagement
with law enforcement, and substance use, as well as assessment of family functioning, family
resources, and strains experienced by caregivers of children with serious emotional disturbance.
These were coupled with an assessment of services received and child and family ratings of
satisfaction with services provided. Instruments typically used in the field of children's mental
health, including the Child Behavior Checklist (CBCL; Achenbach, 1991), the Child and
Adolescent Functional Assessment Scale (CAFAS; Hodges, 1990), and the Behavioral and
Emotional Rating Scale (BERS; Epstein & Sharma, 1998), were used to collect these data.
Service system assessment data collected during multiple years through systemwide and family
assessments of service delivery in system-of-care communities.
Child and family outcomes data, as well as service system assessment and management
information system (MIS) data obtained in communities with system-of-care grants and
communities without these grants.
Descriptive data (e.g., demographic information, diagnostic status, functional characteristics, and
referral sources) obtained at the time children entered services.
The report is comprehensive and involves the grant communities, the children and families served
by the CMHS programs, service providers, and partner agencies. It also involves non-funded
comparison communities. The number of grantees and participants and number of components and
variety of methodologies incorporated into the evaluation make it the most extensive study ever
undertaken of a children's mental health services initiative.
The format for reporting findings in this Executive Summary is to present a brief finding followed
by its corresponding graph. Findings of change over time are reported as the change occurring among
children from the time of entry into services to subsequent data collection times.
A list of the grant communities funded in 1993, 1994, 1997, 1998, 1999, and 2000 under this
congressionally mandated program is on pages xxxvii-xxxix.
CHILD OUTCOMES
Children and adolescents participating in systems of care funded in 1993-94 experienced improved
functioning and decreased behavioral and emotional symptoms across 2 years of receiving services.
These positive changes were accompanied by improved school performance, decreased law
enforcement contacts, and sustained satisfaction among caregivers and youth.
Children's Behavioral and Emotional Problems Improved
Nearly one-third of the children who received services during their first 6 months in systems of care
showed significant improvements in their behavioral and emotional problems. More children who
received services to 1 year showed improvement, and still more children who received services for
up to 2 years showed improvement. These trends were measured using the total problem score on
the Child Behavior Checklist (see Figure ES-2).
Children's Behavioral and Emotional Problems Improved
After 2 years in system-of-care services, 46 percent of the children showed a significant reduction
in their total problem behaviors. For about 70 percent of these children, total reported emotional and
behavioral problems fell below levels indicating a need for clinical care after 2 years in system-of-care services (see Figure ES-3).
Children experienced significant reductions in their behavioral and emotional problems during 2
years in system-of-care services (see Figure ES-4).
Social Functioning Improved
Average CAFAS scores declined from 91.3 (intake) to 73.9 (2 years), indicating improvement in
children's overall functioning by themselves, in social roles, and in interaction with others after 2
years in systems of care. Although girls made slightly greater improvement in functioning during
their first 6 months in services, both boys and girls improved significantly from intake to 2 years.
(see Figure ES-5).
Children's Behavioral and Emotional Strengths Improved
Caregivers' ratings of children's strengths increased significantly in all areas after 6 months in the
system-of-care programs. The exception was school functioning, which improved slightly. Children
made the greatest improvement in intrapersonal strength. Children diagnosed with conduct-related
disorders had the greatest increases in overall strengths scores 6 months after intake into system-of-care services to above average strengths for children with behavioral and emotional disorders (see
Figure ES-6).
School Attendance and School Performance Improved
Improvements in school attendance and school performance were found for both boys and girls.
Although boys remaining in services through 2 years attended school more regularly (50 percent of the
time or more), girls made greater gains in their school attendance during that time (see Table ES-1).
Improvements in academic performance after 2 years were also found among those children
receiving special education services (see Table ES-2).
More Children Had an Individualized Education Plan (IEP)
Increased use of IEPs was found for children in the outcomes study over time. At intake into
services, 41.7 percent of the 726 children in the outcomes study who had complete data at all four
data collection points did not have an IEP (see Figure ES-7). The percentage of children who had
an IEP increased from intake to 2 years. These statistics demonstrate an overall increase in the use
of IEPs of 19 percent from intake to 2 years.
An IEP is an important component for providing effective services through the school to children
with emotional disturbance. These plans clarify service provision and provide annual goals for
measuring progress in behavioral and emotional as well as academic areas. IEPs can facilitate
interagency collaboration in meeting the needs of individual children and are consistent with the
system-of-care philosophy.
Children With an Individualized Education Plan (IEP) Showed Improvement
in Educational Performance
School performance improved among all children served in the systems of care from intake to 2
years. This improvement was evident among both children who had an IEP throughout the 2 years
and those who never had an IEP in the 2-year period (see Figure ES-8). However, the patterns of
improvement in school performance were different across time for the two groups. While children
with an IEP throughout the 2 years improved their school performance steadily from intake to 6
months to 1 year and to 2 years, school performance for children who never had an IEP in the same
period improved from intake to 6 months, but deteriorated from 6 months to 1 year. However, these
same children were reported to improve dramatically from their 1-year assessment to their 2-year
assessment.
Law Enforcement Contacts Were Reduced
Decreased involvement with the legal system is also an indicator of positive change for children and
adolescents who received system-of-care services. Overall, contacts with law enforcement decreased
among youth in the system of care from intake to 2 years. Although most youth had not had any
contact with law enforcement in the year prior to intake into system-of-care services, 23.9 percent
of the youth had one or more contacts with law enforcement in the year prior to intake as a result of
one or more violations of the law (see Figure ES-9). Overall, for youth reporting on their law
enforcement contacts at all four data collection points (intake, 6 months, 1 year, and 2 years), there
was a decrease in the number of contacts with law enforcement from intake to 2 years.
Residential Stability Improved
One of the major principles of the system-of-care initiative is to provide services so that children can
remain in their homes and in their communities. Stability of living arrangements is a reflection of
how well a system of care is achieving goals related to that principle. Overall, the stability of living
arrangements increased among children in the system of care from intake to 2 years. The majority
of children reported only one living arrangement in the year prior to intake (64 percent); however,
there was a decrease from intake to 2 years in the percentage of children with multiple living
arrangements (see Figure ES-10).
FAMILY OUTCOMES
Caregiver's Strain Decreased
The Caregiver Strain Questionnaire (CGSQ; Brannan, Heflinger, & Bickman, 1998) assesses the
extent to which caregivers experience additional difficulties, strains, and other negative effects as
the result of their caregiving responsibilities. Respondents assess strain along four dimensions: the
total impact on the family (global strain); observable negative events or consequences related to the
child's disorder have been a problem for the family (objective strain); negative feelings about the
child such as anger, resentment, or embarrassment (subjective externalizing strain); and negative
personal feelings such as worry, guilt, and fatigue (subjective internalizing strain).
Caregiver responses indicated that strain was reduced significantly across all dimensions from intake
to 6 months, particularly in the domain of objective strain (see Figure ES-11). Decreased scores may
indicate reduction in negative events such as disrupted family relationships, routines, social
activities, and loss of personal time.
SERVICE SYSTEM DEVELOPMENT AND SERVICE DELIVERY
Systems of Care Show Success in Implementing Guiding Principles
Success Greater in the Delivery of Services
The system-of-care model calls for individualized, family-focused, and culturally competent services
and supports. These services should be community based and accessible, provided in the least
restrictive environment possible, and provided through a collaborative, coordinated interagency
network. Figure ES-12 shows the score averages for the eight principles applied to the infrastructure
and service delivery domains of systems of care across sites. Components of these domains are
shown in Table ES-3. On average, sites tended to score higher in the service delivery domain than
in the infrastructure domain.
Children and Families Received Needed Mental Health and Support Services
Among grant communities funded in 1997 and 1998 in which caregivers had completed a 6-month
assessment, children and families received a broad array of services. Children and families used an
average of six different services between intake and 6 months. Figures ES-13 and ES-14 show the
percentage of children receiving different types of services.
CAREGIVER RATINGS OF SERVICES
Caregivers Rated Service Activities at a High Level
- Caregivers were satisfied with services. Nearly 70 percent of the caregivers indicated that they
found services to be good or excellent after 2 years (see Figure ES-15).
- Caregivers were satisfied with their child's progress. Over 70 percent of the caregivers were
satisfied or very satisfied with their child's progress after 2 years in services (see Figure ES-15).
- Caregivers reported having a choice in making service decisions. Over 75 percent of the
caregivers reported being satisfied or very satisfied with their choice of services (see Figure ES-15).
- Caregivers reported being asked their opinions about their child's treatment. Nearly 70
percent of the caregivers indicated that they were usually or always asked for their ideas and
opinions (see Figure ES-15).
- Caregivers received unconditional, high-quality care. Nearly 70 percent of the caregivers felt
they would receive care unconditionally and believed that the quality of their care would be high
(see Figure ES-15).
YOUTH RATINGS OF SERVICES
Youth Rated Services as Good or Excellent After 6 Months
- Youth were satisfied with services. Nearly 70 percent of the youth rated services as "good or
excellent" after 2 years in services (see Figure ES-16).
- Youth were satisfied with their progress. Nearly 70 percent of youth were satisfied or very
satisfied with their progress after 2 years in services (see Figure ES-16).
- Some youth reported having a choice in making service decisions. Less than half of the youth
reported having a choice in the services they received (see Figure ES-16).
- Some youth reported being asked their opinions about their treatment. Less than half of the
youth reported that they were usually or always asked for their opinion or ideas (see Figure ES-16).
- Youth received unconditional, high-quality care. Nearly 70 percent of the youth felt they
would receive care unconditionally and believed that the quality of their care would be high (see Figure ES-16).
Youth were less likely to report having a choice in services, being asked their opinions, and believing
that their care was unconditional than caregivers.
CHARACTERISTICS OF CHILDREN AND FAMILIES SERVED IN GRANT
COMMUNITIES FUNDED FROM 1993 TO 1998
Children with Serious Emotional Disturbance Were Disproportionately
Poor, Male, and in Living Situations Other Than Two-Parent Homes
- About two-thirds of children served were boys. Sixty-two percent of the children were boys
and 38 percent were girls (see Table ES-4).
- More than half of children were in early adolescence. The children's average age across grant
communities was 12.1 years. (see Table ES-4).
- A diverse racial-ethnic population was served. Fifty-three percent of the children were White,
24 percent were Hispanic, 14 percent were African-American, 2 percent were American Indian,
3 percent were Asian American or Pacific Islander, and 4 percent were of other racial/ethnic
background (see Table ES-4).
- The majority of families were poor. Sixty-eight percent of the children lived in households
with an annual income below the poverty level. According to the 2000 U.S. Department of
Health and Human Services poverty guidelines, a family of four with two children is living in
poverty if their income is below $17,050 (U.S. Census Bureau, 2000).
- Mother-maintained households had the highest poverty rates. Seventy-six percent of those
living with their mother only were from households with an annual income below the poverty
level, as compared to 56 percent of those living with both parents or one biological parent and
one stepparent and 60 percent of those living with their father only. This high percent of single-mother, low-income households in systems of care exceeds the national rate. Nationally, 34
percent of all female-maintained, single-parent households had poverty-level incomes in 2000
(U.S. Census Bureau, 2000).
REFERRAL SOURCES
Children Entered Systems of Care Through Various Sources
Twenty-two percent of the children were referred to systems of care by mental health agencies,
nearly 15 percent were referred by juvenile justice agencies, 20 percent were referred by schools, 14
percent were referred by social service agencies, 16 percent were referred by caregivers or youth
themselves, and 17 percent were referred by other sources (see Figure ES-17).
There was a significant difference in the racial or ethnic characteristics of the children referred by
their parents or the youth themselves (i.e., self-referral) and those referred by external sources such
as schools or mental health agencies (i.e., external referral). Although external referrals were in
proportion to the ethnic distribution of children in the overall sample, White families were over-represented and Hispanic families were under-represented among those who referred themselves to
services. In the self-referral group, 69.5 percent of the children were White, 13.9 percent were
African-American, and 6.8 percent were Hispanic. In contrast, 52.9 percent of the children in the
external referral group were White, 25.3 percent were Hispanic, and 14.3 percent were African-American. Even though minority children were over-represented among those receiving services
when compared to population statistics (U.S. Census Bureau, 2000), they were no more likely to be
referred to services from external sources.
CHILD RISK FACTORS
Most Children Entered Services with One or More Risk Factors
Sixty-seven percent of the children were described by their caregivers as having experienced one or
more child risk factors, including physical abuse, sexual abuse, previous psychiatric hospitalization,
sexual abusiveness, suicide attempt, drug and alcohol use, and a history of running away. Figure ES-18 presents the percentage of children with each of these risk factors at entry into system-of-care
services. Figure ES-19 illustrates the proportion of children who experienced multiple child risk
factors.
FAMILY RISK FACTORS
The Majority of the Families Had Experienced at Least
One Family Risk Factor
Most children (84 percent) were exposed to at least one family risk factor, significantly higher than
those with at least one child risk factor (67 percent). Family history of substance abuse, violence, and
mental illness were the most frequently reported family risk factors (see Figure ES-20). Forty-two
percent of the caregivers reported three or more family risk factors experienced by children's
biological families (see Figure ES-21).
DIAGNOSTIC CHARACTERISTICS
Disruptive Behavior Disorders Were Most Common Diagnoses
Of the 35,625 children in grant communities funded from 1993 to 1998 for whom a primary
diagnosis was reported, 43.2 percent displayed a disruptive behavior disorder (29.4 percent were
conduct-related disorders and 13.8 percent were attention-deficit/hyperactivity disorder, or ADHD).
Over 25 percent of children were diagnosed with depression, 7.9 percent with an anxiety disorder,
and 6.3 percent with an adjustment disorder. The remaining primary diagnostic categories (assigned
to approximately 16.8 percent of the sample) included, but were not limited to, substance abuse,
eating, somatic, and speech disorders, as well as enuresis, encopresis, abuse/neglect, personality
disorders, and learning disabilities (see Figure ES-22).
Of the children with a valid DSM-IV primary diagnosis, 24.2 percent also had a secondary diagnosis.
Among these 8,600 children, 22 percent had a secondary diagnosis of a conduct-related disorder and
20 percent had a secondary diagnosis of substance abuse disorder. These 20 percent represent about
5 percent of all children with a primary diagnosis. These findings are consistent with recent research
among clinical samples that indicates that adolescents with behavioral and substance abuse disorders
tend to have other psychiatric disorders as well (Grilo, Becker, Fehon, Edell, & McGlashan, 1996;
Grilo, Walker, Becker, Edell, & McGlashan 1997; Wilens, Biederman, Abrantes, & Spencer, 1997).
STABILITY OF LIVING ARRANGEMENTS
About Half of the Children Had Lived in Multiple Settings Before Intake
One way to gauge children's social well-being is to examine the stability of their living arrangements
over time. Almost half of the children had lived in more than one setting in the period before
entering services. Living arrangements for children enrolled in services in communities funded in
1997-98 (Phase II) were assessed for the 6 months before entering services. When compared to
children in communities funded in 1993-94 (Phase I) who were assessed for 1 year before entering
services, these children had experienced more living situations in a shorter period of time, with over
25 percent living in three or more settings in 6 months (see Figure ES-23).
EDUCATIONAL STATUS
Children Entered System of Care with Difficulties in School
In communities funded in 1993 and 1994, caregiver reports of educational placement, school
attendance, and school performance at entry into system-of-care services included the following:
- At intake, about 72 percent of the children were reported to attend school on a regular basis
(more than 75 percent of the time), while 16.2 percent were reported to attend infrequently (less
than 50 percent of the time).
- Although 54 percent of the children were reported to earn average (37.6 percent) or above
average grades (16.4 percent), about 30 percent were earning below average grades and almost
16 percent were reportedly failing in school.
- More than half of the children (57 percent) had an Individualized Education Plan (IEP) at intake.
In communities funded in 1997 and 1998, 48 percent of the children enrolled in the outcomes study
had an IEP at intake into system-of-care services. Fifty-three percent of those children who had an
IEP had an IEP that reflected behavioral or emotional disturbance. Thirty-five percent of the
children had IEPs for challenges due to learning disabilities, and the remaining 12 percent had IEPs
for physical disabilities and various other reasons.
Child Risk Factors Impact School Performance
Difficulties that children experience in other areas of their lives can have a strong impact on their
success in school. School performance was highest among those children who had experienced the
fewest child risk factors. As shown in Figure ES-24, those children who had three or more child risk
factors at intake were more than one and one-half times as likely to earn failing grades than those
children with no child risk factors. No differences in school performance by number of family risk
factors were found.
DELINQUENCY
Youth aged 11 years or older reported the following information about involvement with the juvenile
justice system and their delinquent activities:
Over Half of Youth Had Contact with Youth Authorities
During the 6 months before entering system-of-care services, approximately 62 percent reported that
they had been accused by the police of breaking the law and 50 percent reported that they had been
arrested for offenses such as assault, driving under the influence of substances (DUI), criminal
mischief, and vandalism. Fifty-four percent of 332 youth reported that they had been on probation.
Forty-three percent of 328 youth reported having been in a detention center or jail; 70 percent of
these youth were in high school, and 84 percent reported a history of substance abuse.
Youth Reported Engaging in Various Delinquent Behaviors
Youth also reported on their delinquent behaviors. Figure ES-25 displays the nine most frequently
reported delinquent activities in which youth engaged at least once in the 6 months prior to intake.
Fifty Percent of Youth Report History of Arrest
The 1997 National Longitudinal Survey of Youth (NLSY), which interviewed 9,000 youth between
the ages of 12 and 16, reported that 8 percent of the youth had been arrested in their life time (Bureau
of Labor Statistics, 1998). This percentage is substantially lower than the 50 percent (of 267 youth)
in the comparable age range who self-reported an arrest history among those enrolled in the
evaluation grant communities funded in 1997-98. This higher rate of arrests among youth served by
system-of-care programs is not unexpected, given that grant communities establish specific criteria
such as prior involvement with the juvenile justice system for service eligibility. Of those youth who
had been arrested prior to intake, 74 percent were boys and 26 percent were girls. Arrest history
differed significantly by age, even after controlling for gender differences. As expected, both older
boys and girls were more likely to have been arrested (see Figure ES-26).
SUBSTANCE USE STATUS
Older Youth Were Three Times as Likely to Report
Alcohol and Marijuana Use
Youth 11 years or older in grant communities funded in 1997-1998 reported on their own substance
use. Fifty-eight percent of 345 youth self-reported that they had used alcohol, 67 percent had smoked
cigarettes, and 50 percent had used marijuana prior to intake. Of the 190 youth (56 percent) who
reported using at least one substance prior to intake, 42 percent had used two to four different
substances, and 8 percent had used five or more substances in their lifetime. When asked about
alcohol and substance use in the 30 days prior to entry into system-of-care programs, 41 percent of
114 youth between the ages of 12 and 16 reported consumption of alcohol and 65 percent of 55
youth reported use of marijuana.
Youth who were 16 years or older were three times as likely to have used marijuana or alcohol than
those between the ages of 11 and 13 (see Figure ES-27).
SUMMARY
Data from both the evaluation of grant communities funded in 1993-94 and the evaluation of those
funded in 1997-98 indicated that children participating in the Comprehensive Community Mental
Health for Children and Their Families Program were challenged by serious emotional disturbance.
Although grant communities differed somewhat in their target populations and the services they
provided, the majority of children served had diagnoses of disruptive behavior disorders or
depression and were challenged by serious behavioral problems and accompanying functional
impairment. Among children enrolled in the evaluation of grant communities funded in 1993-94,
their social functioning and behavioral and emotional symptoms improved significantly across 2
years of participation in systems of care based on parent, clinician, and self-reports. Children also
improved in school performance and attendance, and they were more likely to remain in stable living
arrangements. Because longitudinal outcomes presented here cannot be compared to outcomes for
children in communities that do not have system-of-care grants, and because children in communities
funded in 1993-94 were only followed while in services, changes across time should be interpreted
cautiously.
Preliminary outcomes data on children participating in the evaluation of grant communities funded
in 1997-98 indicate that these children faced similar challenges yet made similar improvements in
their social functioning and behavioral and emotional problems. With the addition of a strengths-based instrument, data indicated that children had average strengths upon entry into the system-of-care programs, although those with less impairment displayed higher levels of strengths.
Improvements in children's strengths at 6 months were also noted. History of substance use was
more frequently reported among children participating in system-of-care programs when compared
to national averages for youth of similar age; however, preliminary findings show decreases in
substance use over the first 6 months in services. Arrest rates among youth served by system-of-care
programs were also higher than those reported nationally among youth; however, involvement with
the juvenile justice system declined for youth in the first 6 months. Children and families used an
average of six services in the first 6 months, receiving each service on multiple occasions. Caregiver
measures of family resources, family functioning, and caregiver strain are providing new information
from families receiving services in communities funded after 1994. Caregivers reported the need for
additional personal and financial resources as they entered services. Six months after service entry,
caregivers reported that the services that they had received improved their ability to work outside the
home, and also indicated decreases in their strain associated with caring for a child with emotional
or behavioral disturbance. Improvements were also noted in overall family functioning, and
caregivers reported that the strain they experienced while caring for their child with serious
emotional disturbance declined after just 6 months in a system of care.
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