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2001 Annual Report to Congress on the Evaluation
of the Comprehensive Community Mental Health
Services for Children and Their Families Program

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DATA HIGHLIGHTS

WHO ARE THE CHILDREN AND FAMILIES PARTICIPATING IN SYSTEMS OF CARE?

Child Characteristics

• Gender: 68% boys, 32% girls.
• Average age: 12.2 years. 4% were aged 4 years or younger, 24% were aged 5 to 10 years, 51% were aged 11 to 15 years, and 21% were aged 16 years or older.
• Race/Ethnicity: 60% were Caucasian, 23% African-American, 10% Hispanic, 12% American Indian or Alaskan Native, .6% Asian, .5 Native Hawaiian or other Pacific Islander, and 6% were of other ethnicities.

Family Characteristics

• Family Composition: 49% of children lived in single-parent homes, 25% lived in two-parent homes, 4% lived with adoptive parents, 9% lived with foster parents or were wards of the State, and 13% had other living situations.
• Living Arrangements: At intake, 56% of children were reported to have lived in just one living arrangement during the previous 12 months; 44% were reported to have lived in two or more different living arrangements.

Risk Factors

• Poverty: 49% of the children's families reported incomes below $15,000, which is below the poverty threshold of $17,650 for a family of four according to the U.S. Department of Health and Human Services (DHHS) 2001 Poverty Guidelines (DHHS, 2001a).
• Family Composition and Poverty: 67% of children in mother-maintained households lived in poverty, 40% of the children in father-maintained households lived in poverty, and 43% of the children in two-parent households lived in poverty.
• Child Risk Factors: 70% reported that their child had at least one risk factor for serious emotional disturbance. The most frequently reported child risk factors included history of running away (35%), physical abuse (29%), previous psychiatric hospitalization (28%), and sexual abuse (21%).
• Family Risk Factors: 94% identified at least one family risk factor and 55% indicated three or more family risk factors. The most frequently reported family risk factors were history of family substance abuse (66%), mental illness (51%), and domestic violence (49%).

Previous Service Experience

• Most children received services prior to entering system-of-care programs. The majority of children received outpatient services (65%) and school-based services (54%) in the 12 months prior to entry into system-of-care programs.
• Children 5 years or older were more likely to have received outpatient services. 68% of children 5-10 years old, 66% of those 11-15 years old, and 64% of youth 16 years or older had received outpatient services, compared to 35% of children under 5 years old.

Referral Sources

• Referral Sources: 29% were referred by a mental health agency, 19% through courts and correctional institutions, 18% by schools, 13% by child welfare or child protective services, 11% by caregivers or youth themselves, and 11% by others.
• Referral source differed significantly by gender. Boys were more likely to be referred from juvenile justice agencies (20% vs. 17% of girls), whereas girls had a higher probability of being referred by child welfare/child protective services (16% vs. 11% of boys).

Diagnoses and Presenting Problems

• Diagnosis: 34% ADHD, 27% oppositional defiant disorders, 26% mood disorders (including depression), 17% adjustment disorders, 11% conduct-related, and 8% substance use. Other frequently applied diagnoses include post-traumatic stress disorder, disorders of impulse control, and disruptive behavior disorder.
• Multiple Diagnoses: 44% of children had two or more distinct diagnoses.
• Presenting Problems: 85% of the caregivers reported at least one presenting problem that their child experienced. The most frequently reported problems were non-compliance (40%) and physical aggression (39%).
• Boys and girls differed in their presenting problems. Girls were more likely to be identified with problems of internalizing nature such as eating disorders, sadness, self-injury, suicide attempt and ideation, and poor self-esteem. Girls also had a higher probability of having run away than boys. Boys tended to have problems of an externalizing nature such as physical aggression, property damage, hyperactive-impulsive behavior, attentional difficulties, and police contact.

Educational Status

• School Performance and School Attendance: Children attending school more than 50% of the time were twice as likely to have a grade average of C or better.
• Individualized Education Plan (IEP): 52% of children had an IEP; 66% of children had IEPs for their emotional or behavioral problems. Children in grades 1 through 6 were more likely to have an IEP than children in higher grade levels.

Juvenile Justice Status

• Contacts with Youth Authorities: 66% of children aged 11 years or older had experienced some contact with law enforcement prior to entering systems of care. 55% of children aged 11 years or older had been accused of breaking the law, 44% had one or more arrests, and 37% reported being found guilty in court in their lifetimes.

Substance Use Status

• Cigarette, Alcohol, Marijuana Use: Based on self-reports from youth aged 11 years or older, 55% had tried alcohol, 64% had tried cigarettes, and 45% had tried marijuana at least once in their lifetimes.

TO WHAT EXTENT DO CHILDREN AND FAMILIES' OUTCOMES IMPROVE OVER TIME?

Clinical Outcomes

• Behavioral and Emotional Strengths Increased: After 6 months of receiving services, 49% of the children showed a significant increase in behavioral and emotional strengths as evidenced by an increase in the total strengths quotient of the Behavioral and Emotional Rating Scale (BERS). In addition, of those who improved, 19% reported above average strengths, and 44% reported average strengths at 6 months.
• Behavioral and Emotional Problems Were Reduced: After 6 months of receiving services, 36% of the children showed a significant reduction in behavioral and emotional problem symptoms as evidenced by a reduction in their total problems score on the Child Behavior Checklist (CBCL). Half of these children had scores that fell below those indicating a need for clinical care at 6 months. Children without a diagnosis of ADHD improved in their behaviors at a greater rate than those diagnosed with ADHD.
• Clinical Functioning Improved: After 6 months in services, children's social functioning improved significantly. At intake, average total scores on the Child and Adolescent Functional Assessment Scale (CAFAS) indicated marked levels of functional impairment. After 6 months of receiving services, average scores indicated moderate levels of functional impairment. Children aged 11-15 years made faster and greater improvements in functioning than younger and older children.

Functional Outcomes

• Residential Stability Improved: 56% of children lived in just one living arrangement during the 6 months prior to entry into system-of-care programs. The percentage increased to 64% during the first 6 months of services in systems of care; 76% of those who had lived in one living arrangement prior to entry into system-of-care services remained in one living arrangement during the first 6 months in services.
• School Attendance Improved: The percentage of children attending school regularly improved by 6% after 6 months in system-of-care services.
• School Performance Improved: After 6 months in services, the percentage of children who had a grade average of C or better increased from 59% at intake to 66%, representing a 12% gain from intake to 6 months. The number of children failing all or most classes was reduced by 18% (from 17% to 14%).
• Law Enforcement Contacts Were Reduced: After 6 months in system-of-care services, fewer youth were accused by the police of breaking the law, arrested, convicted of crimes, or sent to a jail or detention center than in the 6 months prior to entering services. The greatest decrease was in the percentage of youth spending time in jail or detention centers (31% at intake, 23% at 6 months), representing a 25% reduction in the number of youth who spent time in these facilities.
• Substance Use Decreased: The percentage of children who consumed alcohol decreased from 40% at entry into system-of-care services to 35% after their first 6 months in services. Use of marijuana decreased from 26% to 23%, and cigarette use decreased from 52% to 48%.

DO CHILDREN SERVED BY THE SYSTEM-OF-CARE APPROACH HAVE BETTER OUTCOMES THAN CHILDREN SERVED BY A TRADITIONAL SERVICE DELIVERY APPROACH?

Phase I Findings

• Children in the system-of-care community experienced greater rates of improvement than children in the non-system-of-care community.4 Children in the system-of-care community entered services with slightly fewer externalizing behavioral and emotional problems than those in the non-system-of-care community. Children in the system-of-care community improved at a greater rate initially; however, children in both communities reached equivalent levels of improvement by 24 months after intake into services.
• Recidivism rates were lower for children in the system-of-care community. After entry into services, 30% of children entering services in the system-of-care community who had two or more previous juvenile justice offenses did not have any further charges during the period of time they were followed in the comparison study. Only 6% of children in the non-system-of-care community with previous juvenile justice charges did not have additional charges against them.

• Service experiences embodied system-of-care principles at high levels in Stark County. Children and families in systems of care had service experiences that were more consistent with system-of-care principles, and children's symptom severity did not vary as a function of intensity of service experiences. In contrast, children and families in matched comparison communities reported more variability in their service experiences, and their symptom severity varied inversely as a function of these experiences.
• Stark County provided more services and a broader mix of individual, family, and group counseling than the non-system-of-care community. Children and families in the Stark County system of care received more than twice as many services in the first 18 months after study entry as children and families in the Mahoning County system. Children in Stark County and Mahoning County differed in patterns of use of various types of counseling. Mahoning County relied more heavily on individual counseling, while Stark County provided a broader mix of individual, family, and group counseling.
• Children with severe impairment in Stark County received significantly more hours of service than children with less severe impairment. When children were divided into severe and less severe impairment groups based on CAFAS total scores, the average hours of services continually decreased for children in both groups for both Stark and Mahoning Counties over the first 18 months after study entry. However, while there was no difference in the average hours of services received by the two severity groups in Mahoning County, children in the severe group in Stark County received significantly more hours of services than those in the less severe group.
• Children in Stark County had slightly fewer juvenile justice placements. In the first 18 months after study entry, 7% fewer children were placed in juvenile detention centers in Stark County as compared to children in Mahoning County.

Phase II Preliminary Findings

• Children in system-of-care communities received needed services. Children in system-of-care communities were significantly more likely to receive case management, medication treatment and monitoring, and day treatment or group home services than those in the non-system-of-care communities.
• Clinical assessments were associated with services received in system-of-care communities. In the system-of-care communities, children who received medication treatment and monitoring, day treatment or group home, or residential services had higher Externalizing and Internalizing CBCL scores, indicating greater emotional and behavioral problems, and higher CAFAS scores, indicating greater impairment in social functioning, than children who did not receive these services. Families who received respite had children with higher externalizing behavior problems than those who did not receive this service.

Services Received in Communities Funded in 1997 and 1998

• Children and families received a broad array of services. The number of services received by any individual child or family ranged from 1 to 16. Children and families received an average of six services. Children who received medication treatment and monitoring differed significantly from those who did not receive this service with regards to gender, age, diagnosis, and referral source.

Family Ratings of Services

• Caregivers were satisfied with services. Over 75% of the caregivers indicated that they were satisfied or very satisfied with services received.
• Caregivers were satisfied with their child's progress. Almost 65% of the caregivers were satisfied or very satisfied with their child's progress after 6 months in services.
• Caregivers reported satisfaction with involvement in planning services. Over 80% of the caregivers reported being satisfied or very satisfied with their level of involvement with planning services.
• Caregivers reported satisfaction with their providers' respect for their family's beliefs and understanding of their family's traditions. Over 80% of caregivers reported satisfaction with their providers' respect for their family's beliefs and understanding of their family's traditions.

Youth Ratings of Services

• Overall, youth reported greater satisfaction with their progress but less satisfaction with services than caregivers reported.
• Youth were satisfied with services. Over 70% of youth indicated that they were satisfied or very satisfied with services received.
• Youth were satisfied with their progress. 74% of youth were satisfied or very satisfied with their progress after 6 months in services.
• Youth reported satisfaction with involvement in planning services. Over 65% of youth reported being satisfied or very satisfied with their level of involvement with planning services.
• Youth reported satisfaction with their providers' respect for their family's beliefs and understanding of their family's traditions. Over 73% of youth reported satisfaction with their providers' respect for their family's beliefs and understanding of their family's traditions.

HOW DO GRANT COMMUNITIES DEVELOP AND IMPLEMENT SYSTEM-OF-CARE PRINCIPLES?

• System-of-care principles are being manifested across the board. The majority of grant communities consistently performed well, scoring above the mid-point range across most system-of-care principles and at three assessment points. The eight system-of-care principles are family focused, individualized, culturally competent, interagency, collaborative/ coordinated, accessible, community based, and least restrictive.
• At the three assessments points, grant communities scored highest on the principles of family focused, accessible, and individualized care. Effective efforts had been made to
• involve families in the care of all children, recognize that families are important contributors and equal partners in any effort to serve children, and maximize family involvement in system and service processes.
• minimize barriers to services in terms of physical location, convenience of scheduling, and financial constraints.
• ensure that provision of care is expressly child centered, addresses child-specific needs, and recognizes and incorporates child-specific strengths.
• At the three assessment points, grant communities scored lowest on the principles of cultural competence and interagency collaboration. No or minimal efforts had been made to
  • ensure that the service system was sensitive and responsive to the inherent value of differences related to race, religion, language, national origin, gender, socioeconomic background, and community-specific characteristics.
  • establish and facilitate multi-agency involvement.

List of Grant Communities

4The term non-system of care is used throughout this report to refer to communities that have not received CMHS funding to establish a system of care and that have been selected as matched comparison communities for the two comparison studies.