PRACTICE GUIDE

A PRACTICE GUIDE FOR THE DEVELOPMENT

AND IMPLEMENTATION OF CLINICAL TREATMENT PATHS

INTRODUCTION | THE IMPORTANCE OF IDENTIFYING RISK FACTORS | TREATMENT PATHS | TREATMENT PATH STAGE I: IDENTIFICATION OF | BEHAVIORAL HEALTH PROBLEMS | TREATMENT PATH STAGE II: REFERRAL | TREATMENT PATH STAGE III: CLINICAL ASSESSMENT | TREATMENT PATH STAGE IV: INTERVENTION | TREATMENT PATH STAGE V: RE-ASSESSMENT | APPENDIX A | APPENDIX B | APPENDIX C | APPENDIX D | APPENDIX E | APPENDIX F

INTRODUCTION

A review of behavioral health services was undertaken over the past three years to evaluate current case work practices and to make recommendations in order to establish an integrated and coordinated practice model. A statewide work group was convened to identify and assess national trends in the assessment and treatment of behavioral health issues, identify current child welfare case practice, and offer recommendations for the development of a state-wide integrated behavioral health system for DCFS.

This review identified a number of problem areas affecting the department's ability to provide consistent and quality services to its clients:

• A very low rate of early identification of behavioral health problems
• A lack of a consistent response to deal with identified behavioral health issues
• Limited knowledge on the part of case work staff of salient risk factors and identifying behaviors of many mental health, developmental and behavioral disorders
• Limited identification of Best Practice principles related to the assessment, diagnosis, and treatment of behavioral health problems
• Insufficient qualified service providers to receive referrals for services

The workgroup identified a number of behavioral health problems and child welfare issues that present the greatest challenges to successful case planning. The areas covered included:

• Physical abuse
• Neglect
• Sexual Abuse
• Failure-to-Thrive
• Shaken Baby Syndrome
• Depression
• Bi-polar disorder
• Reactive attachment disorder
• Conduct disorder
• Intermittent explosive disorder
• Domestic violence
• Attention Deficit Hyperactivity disorder
• Developmental Disabilities
• Substance abuse
• HIV/AIDS
• Sexually problematic behaviors

For each of these identified behavioral health/child welfare issues the following work products have been produced:

· A review of the scientific and clinical literature to identify:

1. Etiology

2. Rates of occurrence

3. Behavioral presentation

4. Issues related to assessment & diagnosis

5. Current treatment modalities

6. Research findings related to treatment outcomes and effectiveness

_ Treatment Pathways. Identification of the five Stages involved in the appropriate child welfare worker's response to behavioral health issues:

7. Identification

8. Referral

9. Assessment & Diagnosis

10. Treatment

11. Review & Re-Assessment

· The identification of Best Practice requirements to guide case work activity, and

· Identification, through research and consultation, of knowledge related to treatment modalities, efficacies of treatment approaches, and expected outcomes of interventions.

THE IMPORTANCE OF IDENTIFYING RISK FACTORS & RESPONDING TO BEHAVIORAL HEALTH ISSUES

One of the major factors impacting a family's ability to successfully participate in both service planning and implementation is the presence of a mental health, developmental, or behavioral disorder. Whether the parent, DCFS client, or sibling is affected by a behavioral health problem, the impact on the entire family and it's functioning often prevents successful implementation of case planning goals.

The successful identification and response to behavioral health problems is a critical component of casework. The determination of the safety and well being of a child must include an assessment of behavioral health issues that may impact on the individual or other family members. There are numerous developmental, behavioral and emotional issues that children must cope with that will affect a determination of safety and well being. While the presence of clear demonstrable behavioral health disorders should immediately raise a flag of concern for the caseworker, there is often neither an available documented history of a mental disorder nor are their often glaring behaviors that are immediately recognizable as symptoms (e.g. command hallucinations) of a serious disorder.

In most cases the investigator and caseworker will be confronted with indications, suggestions, or hints that there are may be a more serious problem. There is often little `proof positive', but rather suggestive bits of information gleaned from observation and interviews with family members and neighbors.

This document is designed to assist the DCP and caseworker in identifying the following three factors that may influence decisions related to case planning around safety and well being:

1. The presence of observable and/or reported behaviors that may indicate the presence of a significant behavioral health disturbance.

2. The presence of risk factors within the family that have been shown to contribute to the development of behavioral health problems

3. The presence of protective factors that have been shown to mitigate against the development of significant behavioral and/or emotional problems.

At the end of this paper there are a number of appendices (Appendices A,B,C,D,E) that provide further detailed information related to risk factors, behaviors, protective factors, and impact of behavioral health problems on the client and family members.

TREATMENT PATHS

Treatment Paths represent two complimentary components:

• A framework for casework activity based on Best Practice principles; and
• The identification of a body of research and clinical information related to specific behavioral health problems, with special emphasis on identification, assessment, intervention, and reassessment processes.

The development and implementation of individual Treatment Paths must consider each of the following five stages:

• Identification
• Consultation & Referral
• Assessment & Diagnosis
• Treatment
• Re-assessment

Throughout these processes good social work principles must be applied:

· Engage the client in a supportive relationship and treat them with positive regard

· Build on their apparent strengths and motivation

· Help them recognize their patterns of dysfunction and support them through alternative behaviors

· Build on their success and anticipate problem areas

· Be consistent, honest, and trustworthy

TREATMENT PATH STAGE I: IDENTIFICATION OF POSSIBLE

BEHAVIORAL HEALTH PROBLEMS

Worker Role/Tasks

· Engage client and family

· Assessment of parent and client functioning

· Early identification of behavioral health issues

· Assessment of risk to client and family of any identified behavioral health issues

· Gathering information from appropriate sources (family, neighbors, school, community)

· Participation in collaborative staffing with parent, service providers, and others to identify service needs

· Timely consultation with supervisor & behavioral health team

· Verification and documentation of contacts with collaterals

Information gathering

The role of the caseworker in the early identification of risk factors and/or behavioral health problems is critical in the overall success of case planning and implementation. There are numerous sources of information that need to be utilized in identifying the presence of behavioral health issues.

• Input from caregivers
• Observation of client and family
• Input from school
• Input from community
• Administration of DCFS-approved assessment/screening forms
• Consultation with supervisor and behavioral health team members

The early identification of problematic behavioral health issues sets the foundation for subsequent assessments, service planning and strategies aimed at problem resolution. Observation of parental, client, and sibling functioning is of critical importance at this stage. Are there problematic behaviors/symptoms present? To what extent is individual and family functioning affected?

During the identification stage the following must be considered:

• Do any members of the family display behaviors suggestive of behavioral health problems
• Do these behaviors affect the ability of the family to meet the child's needs of nutrition, safety, shelter, and supervision
• Is the child's safety from harm affected by the presence of the behavioral health problems
• Is the level of participation by family members in the case planning process affected by behavioral health problems? If so, to what degree?
• Is there a history of maternal psychiatric impairment
• Has the mother been psychiatrically hospitalized in the past three years
• What sources of support are available to the family
• Do the children have a strong positive relationship with at least one adult in the family? A friend or neighbor?
• Do the children attend school regularly
• Do the children participate in any activities outside of the home

The presence of behavioral health problems often leads to negative effects on individual and family functioning. At a minimum, the presence of behaviors and symptoms consistent with, or suggestive of, a mental health, developmental, or behavioral disorder, implies some risk to optimum individual and/or family functioning.

Within the Identification Stage, caseworkers must be aware of not only the presence or absence of specific behavioral health issues, but also the increased risk to client and family functioning posed by behavioral health problems. To one degree or another, individual family members are affected or placed at risk by the presence of behavioral health issues. These `general risk factors', while not always present, need to be considered by the caseworker.

Seeking consultation with appropriate staff is a critical component in Treatment Pathway development. A great deal of case planning evolves from direct consultation with one's supervisor and members of the regional Behavioral Health Team. There are numerous reasons to seek consultation, not the least being simply wanting to talk with someone about a particular case issue. Listed below are some (but certainly not all) of the reasons for seeking consultation, the most appropriate source for the consultation, and the associated required tasks:

Reason for Explanation Required Tasks

Consultation

Consensual validation	Staff are fairly certain as to the correctness of their approach, but want approach affirmed	Knowledge of family/client; up-to-date documentation;
Another opinion	Staff want to bounce ideas off another person to generate discussion & possible alternative approaches
Needed expertise	Staff recognize that specific expertise beyond their current skills is needed to address identified problem
Required By Rule & Procedure	DCFS policy requires staff to met with supervisor and/or BHC staff	Completed forms; Specific documentation (e.g. recent psych assesment, treatment summary, updated social hx)

TREATMENT PATH STAGE II: REFERRAL

Worker Role/ Tasks

· Continue to engage client and family

· Continue to assess client & family functioning

· Continue to assess safety and well being of individual and family

· Organize information

· Identify behaviors/symptoms that are of concern

· Complete necessary referral forms

· Identify referral question(s)

· Identify approved providers

The referral of a client to an appropriate service provider is the second step of the treatment path process. The Behavioral Health program, in collaboration with regional resource and clinical staff, has been moving forward on developing lists of approved service providers qualified to address specific behavioral health problems.. It is the goal of the Behavioral Health program to identify qualified providers for all of the major behavioral health problem areas impacting on wards and their families.

The referral process usually encompasses a number of discrete steps that must be completed in order to effect the referral:

1. Complete all necessary paperwork. This often requires the completion of a specific referral form (e.g. CFS 417 for psychology assesment, CFS...... for counseling)

2. Obtain necessary approval signatures. Often, the written approval of one's supervisor is all that is needed to begin the actual referral process. At other times, the approval and signature of specific Behavioral Health staff (consulting psychologist for a psychology assessment) is also needed.

3. Obtain necessary supporting documentation. Most referral procedures require that specific documentation be included when the referral is to be reviewed by a supervisor, behavioral health consultant, or when sent to a service provider. It is critically important that all of the requested/required documentation be included in the referral packet. By failing to do so, the referral may be deferred or rejected, and the service provider will not have as complete an understanding of the client's problems as needed to formulate assessment and/or treatment strategies.

4. Meet with supervisor. An early step in the referral process for services (assessment or treatment) is often a meeting with one's supervisor. This meeting is designed to both provide case planning information to the supervisor but also to elicit their viewpoints and comments on what the best approach would be in dealing with a behavioral health issue. Whatever the reason(s) for meeting with the supervisor, the caseworker needs to have a good knowledge of the psychosocial history of the family and the child welfare issues pertaining to the specific case in order to allow the supervisor the ability to respond in an appropriate fashion.

5. Meet with behavioral health consultant. In some instances, it is required that a caseworker meet with a regional behavioral health consultant after meeting with their supervisor. In these instances, the nature of the services requested (e.g. psychology evaluation) require that approval be obtained from the behavioral health consultant prior to making a referral. On others, the caseworker may simply want to discuss the behavioral health issues with another professional with expertise in the behavioral health area. Whatever the reason(s) for meeting with the regional behavioral health consultant, the caseworker needs to have a good knowledge of the psychosocial history of the family and the child welfare issues pertaining to the specific case.

6. Selection of qualified provider. The selection of a qualified service provider is of critical importance to successful service provision. In many instances, DCFS has developed lists of providers who have been approved by the Department to provide specific services for specific behavioral health issues. In these cases, only providers who are listed on the "Approved Lists" can receive referrals. In situations where an approved provider lists has not been developed, case work staff should consult with their resource development staff, clinical coordinators, and behavioral health consultants to identify providers.

7. Preparation of Referral Packet. The information sent to the service provider is critical in laying the groundwork for the planned service intervention. Insuring that up-to-date child welfare information, as well as any recent clinical assessments, are include in the referral packet allows the service provider to have the broadest possible sense of the client, their behavioral health problem(s), and the details of the child welfare issues.

TREATMENT PATH STAGE III: CLINICAL ASSESSMENT

Worker Role/Tasks:

· Continuing to engage client and family

· Sharing with individual and family information related to need for clinical assessment

· Supporting individual and family through assessment process

· Support client and family to understand assessment results

· Providing/arranging needed transportation

· On-going communication with assessment provider

· Insuring all necessary documentation is gathered and shared with assessment provider

· Insuring individual and family compliance with assessment appointments

· Insuring information and assessment reports are submitted in a timely manner

· Sharing of assessment information with appropriate staff and personnel.

Key Components of Clinical Assesment Process

Because the clinical assessment is usually not completed by the caseworker, there are many aspects of the clinical assessment that are not under the direct purview of the caseworker. However, there are aspects of the assessment process that the caseworker can monitor.

There are five general components to the assessment process that are of particular interest to the caseworker

1. Gathering of Information. As a general rule, assessments that gather information from multiple sources will result in superior results as compared to those that are completed at only one site. In fact, some Best Practice statements by professional organizations (e.g. APA) and governmental agencies (e.g. National Institutes for Mental Health) have identified the various sources of information that need to be gathered in order to address specific referral questions

Caseworkers should always insure that the provider of clinical assessments has gathered all the necessary and diverse information necessary to complete their assessment. Casework staff should seek to have information gathered from the following sources

1. Family members

2. Teachers

3. Casework staff

4. Other professionals (e.g. therapist) involved with the client

2. Location of assessment. Traditionally, assessments were completed in the office of the service provider. Over the past number of years there has been greater emphasis on the environment of the assessment process, leading to a greater understanding and emphasis on gathering data from multiple environments. It is widely believed that observing and assessing a client in their `world' (e.g. community, home) will yield more accurate and valid data. Because of this, home-based assessment are now mandated components of some assessment processes (e.g. Parent Capacity Assessment)

3. Direct observation and interaction with client (including changes due to previous or on-going interventions). Collecting second-hand information, either through talking with friends or family members can yield valuable insights into a client's behavior and mental state, there is no substitute for direct interaction with the client. It is axiomatic that a formal assessment protocol must include direct observations and interview with the client. Changes that have occurred since a previous assessment or as a result of on-going intervention services are critical to identify and document.

4. Administration of assessment measures/Use of appropriate assessment instruments. In most cases, DCFS does not prescribe which clinical assessments or protocols are to be used during the assesment process. These decisions are usually left to the professional discretion of the assessment provider. However, there are guidelines that some programs have developed (e.g. Psychology Assessment Program) that indicate basic requirements related to assessments:

1. Assessments instruments must be valid and reliable

2. There must be sufficient clinical research data to support their use

3. The assessment instruments must be able to generate information specific to the referral question(s)

TREATMENT PATH STAGE IV: INTERVENTION

Worker Role/Tasks

• Continue engagement with client and family
• Identification of service needs
• Identification of service objectives
• Referral to qualified provider
• Support client and family in accessing treatment services
• On-going communication with treatment provider
• Obtain regular progress reports

Selection of Best Treatment Approaches

Over the past number of years a great deal of clinical research has been conducted on treatment approached for specific kinds of problems. While there continues to be only a few cases where overwhelming evidence exists to support a single approach for a specific behavioral health problem, much of the research literature of the literature has begun to identify those treatment modalities that appear to have efficacy in ameliorating the effects or symptomatology of certain problem areas.

The development of Treatment Paths for each specific behavioral health problem has identified, where possible, those intervention(s) that are considered to be offering a reasonable positive outcome for clients.

Some general principles of treatment selection are listed below:

· Most behavioral health problems respond to a `multi-modal' approach, where interventions are designed for multiple environments (e.g. home, school, community) and multiple treatment approaches are employed (e.g. individual and group counseling, and medication.)

· The most effective treatment modalities have been able to identify relatively specific goals and objectives that allow the client and provider to measure success.

· The selection of treatment approaches need to take many factors into account, including the age, gender, and cultural background of the client and provider, client's the degree of impairment, receptivity to treatment, and previous treatment

Identification of treatment objectives

The identification of objectives for specific interventions is dependent on the following key elements:

• Specific behavioral health problem
• Degree of functional impairment the behavioral health problem is causing
• The assessed relative strengths that the client will bring to the intervention process
• Short and long term goals of the child welfare system's involvement

Similar to the general issues related to selecting treatment strategies, the selection of objectives require the close collaboration of the client and the provider. While the child welfare system has identified goals related to addressing family reunification or termination of rights, the selection of specific treatment objectives is typically within the province of the therapist-client relationship.

The case worker, however, has a vested interest in insuring that the selected treatment objectives do not conflict with the case management process and that the objectives selected are consistent with the clients individual's identified needs.

Preliminary treatment objectives are often developed as a result of specific assessment results and staffing processes. These objective are often necessarily `best guess' approaches to treatment needs, based on limited assessment and case management time. These preliminary treatment objectives tend to be global in nature (e.g. reduce aggressive behavior; increase sense of self-regard).

More formalized treatment objectives tend to be developed after a few treatment sessions where the therapist has completed his/her own clinical assessment of treatment needs, consistent with the referral question(s) and identified behavioral health problem. These objectives tend to be more focused, and should be articulated in objective, measurable terms.

If there is minimal movement towards attainment of these objectives a reassessment of the objectives, treatment approach, client investment, etc. needs to occur. It is important to remember that the while the objective may be logical and even based on best practice principles,

Use of multi-modal systems of intervention

Many, if not most, of the behavioral health issues that are observed within the child welfare environment have been found to respond to treatment interventions across various environments.

Caseworkers need to be aware of which combination of approaches (both treatment modality and treatment venues) have been found to offer the best outcomes. Caseworkers should consult the specific behavioral health Treatment Path for information on how effective are the interventions utilizing the following approaches and venues:

• Medication
• Individual intervention
• Group Intervention
• Support groups
• Office
• School
• Home
• Community

In general, multi-modal approaches tend to be more effective than treatment interventions restricted to one environment. However, the implementation of the multi-modal intervention strategy requires the following casework requirements:

• Detailed information from treatment provider
• Communication between all treatment environments
• Management of documentation and treatment reports

Assessment of Treatment Effectiveness

The information gathered to assess treatment effectiveness is utilized to determine whether there has been a diminution or increase of identified behaviors, and an increase in identified functional skills. Changes in treatment objectives and frequency of services are determined by the measurement of treatment objectives. (It must be stressed that the principal measurement of treatment effectiveness is not determined by the number kept service appointments)

TREATMENT PATH STAGE V: RE-ASSESSMENT

Worker Role/Tasks

· Continue engagement with client and family

· Continue communication with service provider(s)

· Seek input from varied sources on potential changes in client

· Revisions, as needed, to service plan

It is always necessary to occasionally `pause and catch one's breath' when working with a client. Are the services needed? Do goals need to be changed due to attainment of treatment goals? Is the intervention targeting the correct issues? These any other questions need to be periodically asked by the caseworker, client and service provider. All to often, either changes in client behaviors or mental health status have occurred as a result of services, or no demonstrable changes have occurred,

While Treatment Path stage IV outlined the nature of identifying and measuring treatment outcomes, this stage requires that the outcome data be integrated into the overall case planning process. This requires a number of specific activities:

1. Communication with the client, service provider, and other involved individuals to identify the specific outcome information that is available.

2. Meeting with supervisory, regional behavioral health staff, and service provider to discuss how the outcome data fits into the overall case plan.

3. Identifying and implementing needed revisions in the case plan and intervention services to reflect changes that have occurred as a result of the interventions.

APPENDIX A

DETERMINING THE SIGNIFICANCE OF BEHAVIORAL HEALTH PROBLEMS:

FOUR VARIABLES

It is critical for DCP, Intact and Placement workers to remember that the significance of any `risk factor' or observed behavior is determined by four inter-related variables: Age, Frequency, Duration and Intensity.

• Age. The age of the individual, especially for children and older adults, can have a significant impact on how certain behaviors and emotional states are interpreted. Sleep patterns, changes appetite, or loss of energy can all be natural correlates of middle to older age. Younger children often have very vivid and violent dreams that are usually considered normal for their age.
• Frequency. How often an emotion or behavior occurs is usually very important in determining its effect on one's daily functioning. While both adults and children experience occasional periods of distress and changes in functional capacity, if the changes occur sufficiently often to cause significant impairment, then there is reason for concern.
• Duration. Most adults and children will go through periods when they are sad, irritable, lose interest or have difficulty concentrating. They may also have occasional nightmares, changes in appetite or sleep patterns, thoughts of damaging objects or hurting other people. What contributes to the clinical significance of these normal and episodic occurrences is the length of time that they occur. While there is no hard and fast rule to denote when a behavior or feeling crosses the line from `within the range expected' to `problematic', the typical `rule-of-thumb' requires that the duration of the emotional state or behavior be in excess of six (6) months. Changes in day-to-day activity, emotional states, and behaviors, while expected in the course of daily life and stress, usually `return to baseline' within a six-month period. When they do not, there is heightened concern that a more significant problem may be emerging or is present.
• Intensity. The degree of impact that these behaviors and emotional states have on the day-to-day functioning of the individual and/or family is directly related to the strength of the feelings and reactions that accompany the behavior and emotion. Intense expressions of emotions can be part of the basic personality makeup of the individual; however, if the intensity is such that the person's ability to function in a given environment is affected, then there is concern.

These four variables interact to cause many different effects on the individual. Some behaviors or emotional states occur very infrequently, but with sufficient duration and intensity, to cause problems in daily functioning. Others may occur quite often but are of limited duration and intensity, thus causing minimal impact on functioning.

The degree of adverse effect on daily functioning that emotions and behaviors can cause is obviously complex. It is not the intent of this document to provide a clinical basis for the diagnosis of specific mental health disorders. Rather, the child welfare worker is being asked to take a `snap shot' of individual and their family in order to identify potential risk factors or problems that may require more in-depth assessment

APPENDIX B

BEHAVIORS THAT MAY INDICATE THE PRESENCE

OF A SIGNIFICANT BEHAVIORAL AND/OR EMOTIONAL PROBLEM

The presence of certain behaviors will almost always raise concern. Individuals who are severely depressed, or who are engaged in highly dangerous social behaviors should always cause the caseworker to seek consultation with a member of the Behavioral Health Team. Other behaviors, while often thought of as being symptomatic of serious disorders, may be transitory and a reaction to an acute stressor or trauma.

The following list highlights many behaviors that should raise a red flag for the caseworker. While not intended to provide the basis for a formal psychiatric diagnosis, the recognition of these behaviors should result in greater exploration by the caseworker, supervisor, and Behavioral Health Team, of the significance of these behaviors on daily functioning.

1. Depressed mood. Sadness, loss of appetite, difficulty sleeping, over activity

2. Excessive energy. Feelings of excitement, euphoria, hyperactivity

3. Paranoia. Feelings of persecution, unrealistic concerns related to motivations of others

4. Unrealistic fears. Feelings of anxiety, nervousness apparently out of proportion to actual circumstances.

5. Grandiosity. Feelings of heightened self- importance, sense of invulnerability

6. Fire setting. Deliberate attempts or actual setting of fires

7. Hurting or killing of animals. Deliberate

8. Excessive sleeping/lethargy. Usually a sign of depression or medical illness. Usually results in missed work or school, failed appointments, diminished care of others.

9. Lack of personal hygiene. Lack of cleanliness, bathing, not washing clothes

10. Poor or excessive eating

11. Difficulty concentrating. Can have a pronounced effect on home work, school, employment

12. Excessive difficulties at school. Academic difficulties, especially in area of reading; fighting, discipline issues

13. Difficulties with employment. Frequent firings, lateness to work. Difficulty finding employment

14. Visual or auditory hallucinations. Command hallucinations (being told to due specific acts);

15. Lack of empathy for others. Unconcern for others, especially those in family and `friends'. Unconcerned with effect of one's actions on others.

16. Self-injury. Frequent scarring or tattooing. Deliberate attempts to hurt oneself.

17. High level of discord between parent and child. Constant fighting, with loud interchanges. Little supportive interactions

18. Increased aggression, fighting, destruction of property, vandalism, fire setting. Often associated with gang activity; reflects extreme frustration and anger at aspects of life.

19. Deliberate lying, violation of house rules. Often associated with drug use. Not unusual for adolescents to test limits of parental authorities.

20. Excessive stealing and contact with law enforcement agencies. Often associated with drug use and/or gang activity.

21. Social isolation. Limited network of friends. Often associated with depression, drugs use.

22. Mutism. Extreme reluctance to communicate. Often associated with withdrawal from social and other interactive activities.

APPENDIX C

RISK FACTORS FOR THE DEVELOPMENT OF SIGNIFICANT BEHAVIORAL

AND/OR EMOTIONAL PROBLEMS IN CHILDREN

Risk factors, by their very definition, imply some distant influence on functioning. The concerns are usually directed, not at immediate functioning, but rather the longer-term impact of prior stressors and trauma. In many ways the `red flags' raised by the presence of these risk factors are early warning signs that problems may lay ahead for the individual. Early research on the effects of PTST, separation, and violence have all pointed to a potential `sleeper effect' of early stress and trauma on the individual. Many years after a traumatic event, disturbances in behavioral and emotional functioning may appear. Because of this, the child welfare worker must be attuned to an individual's prior history and be knowledgeable about those risk factors that have been demonstrated to pose potential problems for individuals.

Another variable that needs to be considered is whether the stress is acute or chronic. It is axiomatic to stress counselors and other professionals that the presence of chronic stress has a much greater long term debilitating affect on an individual. While acute stress often causes very serious immediate consequences to an individual, with professional help, the long-term effects are often diminished.

In many ways the `red flags' raised by the presence of risk factors are early warning signs that problems may lay ahead for the individual. Early research on the effects of PTST, separation, and violence have all pointed to a potential `sleeper effect' of early stress and trauma on the individual. Many years after a traumatic event, disturbances in behavioral and emotional functioning may appear. Because of this, the child welfare worker must be attuned to an individual's prior history and be knowledgeable about those risk factors that have been demonstrated to pose potential problems for individuals.

The following list of functional and adaptive behaviors is presented to demonstrate how widely divergent factors (social, individual, biological) can present risks to an individual for the development significant behavioral health problems. Staff needs to be aware that any one of these factors places a family member (parent or child) at risk for behavioral health problems, and the presence of multiple risk factors increases exponentially the risk.

1. School difficulties. Academic difficulties, especially in the area of reading. Attentional problems, placement in special education, peer interaction problems.

2. School attendance. Truancy is a major correlate of behavioral and emotional problems.

3. Behavioral problems. Acting-out, non-compliance, fighting, stealing, and other anti-social behaviors

4. Social isolation. Not having friends, not being included in social activities

5. Early drug & alcohol usage. Early experimentation and then regular use of alcohol and/or drugs (including marijuana)

6. Low self-esteem. Feelings of inferiority, worthlessness

7. Depression. Marked sadness, loss of motivation, anger

8. Lack of structure and control by parent. Inconsistent rules of enforcement of rules, punitive responses to children

9. Paternal criminality. Biological father's history of criminal behavior, whether child is living with father or with another male

10. Maternal hx of psychiatric disorder. Mother psychological status and previous history. Prior use of psychiatric medication

11. Maternal hospitalization for psychiatric disorder. Prior psychiatric hospitalization of mother

12. Temperament of child & parent. Children's temperament must compliment that of parent. Children with anxious, active, or overly sensitive temperaments are less able to deflect problems and approaches of parents.

13. Emotional fatigue of parents. Parents worn out from caring or responding to problems of children have less ability to moderate and respond positively to child's needs.

14. Marital discord. Unresolved marital discord in home heightens anxieties and concerns of children, making them more vulnerable to emotional and physical stressors

15. Limited social support network. For both parents and children, having few supports outside of home, including family, community, religious

16. Unemployed parent. Unemployed parent increases risk of lowered self-esteem and worthiness for adult, and increases risk of reduced responsiveness on part of parent for child's emotional needs.

17. Lack of good relationship with one adult. Ability to form long-term stable attachments is important. Child needs availability of at least one adult, either parent or relative/friend who can supply stable nurturing relationship.

18. History of illnesses requiring multiple hospitalizations. Multiple hospitalizations can cause feelings of lowered self-esteem, a sense of `damaged body', feelings of anxiety and abandonment.

19. History of childhood maltreatment. Prior abuse and neglect increases risk for development of emotional problems.

APPENDIX D

PROTECTIVE FACTORS AGAINST THE DEVELOPMENT OF SEVERE

BEHAVIORAL & EMOTIONAL PROBLEMS

In many ways, protective factors are the reverse of risk factors. When protective factors are present, there are presumed to be clear potential benefits to the individual. While certainly not a guarantee (e.g. vaccination) against the development of behavioral health problems, the presence of any one protective factor certainly affords the individual a greater chance of responding to stressors without long-term negative effects.

Decisions related to safety and well being, while not solely determined by the presence of protective factors, need to be informed by them. To the extent that there is a strong family social support network available, the parent is employed, or the children live in a home with clear consistent supervision, the chances of avoiding more serious emotional and behavioral problems are increased.

The following factors have been shown to offer individuals varying degrees of `protection' against the effects of significant stress. While no one protective factor can be shown to inoculate an individual against behavioral health problems, the presence of multiple protective factors often mitigates against the most damaging effects of behavioral health problems.

1. Strong social support network. Access to, and support of, support systems, including religious, community, friends, family (immediate and extended) can provide a safety valve for strong feelings and stress.

2. Good relationship with at least one adult. A trusting, stable, supportive relationship with at least one adult, either a parent, sib, family, friend, neighbor allows for problem solving and support to occur.

3. Responsible adult supervision and discipline. Caregivers who provide consistent, well-delineated supervision and rules of conduct allow children to grow in a more predictable environment. Will not reduce likelihood of adolescent testing of limits.

4. Parental employment. Employment increases self-esteem, can raise optimism towards environment, and allows adult to be more responsive to children's needs.

5. Temperament. Children who are easy going, flexible, and capable to modulated reactions to stress tend to develop greater resistance to effects of environmental and personal stressors.

6. Scope of opportunities for activities and success. Access to activities that educate, provide social interactions, development of athletic and physical skills reduce risks associated with idleness and social isolation. Greater sense of self-esteem associated with successful social interactions.

7. Coping skills. Children with ability to solve problems, navigate stressful and complex individual and social situations tend to develop resistance to

8. Self-esteem. One's sense of self-worth is a major source of protection against the development of behavioral and/or emotional disorders. One's ability to cope with stressors is often directly related to one's own sense of self.

9. School attendance. While many aspects of school contribute to stress and are linked to later behavioral and/or emotional problems, consistent attendance has been shown to be a significant protective factor for children.

10. Academic success. Nothings breeds' success like success! Children who are academically successful tend to have less pronounced behavioral and emotional problems, although unrealistic pressure for success may contribute to behavioral and/or emotional problems.

11. Resolution of family discord. The ability to resolve either long-standing or acute conflicts within the family (either parent-child or parent-parent) has been shown to offer a degree of protection to the child.

12. Avoiding teen pregnancy or fathering of a child. Children who avoid pregnancy and fatherhood tend to be less likely to develop serious emotional and/or behavioral problems than those who do become pregnant or father a child.

13. Being female. The incidence of serious behavioral and/or emotional disorders is less for females than males. Whether this is genetic, social or environmental is unknown. What is clear is that as a group, females tend to suffer fewer mental and behavioral disorders than males.

14. Involvement in counseling/therapy. Access to qualified professional staff to help individuals cope with their stresses and problems has been shown to partially `inoculate' them from more serious disorders. Early intervention for identified problems acts to protect the individual against more serious occurrences.

APPENDIX E

EFFECTS OF BEHAVIORAL HEALTH PROBLEMS

ON INDIVIDUAL AND FAMILY FUNCTIONING

In addition to these `general risk factors' that require case workers to be extra observant in their interactions with the DCFS client and their family, there are numerous problems that are often observed within a family where there are long standing behavioral health problems. There is a great deal of clinical data to suggest that these problems occur regardless of the specific behavioral health problem. In essence, the presence of one or more long-standing behavioral health problems have the potential to affect all family members. Staff need to be observant for the presence of these `signs'

• Emotional fatigue of family members
• Loss of extended support from family, friends, community
• Social isolation
• Frustration with attention paid to person with behavioral disorder
• Anger at loss of ideal child
• Anger at intrusiveness of agencies
• Chronic stress associated with care and planning
• Marital problems
• Difficulties with developmental transitions
• Parental guilt
• Depression
• Burnout
• Excess financial costs

APPENDIX F

SELECTED CHILD WELFARE ALLEGATIONS & OBSERVED PROBLEMS

BEHAVIORAL INDICATORS, TREATMENT OBJECTIVES

& TREATMENT CONSIDERATIONS

ALLEGATION/ BEHAVIORAL INDICATORS/ TREATMENT

PROBLEM TREATMENT OBJECTIVES CONSIDERATIONS

Physical Abuse	Behavioral Indicators of Victim _ School absence correlates with appearance of injury _ Behavioral extremes, i.e. overly compliant, passive or undemanding, aggressive, withdrawn _ Easily frightened, fearful _ Wary of physical contact or touch _ Poor social relations _ Afraid to go home _ Destructive to self and/or others _ Chronic runaway _ Complains of soreness or moves uncomfortably _ Wears clothing inappropriate to weather to cover body Caretaker's Characteristics · Conceals the child's injury · Does not seem concerned about the needs of the child · Describes the child as bad, different, selfish · Unrealistic expectations · Low self-esteem · Abuses alcohol or drugs · Markedly immature · Maltreated as a child · Projects blame on other · Poor impulse control	Clients present at treatment w/ denial and resistance of individual responsibility General treatment areas to be addressed for adults: _ Anger and stress management _ Coping mechanisms _ Stressors _ Ability to manage feelings _ Learning individual triggers, patterns and strategies _ Identifying effective parenting strategies General treatment areas to be addressed for children: _ Safety _ Ability to trust their perceptions of situations _ Role in the family _ Impact of abuse on developmental functioning _ Self-protection methods Treatment modalities found to be effective: _ Cognitive-Behavioral _ Family therapy _ Education support groups _ Art therapy for children _ Play therapy for children Minimal evidence to support effectiveness of psycho-dynamic intervention w/ either victims or perpetrators of physical abuse Interventions across environments found to be most effective; Family therapy beneficial in later stages and must be done w/ caution
Sexual Abuse	Physical Indicators · Venereal disease · Physical injury to the private parts · Bloody underclothing · Bruise, blood or discharge from genital or anal area · Unusual sexual behavior or knowledge · Bed wetting and fecal soiling · Difficulty walking or sitting · Loss of appetite or unexplained gagging · Excessive pain or itching in genital area · Frequent urinary or yeast infections · Frequent unexplained sore throats · Massive weight change Behavioral Indicators of Victim · "Damaged Goods Syndrome" · Withdrawal, fantasy or unusually infantile behaviors · Clinging, whining, new fears, hysteria, lack of emotional control, · Crying with no provocation · Poor self-esteem, self devaluation, suicide attempts, chronic runaway · Threatened by physical contact, fear of closeness · Eating disorders, e.g., anorexia · Avoidance of bathrooms · Sudden school difficulties · Role reversal, overly concerned for siblings · Sexualized behavior · Difficulty trusting · Repressed anger and hostility · Blurred role boundaries · Psuedomaturity, coupled w/ failure to accomplish developmental tasks Caretaker's Characteristics · Possessive or jealous of the child · History of sexual abuse in childhood · Abuses alcohol or drugs · Socially isolated, poor relationship with spouse · Immature, childlike impulse control · Perceives that child enjoys sexual relationship · Perceives sexual relationship to be indicator of love and affection	Clients present at treatment w/ denial and resistance of individual responsibility General treatment areas to be addressed for adults: _ Anger and stress management _ Identifying effective parenting strategies _ Denial _ Boundaries _ Support systems _ Alliances _ Marital styles _ Parenting styles _ Family structure _ Family styles of interaction _ Socio-environmental factors _ Coping strategies _ Issues of sexual vs. non-sexual intimacy General treatment areas to be addressed for offending adult: _ Denial as a coping mechanism _ Family of origin _ Psychosocial development _ Psychopathology _ Sex roles _ Sexual beliefs, feelings, and outlets _ Issues of power and control _ Issues of domestic violence _ Substance abuse General treatment areas to be addressed for non-offending adults: _ Issues of anxiety _ Issues of depression _ Guilt _ Role of secondary victim _ Feelings about partner _ Feelings about children _ Self-esteem _ Family of origin issues General treatment areas to be addressed for children: _ Safety _ Impact of separation and loss _ Relationship to parents _ Relationship to siblings _ Relationship to extended family _ Self-esteem _ Self-perceptions _ Issues of trust, intimacy, shame, guilt _ Depression _ Role in family _ Substance abuse _ Eating disorder Treatment modalities found to be effective: _ Group therapy generally thought of as best approach _ Cognitive-Behavioral _ Psycho-dynamic therapy _ Education support groups _ Art therapy for children _ Play therapy for children _ Social skills training for victim _ Assertiveness training for victim Family therapy beneficial in later stages and must be done w/ caution Developing trust of victim is critical first step for therapist
Neglect	Behavioral Indicators of Victim · Extremes in behavior, self-destructive, depressed, dull, apathetic · Food associated problems i.e. begs, steals, refuses to eat · Failure to thrive · Extremes in school i.e. frequently absent or tardy, constant fatigue or · Listlessness, falls asleep in class · Developmental lags · Lacks adequate food, clothing and/or housing · Poor hygiene · Thin, emaciated, distended stomach · Starvation, malnutrition Caretaker's Characteristics · Does not meeting the child's needs to the extent that the child's health is at risk. · Apathetic or passive · Depressed · Socially isolated · Lack of supervision or guidance · Low self-esteem · Shows little concern for their child's problems · Unsafe living conditions	Treatment for victim typically centers on issues of: _ Identify _ Self-esteem Non-traditional treatment modalities have been found to be most effective with young victims: _ Play therapy _ Art Therapy
Emotional Abuse	Behavioral Characteristics of Victim · Regressive behavior · Low self-esteem, long-term depression · Substance abuse · Enuresis · Sleep disturbances · Behavior extremes i.e. overly passive or compliant, aggressive or · Demanding · Overly adaptive behavior · Developmental lags · Neurotic traits, sleep disorders, inhibition of play · Conduct disorders i.e. antisocial, destructive, delinquent behavior · Habit disorders i.e. sucking, rocking, biting Caretaker's Characteristics · Unrealistic expectations of child, treats siblings unequally · Low self-esteem · Seems unconcerned about child · Withholds love · Threatens child, name calling or belittling · High incidence of domestic violence toward significant other	Treatment for victim typically centers on issues of: _ Identify _ Self-esteem Treatment modalities: _ Individual _ Internal Family Systems _ Family therapy with caretakers being coached in positive interactions Non-traditional treatment modalities have been found to be most effective with young victims: _ Play therapy _ Art Therapy
Failure to Thrive with No Organic Etiology	Physical Characteristics _ Height, weight, and head circumference in infant or young child does not progress normally _ Physical skills (e.g. rolling over, sitting, standing, walking) are delayed _ Delayed cognitive and social skills _ Development of secondary sex characteristics are delayed in adolescence Problems often facing mother/caregiver: _ Problems with mother/child interaction _ Problems with interpersonal and affective behaviors _ Maternal deprivation _ Behaviors in child that limit quality of stimulation given Problems often facing child: _ Issues with eating _ Issues with sleeping _ Issues with elimination _ Issues with auto-erotic and self-harming behaviors Risk factors include: _ Medical: Genetic, metabolic, damage to CNS, malnutrition _ Psychological: Parental emotional and physical withdrawal from child; rejection, hostility; psychiatric symptoms _ Social: Poverty, living conditions, malnutrition	If identification and treatment is made early, effects of non-medical FTT can be minimized. Long term effects of medically-based FTT tied to nature of medical problem If causes are non-medical, interventions must consider: _ Family dynamics _ Parental attitudes toward child _ Psycho-social supports available to family Treatment Modalities: _ Family therapy to reorganize family to meet emotional needs of child
Substance Related Disorders	Caregiver's Characteristics _ Cognitive impairment _ Impaired judgment _ Difficulty w/ school, work _ Repeated absences from school, work _ Neglect of children _ Social isolation _ Public intoxication _ Self-administration, `self-medicating' _ Impulse control problems _ Aggression towards family & friends _ Automobile accidents _ Encounters w/ law enforcement officials	Multi-modal treatments are most effective: Limited data to support treatment matching approach (personality traits & tx approach) -Medication: May be useful in treating co-morbid conditions (e.g. depression); use of medication to reduce cravings -Psychosocial: Commonly used treatments include: 1. Group therapy 2. Cognitive-behavioral 3. Couples/family therapy 4. Behaviorally focused 5. Motivational 6. 12-step 7. Psychotherapy -Environmental. Interventions across environments (school, community, home) Significant co-morbidity with psychiatric symptoms Individuals w/ intact marriages &b whose spouses attend tx have better results Individuals experiencing withdrawal symptoms need supervised de-tox. Brief interventions (30-60 mins) produce significant changes in drug and alcohol use. Intensity of treatment (inpatient vs. outpatient) shows little correlation with success and relapse. Motivation to change is critical in selecting tx options.
Domestic Violence	Adult Victim characteristics _ Obvious injury _ Feelings of depression _ Anger _ Low Self-esteem _ Suicidal Ideations _ Frequent somatic complaints _ Allows children to act aggressively towards self or others _ Frequent use of alcohol _ Agitation _ Confused thinking _ Difficulty making decisions _ Hx of violence in immediate or extended family Batterer Characteristics _ Constant blaming of others for own violent behavior _ Criminal record of violent offenses _ Obsessive behavior- jealous, accusatory _ Monitors the adult victim _ Threats of suicide, violence or kidnapping children _ Alcohol or drug use _ Access to weapons _ Training in martial arts or boxing _ Stalking behavior _ Hurts animals _ Manipulative- often claims to be the real victim _ Vengeful, e.g. files an order of protection against the adult victim _ Acts paranoid and hypersensitive _ Belligerent toward authority figures, or the opposite: _ Acts charming and mild-mannered to outsiders Characteristics of Infants _ Poor sleeping _ Excessive screaming _ Difficulty bonding _ Difficulty regulating emotions Characteristics of Toddlers _ Stress reactions _ Insecurity _ Aggression _ Frequent illnesses _ Social problems, e.g. biting, hitting, fighting Characteristics of Pre-Schoolers _ Distress reactions _ Feelings of sadness _ Physical and verbal aggressive w/ peers _ Anxiety Characteristics of Primary Schoolers _ Poor academic performance _ High levels of aggression _ Depression _ Diminished social competence _ Externalization of problems _ Delayed adaptive skills Characteristics of Adolescence _ Anxiety _ Depression _ Early on-set substance abuse _ Early sexual activity _ Aggressive behavior _ Increased contact w/ law enforcement	Recommended treatment modalities for adult victims and children: _ Domestic violence counseling through a domestic violence program _ Counseling to address personal safety issues and to plan for safety _ Education on the effects of domestic violence on children Recommended treatment modalities for batterers: _ Specialized DHS-approved batterer treatment programs _ Education on the effects of domestic violence on children Inappropriate interventions: _ Options that the adult victim states will increase the danger to children _ Couples therapy _ Court mediation/divorce mediation _ Anger management groups and other non-DHS approved offender treatment options _ Visitation arrangements that endanger adult victims or children Confidentiality guidelines must be followed: _ Disclosures made by adult victims and children should not be made to the batterer _ Addresses of victims seeking safety should not be shared with the batterer
Depression	Characteristics of Caregiver or Child _ Poor or excessive appetite _ Disrupted sleep patterns _ Low self-esteem _ Social isolation _ Sexual dysfunction _ Employment difficulties _ Difficulty following through on routine tasks _ Suicidal ideations _ Somatic complaints _ Drug & Alcohol abuse _ Failure to follow-thru w/ medication _ Excessive sleeping _ Disregard for physical welfare of children _ Disregard for cleanliness of self, children and home _ Failure to f/u on activities /appointments for children _ Irritable _ Low tolerance for noise, activities _ Quick to anger _ Frequent scapegoating of others, especially children	Need to establish clear objective goals and criteria for measurement. -Reliance on only one method of treatment (medication or psychosocial) has been shown to be less effective than combining multiple approaches across multiple settings. Approximately 80% of people w/ depression respond to tx. Cognitive therapies are as effective as medication Interpersonal therapy also effective -Medication has not been found to any more effective, long term, in preventing relapse. Combination therapy is viewed as most effective Specific type of intervention based on type & severity of disorder: 1. Major Depressive Disorder: Typically psychotherapy, medication or ECT 2. Dysthymic Disorder: Recently, combination of psychotherapy & medication 3. Other tx modalities: hospitalization, phototherapy, herbal, self-help
ADHD	Behavioral Characteristics of Child _ School difficulties, e.g. academic, behavioral, social _ Depression (in adolescence) _ Social Isolation _ Early drug experimentation _ Low self-esteem _ Auto-accidents & injuries _ Anti-social behaviors & gang activities _ Somatic complaints, w/ problems at school _ Anxiety related fears	Need to establish clear objective goals and criteria for measurement. Multi-modal treatments are most effective: -Medication. Typically stimulants are used; specific anti-depressants also helpful -Psychosocial. Behavioral & psycho educational approaches most effective of non-medication approaches Behavior parent training classroom & Behavior modification are effective interventions -Environmental. Interventions across environments (school, community, home)
Reactive Attachment Disorder	Behavioral Characteristics of Child _ School difficulties _ Depression, especially in adolescence _ Difficulty bonding w/ caregivers, family _ Social isolation _ Aggressive behavior _ Non-compliance _ High co-morbidity w/ Oppositional Defiant Disorder, and other anti-social behaviors _ Early drug use _ Early on-set sexual activity _ Impulsive behaviors _ Frequent injuries _ Hyper-vigilance _ Difficulty regulating emotional responses Caregiver Characteristics _ Persistent disregard for child's emotional needs _ Persistent disregard for child's physical needs	Need to establish clear objective goals and criteria for measurement. Multi-modal treatments are most effective: Efficacy of specific treatments for RAD has not been established. Multi-modal tx is best option Current tx paradigms: 1. Infant-parent Psychotherapy 2. Integrative therapy 3. Theraplay 4. Holding therapy: Is not accepted by DCFS as an appropriate intervention 5. Rage reduction therapy: Is not accepted by DCFS as an appropriate intervention
Conduct Disorder	Behavioral Characteristics of Child _ School difficulties _ Attentional difficulties _ Depression, especially in adolescence _ Aggression _ Damage to property _ Bullying _ Social isolation _ Anti-social, gang activity _ Frequent contact w/ law enforcement & legal system _ Aggressive behavior _ Non-compliance _ High co-morbidity w/ Oppositional Defiant Disorder, and other anti-social behaviors _ Early drug use _ Early on-set sexual activity _ Difficulties across multiple settings (school, home, community) _ Lying & stealing _ Limited empathy or concern for welfare of others _ Early drug experimentation _ Low self-esteem _ Anti-social behaviors and gang activities _ Somatic complaints, w/ problematic school attendance	Need to establish clear objective goals and criteria for measurement. Multi-modal treatments are most effective: -Medication: Can be useful in controlling aggressive outburst; symptoms associated w/ co-morbid conditions (e.g. ADHD; mood disturbances) -Psychosocial: Commonly used treatments include: 8. Psychotherapy 9. Anger & crisis management 10. Cognitive-behavioral therapy 11. Social skills training 12. Support groups 13. Multi-systems therapy -Environmental. Interventions across environments (school, community, home)
Post Traumatic Stress Disorder (PTSD)	Victim characteristics: _ Somatic complaints of headaches, stomach pain, dizziness, chest pain _ Flashback episodes _ Night fears _ Sleep disturbances _ Emotional numbness _ Depression _ Anxiety _ Irritability _ Guilt at having survived traumatic event Risk factors for PTSD: _ Exposure to extreme traumatic event, that involves death, injury, violence, threat of violence Medical/biological findings associated with PTSD: _ Changes in long term memory function _ Persistent changes in arousal hormone levels associated with stress _ Higher than normal levels of natural opiate production	Effective Treatment Modalities: _ Cognitive-behavioral therapy _ Group Therapy _ Exposure Therapy Medications have been shown to ease associated symptoms of: _ Depression _ Anxiety _ Sleep Disruption High risk of Co-morbidity for: _ Depression _ Other anxiety disorders _ Alcohol and Substance abuse
Shaken Baby Syndrome	Physical Characteristics _ Ocular or cerebral trauma _ History of poor feeding _ Subdural hematomas _ Injury occurs in child less than 1 year old _ Greater than 90% of serious intracranial injuries due to abuse Behavioral Characteristics of Victim _ History of poor feeding _ Vomiting _ Lethargy _ Irritability _ Seizures _ Lack of affect _ Diminished vocalizations Caretaker's Characteristics _ Usually no intent to cause harm to child _ Paramours usually abuser of child _ Event of shaking baby sufficient to cause injury usually an isolated episode _ Very few repeat offenses _ Impulse control problems _ Aggressive behaviors _ Unrealistic expectations of child _ Presence of psychiatric disorders _ High levels of perceived stress _ Careless disregard for the safety of child _ Current psychiatric difficulties	Because episode is usually isolated, and with minimal intent to cause injury to child, treatment focuses on _ Anger management _ Control of impulses

INTRODUCTION | THE IMPORTANCE OF IDENTIFYING RISK FACTORS | TREATMENT PATHS | TREATMENT PATH STAGE I: IDENTIFICATION OF | BEHAVIORAL HEALTH PROBLEMS | TREATMENT PATH STAGE II: REFERRAL | TREATMENT PATH STAGE III: CLINICAL ASSESSMENT | TREATMENT PATH STAGE IV: INTERVENTION | TREATMENT PATH STAGE V: RE-ASSESSMENT | APPENDIX A | APPENDIX B | APPENDIX C | APPENDIX D | APPENDIX E | APPENDIX F