There is a set of givens supported by years of research and the evolution of Children’s Systems of Care that informs the development of effective care for children with intellectual and behavioral challenges: (A) The earlier services begin the better; (B) Services need to be tailored to the individual needs of children and their parents or care takers; (C) Complex issues facing a child require an interdisciplinary approach; (D) Collaboration and close coordination among the key people involved in a child’s life (family members, caregivers, therapists, physicians, teachers, etc.) improves outcomes and reduces costs; and (E) For there to be a true continuum of services, providers should consider expanding their range of services, including comprehensive behavior support and assistive technologies in order to productively focus on what is appropriate and effective for the individual served. Providers often focus on one method of treatment, typically Applied Behavior Analysis or Cognitive Behavior Therapy, to the exclusion of others and miss the opportunity to maximize the effectiveness of their services. Better clinical outcomes and cost effectiveness can align.
First Children’s Services operates in New Jersey where the public system of care for children with intellectual and behavioral challenges is aligned with the principles above, which sets a foundation to meet our objective of flexibly meeting the needs of families regardless of payers. The NJ Children’s System of Care (CSOC), managed under the Department of Children and Families (DCF) has evolved over fifteen years and offers a variety of behavioral health services based on the needs of the children it serves including traditional one-to-one therapy as well as behavior support services utilizing paraprofessional and professional staff. NJ CSOC is an example with statewide architecture and operations including 365/24/7 access, screening, mobile response, assessment and service planning, and case management without any barriers related to insurance, language, or geography. In 2013, NJ became the first to integrate youth with IDD into the statewide system of care.
While there is broad agreement as to major SOC principles nationally, many other service delivery systems don’t follow them due to resource limitations. This article addresses practical approaches for integrating key principles into a comprehensive and effective children’s behavior health system of care for children with intellectual and behavioral challenges. The following examples define key strategies and illustrate why they have been employed to benefit child and family consumers.
- Early Screening and Referral. The CDC encourages pediatricians and other primary care physicians to use basic developmental screening tools during routine “well-baby/well child” visits. Unfortunately, many pediatricians still fail to incorporate developmental screening as a routine part of care. This results in a missed opportunity to identify issues that can be addressed early in a child’s life and improve outcomes.
As a remedy, reliable screening tools, such as the MCHAT 2 are available at no cost and physician’s staff can be briefly trained to have a parent complete a short questionnaire, score and file it in the medical record for the physician to review during a child’s office visit. If the doctor’s observations and MCHAT findings both suggest the possibility of developmental deficits, timely referral should be made to an appropriate specialist, e.g., developmental pediatrician, neurologist, child psychiatrist or psychologist, for a comprehensive diagnostic evaluation. To achieve this integrated care approach, systems need to adapt by augmenting practice within specific types of diagnostic professionals to exponentially increase who can screen young children, through training and continuing education.
In our current healthcare system, integrated medical and behavioral health care innovation is a hot topic but medical providers are often not reimbursed for behavioral health screening. If a specific emotional, behavioral or developmental diagnosis can be confirmed or ruled-out, or if a diagnosis is confirmed, parents can be supportively referred to a clinician. Screening and early intervention for children improves the likelihood of good functional outcomes and this does not occur often enough in many states.
Systems of care should also tackle the longstanding nightmare for families of disconnected silos by creating seamless early intervention, insurance funded services and services provided by school districts as part of IDEA – this is good public policy that arguably could demonstrate significant savings in the lifetime cost of care. In NJ the Department of Health operates a separate network for Early Intervention outside of the Children’s System of Care. Systems vary nationally, but the goal should be to eliminate a family’s challenge to navigate access, affordability, coordination and continuity of care for early intervention on to child behavioral health and education services.
- Simple Communications Strategies. A pediatric neurologist who presented to a group of special educators stated: “just a simple handwritten note from the child’s teacher letting me know what’s happening in school would be a huge help!” Despite all of the technology employed by professionals in the field today we seem to have overlooked the simplest solutions. Communication as a Best Practice goes a long way toward identifying issues before they become major problems. Providing vital feedback can be used to productively modify various interventions including medications, and clinicians can use input to interpret data and evaluate the effectiveness of their interventions.
Some public systems of care, like NJ DCF CSOC, have developed centralized communications systems, including shared electronic case management and health record, and routine family case conferencing in order to gather vital information from a child’s treaters.
Provider software solutions are also available to achieve desired communication strategies. A practice management system can include mechanisms to prompt therapists to share certain data with other members of the treatment team. Notes are available on the system for all therapists to see and can be easily and automatically emailed to external users (e.g. pediatricians).
- Use of a Wide Range of Behavioral Interventions. Most providers recognize that in the age of EBT clinical accountability is required. Accordingly, when addressing children’s behavioral problems, “one size doesn’t fit all” with regard to treatment approaches. Providing individualized intervention strategies, including person centered planning, is essential to an effective children’s system of care. Those services should include early intervention, intensive individual therapy, parent training, and family therapy, along with social skills group training and a breadth of behavioral support services aimed at helping a child integrate into the community, school and family system.
Behavior Therapy offers an over-arching treatment model that incorporates a flexible array of evidenced-based interventions. Specific interventions include cognitive behavior therapy, structured social skills training, behavioral parent training, behavioral self-management and Applied Behavior Analysis. All treatment services should be delivered under the philosophical umbrella of “Positive Behavior Support” to insure use of positive reinforcement, encouragement, pursuit of autonomy and freedom from aversive techniques.
- Adapt Services to the Needs of Families. To provide effective services within a public system of care, one has to recognize that not all families with children experiencing behavioral, emotional or developmental challenges have the same needs, resources, schedules, ability to commit to services, and cultural mindset concerning therapy. Provider agencies need to be flexible, creative and have a broad range of programs and clinical specialists to achieve desired treatment outcomes.
Placing the needs of families first can result in adoption of practical service delivery models. While in-home behavioral services are the increasing choice of SOC payers, parent schedules and other family obligations often result in limiting factors with the overall effectiveness of service. Clinic-based services can be a clinical and cost-effective SOC component in circumstances where group treatment or group parent training is indicated and when access to needed treatment services can be facilitated. At FCS we provide therapy services to young children in our child care program. Families drop their kids off for much needed therapies and opportunity to interact with other children who may or may not have behavioral challenges. We have taken similar approaches with school-aged children in some of our educational contracts. This permits continuity of care as the same therapist who works with the child in school often works with the child and family after school and then at home.
Transcending the communication and practice boundaries between school districts and public human services permits a unified approach to meeting the comprehensive needs of children and families. Under NJ’s Children’s System of Care there is evidence of cooperation among the education and children service entities. In NJ and in most states nationally, there is an enormous opportunity to improve outcomes and support working families who have children with intellectual behavioral health needs.
In summary, effective systems of care for children with behavioral, emotional and developmental challenges begins with a commitment to certain tried and true principles: use of multiple evidenced based interventions with a focus on positive behavior supports; early screening and intervention; individualization of treatment; multi- and inter-disciplinary approaches; and basic communication among all of those impacting a child’s life. SOC’s need to be developed and implemented as early as possible, in response to an in-depth understanding of the needs of children and their families. Along the way we just might calculate the financial benefits of better outcomes, family support and continuity of care.
Howard Savin, Ph.D., is Senior Clinical Advisor, First Children Services, and is transitioning from work with Beacon Health Options. Joseph J. Hess, Jr. MSW, MBA is the Founder and President of First Children Services. Lisa B. Eisenbud, MSW is the Principal of Get Going LLC consulting with FCS and a former Chief of Staff to New Jersey’s Departments of Children and Families, and Human Services. Matthew Hess is co-founder of First Children Services and its Chief Operating Officer. Valery Bailey, MPA held senior positions at NJ DCF and DHS as well as at Mentor, Inc. and Covenant House before joining FCS as its Vice President of Behavioral Health Treatment Services.
For further information about anything found in this article, please contact: Joseph J. Hess, Jr., President, First Children Services at jhess@firstchildrenservices.com.
References
Center on the Social and Emotional Foundations for Early Learning (2009), “Positive Behavior Support: An Individualized Approach to Addressing Challenging Behaviors,” Brief #10, Vanderbilt University.
Cherney, K and Krucik, G, “Behavior Therapy,” Healthline, healthline.com June 4, 2013.
Ringwalt, S. (2008), Developmental Screening and Assessment Instruments with an Emphasis on Social and Emotional Development for Children Ages Birth to Five, National Early Childhood Technical Assistance Center.
Wotring, James & Stroul, Beth. (2011) The Intersect of Health Reform and Systems of Care for Children and Youth with Mental Health and Substance Use Disorders and their Families, National Technical Assistance Center for Children’s Mental Health, Georgetown University Center for Child and Human Development – System of Care Brief #1.
