27 Managing Care

INTRODUCTION

The initiative of the Department of Public Welfare to deliver what is referred to as ‘behavioral health rehabilitation services’ to medical assistance recipients through a managed care process separate from physical health care processes is not dramatically different from the original federal decision to create community mental health services in 1966. In both cases, the operational entity was given a set amount of money to care for a set number of people [all within the ‘catchment area’ boundaries who needed service]. The process is essentially one of ‘capitation’, or paying a premium for expected services and the risk to the operating entity is whether they can provide the services to all of the people who need the services at the level required, while remaining within the limits of the resources.

This capitation process places the county contracted managed care organization [MCO] at both financial and health risk, for if required services cost more than the available funds, the county/MCO must cover the costs OR risk not fulfilling the service delivery responsibilities. It is questionable whether the county that has a legal responsibility for the care of its citizens can place this responsibility outside itself, even in a contractual way. The variables of this risk are: the resources [finances available]; the population size [universe]; the population context [the number of people in the population who will need to receive services – e.g., the percentage who are in need of help]; the cost of providing services; and finally the effectiveness of the services. The trade off decision may be anguish for a county that must decide what to do when resources are less than adequate, but the decision of a profit organization is clear.

The present projections about the need for behavioral services are rather dramatically large. However, two factors seem to cause these high predictions. First, is the self-serving process of psychological experts attempting to ensure future financial resources? Catastrophic predictions are much better at ensuring that society will allocate funds than modest predictions. Second, is the discrimination of what is a ‘behavioral health’ issue that requires professional service. Just as our society is prone to go to the family doctor for a common cold despite the fact that there is no medical attention which can affect the progress of the cold; so too, does our society tends to regard normal reactions to trauma or loss as requiring ‘clinical treatment’. Thus, the attitude of the community toward the need for psychological services is an artifact of how the public agencies respond to issues and concerns of the public.

If a public office decides that any person receiving a speeding ticket in the county is in need of clinical treatment, we obviously foster increased potential need. Thus a fundamental assumption about atypical behavior and a theory of change are required to help appropriately set a standard regarding the nature of the population to be served.

The actual percentage of people who need professional services to overcome problems in living may be very different from the number of people who are identified as being in need. The decision about how to identify and respond to social issues is a critical part of the determination of the percentage of people who will need services. If, for example, we simply require ‘speeders’ to attend a driving class, rather than have ‘clinical treatment’, we have addressed the issue without committing the ‘behavioral health’ resources. It is important to note that the local government is heavily involved in this trade-off. The county can spend its funds through education or clinical categories, but it is still county taxpayer money.

Perhaps an even more important trade off is the option between custodial care and prevention. If the public policy is to provide custodial care without prevention services, one can assume there will always be the need for custodial care. This is both a philosophical and a theoretical problem. From a philosophic standpoint, the need for prevention may be obvious. But if one believes in certain theoretical positions concerning biology, prevention is useless. One cannot prevent an epidemic of chemical imbalance. This is an ‘act of God’ and beyond the scope of mere mortals. In this situation, we can only respond to the presenting problems and a crisis mode will always be predominant.

The cost of providing ‘behavioral health’ services is difficult to assess for two reasons: first, ‘behavioral health’ professionals have never developed the same types of protocols as physical medicine, therefore treatments may be necessary for one week, one month, one year or one lifetime. The second, is that the nature or response varies from the very expensive ‘medical’ to the relatively inexpensive ‘psychosocial’, and there is no public stance on the appropriateness of either. In fact, ‘behavioral health’ professionals, just to be safe, tend to recommend both approaches.

One of the clear problems that the present MCOs are having is the increased cost of doing business that medical model approaches entail. Managed care has effectively moved public ‘behavioral health’ services back twenty years to a full medical model, ignoring the learning of the traditional public system. One needs to remember that private health care staff and organizations such as MCOs have no history of working with people with severe and persistent problems in living. Historically, unless the person was independently wealthy, insurance coverage ran out quickly and the person with severe and persistent problems in living came under the auspices of the public system. The Commonwealth of Pennsylvania had, in the late 1990s, finally arrived at an understanding that people with ‘chronic’ problems were much better served in home, school/work and community [although the child services hardly got off the ground since, until the advent of EPSDT in the early nineties, there were virtually no services]. The National Institute of Mental Health [NIMH] formally supported ‘community based programs’ [psychosocial programs of residential, vocational and social intent] as early as the 1970s. In fact, NIMH created the CASSP [Children & Adolescent Service System Programs] to emulate the adult programs in the early 1980s, although true funding for children’s programs did not come until the 1990s with the Scott court settlement. [And then, much to the loss of the emerging paradigm, were funded through a medical category]. Much of this gain in community services has been lost to the resurgence of the ‘medical model’ and the idea that through medication and incarceration, we can ‘cure’ the chemical problems. This revisionary position has occurred despite the fact that there is no evidence to support this notion and that the costs are much higher – if for no other reason than the maintenance of the necessity for a psychiatrist – a ‘no value added’ appendage who is required to diagnose and ‘oversee’ all services.

The effectiveness of the service delivery system has a direct correlation to the potential financial risks. Low cost, ineffective services are costly since the problem never goes away. High cost ineffective services are even worse. High cost effective services – those that make the problem go away after some specific period of time, may hold short term risk, but have high long term potential. The ideal is of course, low cost effective services. There is significant evidence to suggest that the high cost long term benefit is not valued by the contracted MCOs because of the uncertainty that they will benefit from this option given their contractual status – i.e., if the contract is for three years, they must make the profit in that time period and long term investment, while it may have value to the client and to the locale, has no benefit to the MCO.

Medical services are by nature high costs. Restrictive services are high cost. Both medical and restrictive services have the short-term benefit of making the symptoms diminish, although they avoid the fundamental issues. Cognitive behavioral approaches are low cost [particularly if they are expanded to include both educators and lay people]. Home, school/work and community costs are lower than residential or ‘factory’ models. The philosophy of communities that take responsibility for their own and cognitive behavioral responses and prevention is clearly the optimal focus. On the other hand there is no indication that medical interventions have any value whatsoever in regard to positive long-term outcomes. While certain medications can be said to eliminate behaviors [although this is not reliable demonstrated], they ignore the fundamental problems and therefore only ‘mask’ the issues at hand. Even if such interventions were low cost they would prove to be very expensive because of this lack of outcome. Contrary to this track record, cognitive behavior management is the most documented and most effective type of intervention available. Thus even if its cost were higher than anything else, it would prove to be the least expensive over time.

Categorical Funding

Presently in the Commonwealth, there are four [04] distinct resources for ‘behavioral health’ services. [This ignores the separation of categories within groups, e.g., partial hospitals or family based rehabilitation services.]

Community Funds: Those monies allocated by government to operate the Office of Mental Health at the County Level and to run certain community programs. These funds are allocated directly to the County Administrator, who under regulation administers their allocation.

State Hospital Funds: Those monies allocated by the government to operate and make available ‘beds’ for county citizens who need them. These funds are allocated directly to the State Hospital Superintendent, who under regulation administers their allocation.

Medicaid Funds: These monies are separated into “fee for service” and “managed care” funds. The first are administered directly by the state Office of Medical Assistance Programs [OMAP] and in the southeast region are incidental.

The second is provided to the MCO by contract between the County/OMAP and the MCO and covers all Medicaid services except as the incidental ‘fee for services’ applies. These funds are managed by the MCO under contract to the county.

County citizens in need of ‘behavioral health’ services may use any or all of these resources. However, these resources are not coordinated into one PLAN. Placement of a citizen in a State institution, for example, holds the County Administration financially ‘harmless’, in that there is no cost to the local budget [either OMH or MCO]. This potentially creates a financial incentive to place costly end users in the institution, rather than expend local resources. If the State Hospital Funds came directly to the County Administrator and s/he could choose either to purchase the very expensive [$90,000+ annually] services of the institution OR provide intensive services in the local community, the clinical issues would be better served. Operating a county program without having all of the resources in one budget, therefore, is inefficient and ineffective. Any attempt to organize a managed care process in the county should attempt to do so with ALL RESOURCES included in the plan.

Business requirements

In order to manage care, there are several basic requirements:

• management information: it is impossible to manage care without a clear understanding of who is receiving care, for how long, with what cost and what impact? This category should include performance outcome management services [POMS]
• assessment of inputs: in human services the client is an input to the system. Inputs vary in quality and the notorious process of ‘creaming’ or taking the easiest client to work with and then comparing oneself to those taking the most difficult clients, is an example of the difficulty in assigning organizational performance status.
• research & development: a critical part of managing care is to be able to a) measure the impact of the care to determine effectiveness and to cease expending resources if there is not substantive improvement and b) to identify, develop or create new options to replace those that do not work effectively.
• decision protocol: there must be clear basis upon which decisions are made as to what services should be offered, for how much time and for what purposes. Present lack of protocol leaves the individual to the mercy of the provider of services who may or may not have any effective means of intervening.
• performance contracts: the preferred providers must perform certain activities in certain ways and cannot be contracted with merely because they always have been. Part of the responsibility, of course, is effectiveness. However, flexibility, creativity, commitment to excellence, etc. are critical characteristics of a ‘learning system’ that is capable of adjusting to new ways of doing business to meet the expected outcome criteria.
• account brokers the term is deliberately foreign in order to ensure that the ‘case management’ concept is taken further, given more authority and responsibility, than traditional thought allows. The ‘account broker’ is critical to user friendly, effective services across all public person serving domains.

Behavior Rehabilitation Services and Education

All children go to school. It matters not whether they are in prison, residential or partial clinical treatment or living at home. School is the great meeting place. Educators in correction facilities and hospitals are usually part of the public school system and owe some allegiance to its policies and procedures. Such educators therefore are either an asset to the child’s psychological fitness or a detriment. As a matter of course, it would seem wise for the county to ensure that they are an asset.

Universe

Definition: Children is the term used to define the population between the ages birth to twenty-one.

According to the latest data for the school year 2000-2001, 63,578 children attended Chester County Public Schools. An additional 12,000+/- attended non-public school giving us approximately 76,000 as the number of children attending schools covering kindergarten through twelfth grade. In addition, 500+/- children between the ages of three to six were enrolled in early intervention. Finally, a number of children between the ages of sixteen to twenty one have either dropped out of school or graduated. The difference between the seventh grade class [5137] and the twelfth grade class [4043] is 1104 or 21.5%. The population in the county is growing, however, and not all of these can be considered dropouts. If we compare the average class size of elementary school [5043] and secondary school [4713] we have a 6.5% increase in class size for younger children indicating population potential growth. Using this as our guesstimate basis, 6.5% of 1104 or 72 would be subtracted as growth leaving 1032 as dropouts. Further, since the graduating class of 2000/1 is 4,032, we could use a figure of 4,000 as the average graduating class for the last three years [assuming the average graduate is eighteen years of age] and get a total of 12,000+/- graduates who are still in the universe.

Adding together, we have the following approximation:

Public school	=	63,500
Non-Public schoo	=	12,000
Drop outs	=	01,000
Graduates	=	12,000
Early intervention	=	00,500
Others below 6	=	25,300
Total Children in Chester County	=	114,300

Thus approximately 114,000 persons between the ages of birth to twenty-one in Chester County are eligible for Behavioral Rehabilitation Services.

Population

While projections vary, most mental health publications use a figure of 10% to 12% to project the portion of the total population who will need behavioral health rehabilitation services. The State of Pennsylvania in 1996 suggested that out of a total population of 192,000 children needing such services, 83,000 or approximately 45% of these would have severe problems. Using these data ratios as the basis for our projections, it can be expected that 11,430 to 13,716 Chester County children will need BHR Services, and 5,145 to 6,172 will have severe problems.

As a comparison to these projections the County public education system identified approximately 600 children as being eligible for special education as Seriously Emotionally Disturbed in the past school year. Since special education has another criteria [being in need of individualized instruction] this figure could be lower than the actual number of children who might be identified by the school as Seriously Emotional Disturbed. Thus it is possible that a child with serious and persistent problems in living continues to be served in the regular classroom. It is also clear that many children with other problems in living – such as specific learning disabilities [4,585], mental retardation [553], PDD/autism [100], etc. develop maladaptive thoughts about themselves, others and future prospects which lead to atypical and problematic behaviors that are not directly connected to the originally disability. But even including the totals of these populations we would only come to 5,818 [We can add another 42 if we count three to six year olds.]

However, it is still difficult to justify the discrepancy between a projection of 12,500 and 600 or 6000. We could use another comparison of a similar and overlapping population – juvenile court dispositions. Disposition is defined as a referral disposed by the probation department and/or the court. Any one youth may be involved in a number of dispositions within a calendar year. In 1996 Chester County had a total of 552 dispositions – a rate of 1.29% of the juvenile population between the ages of 10 and 17. Using our projections for 2000/1, the population would approximate 50,500 and the dispositions 651. The population of the detention center averaged an annual figure of 342 children [with possible duplication] for the years 1997 to 1999. Neither of these figures necessarily indicates the total delinquency population. However, even considering the incarcerated population to represent 10% of the delinquent population leaves us short of the kinds of projections that mental health makes. We must use a lower projection of 5% to gives us our first possible comparison [342 incarcerated projects to a delinquent population of 6840, while 651 would project to 13020] that would equate to the mental health projections. And we must remember that the baseline figures are likely to include the same child several times.

The numbers presently being provided mental health services is also well below such projections. While no standard references are available. The following projections, counting children served in the each category at any one time, approximate what is occurring:

In-patient hospitalization	0010
Residential Treatment	0100
Partial Hospital Programs	0100
Home & Community Services	0200
Outpatient services	0500
	0910

This number is also significantly below the projections.

Three factors can be considered regarding these discrepancies:

• Projections such as 10/12% are self-serving for purposes of raising funds and far exceed actual practice.
• Even if such projections were true, the occurrence of problems in living would happen at differing times in one’s life and therefore a smaller number are active at any given moment – or,
• Children are significantly undeserved in Chester County.

We would suggest that all three of these factors are true and contribute to the discrepancy that is observed. It should also be noted, however, that public education [which in this conjecture includes Approved Private Schools as an arm of, and funded by, the public system] serves children both in the BHS system and those who should be in the system by whatever criteria used. We suggest that nonpublic schools do not entertain educational services for students with atypical behavior and by and large these children are funneled back into the public system. Additionally, any child who is in the BHRS system is also served by public education at some level. Consider for example, the fact that the CCIU operates:

The Child and Career Development Center, a school for students with physical, emotional and mental disabilities ages 3 -21 years.

The Center for Alternative Secondary Education, a school for middle and high school students with behavioral problems who experience difficulty in the regular education setting.

The Chester County High School, a school for students who have left the public school system before obtaining their high school diploma.

In addition, the Chester County Intermediate Unit provides academic, pre-vocational and life skills instruction to adolescents incarcerated at the SouthEast Secure Treatment Unit (SESTU) in Embreeville and the Chester County Prison.

Nonetheless, we are required to find some basis upon which to determine the expected population that might need to be served. It would seem that a 1% to 1.5% projection is subject to some consideration, based upon empirical experience. 1143 to 1715 children at any given time might be considered slightly above the present allocation of resources, but well below what is considered to be a national standard. In addition, one could begin to explore the notion of where and how services are provided, for some children might be able to receive services in nonidentified and nonintrusive ways in valued settings depending upon how we determine the fundamental assumption and theory of change.

What is more important, perhaps, is to determine the number of all children with problems in living as identified by clinical, educational, protective and correctional enrollments, without any duplication in numbers. This number of children who demonstrate problems in living of withdrawal or aggression might then be considered to be 75% to 85% of the target population that has been identified for services.

However, we can take another tack entirely and suggest that the whole process of decision-making based on a chemical imbalance posture is wrong. You may have noticed we have dropped the word ‘health’ out of the equation and have been calling it a behavior rehabilitation system. Since cognitive behavioral interventions are the only research documented effective services, and since all children with or without problems in living, regardless of type would benefit from cognitive behavioral interventions, these services should be the option of choice for a new behavioral rehabilitation service.

In addition, we would draw attention to the use of schools as a fundamental ‘valued’ setting, which is uniquely both an institutional and natural support, to be a primary environment, along with the home, in which to implement supportive services and to coordinate all educational, clinical, and corrective interventions. Since all children are served in or by educational facilities and we posit that all children with atypical behavior are served through the auspices of public schools, it would seem that a close relationship between public schools and BRS services would prove to be useful.

Methodology

The first issue of concern is to develop a coherent basis upon which to develop this relationship. There needs to be some way to decide what is education, what is BR and what is combined. We would suggest that to entertain this effectively, stakeholders should discuss some fundamental assumptions about atypical behavior and adopt a theory of change with is compatible with these assumptions. The Institute For Cognitive Behavior Management has a reasonably coherent fundamental assumption which is that: people are the sum total of their thoughts. People cannot act differently than they think, unless of course they are acting. This is a fundamentally different order than an assumption of pathology.

From this fundamental assumption we would suggest that the theory of change is that people will only change their behavior when they change the way in which they think. Therefore interventions which change the ways in which people think are the one’s which would produce the most change. Since research indicates that cognitive behavior interventions are the most validated to be effective, we suggest that the research supports our basic assumption.

Once this basic theory of change agreement is established, two secondary issues remain:

• how do we identify all of the children who could benefit form BRS without over-identifying them?
• how do we sort these children based upon the level of care needed between educational and clinical services?

Since education deals with learning and thinking, it has a responsibility to deal with some of the thinking issues that occur in atypical children. However, at some point in time such thinking leads to behaviors that are far beyond the boundaries of what one would normally consider to be educational. So while, based on our fundamental assumption, education can and should provide interventions that are both preventative and developmental, it does not seem that they should be required to address remedial issues. Additionally, BRS personnel should have some level of concern and participation in the advancement and implementation of prevention and developmental services in the schools, both because effectiveness at these levels would reduce the need for later remedial intervention, and also because this is presumably the area of their expertise. While teachers have excellent teaching skills, their understanding of cognitive behavior content is no greater than any other lay person. By combining the content skills of the BRS staff with the teaching skills of the education staff, we can effectively create a merger of interest and expertise.

Step 1. IDENTIFICATION

Two methods of identification occur.

• The parent identifies atypical behavior in their child
• The school personnel identify atypical behavior in the child

If the parent identifies the difficulty to the school or the school staff identify atypical thoughts or behaviors, there is generally considered to be a requirement to:

• consider instructional support
• consider the development of a 504 plan
• consider the implementation of a multidisciplinary evaluation

Depending on the severity of the situation or how it came about the school may try counseling, instructional support or other options to address the needs. When it is identified that BEHAVIOR IS THE PROBLEM, rather than behavior being the result of another disability, perhaps school personnel should initiate a specific protocol, a Functional Cognitive Behavior Analysis [FCBA] to identify:

• the thoughts of the child
• the thoughts of the care managers [parents, teachers, aides, etc.]

Social learning theory suggests that thoughts drive behavior. Three types of behavior occur: active, conversational and cognitive. Active or overt behavior is that which we can observe and would include verbalization. We extract communication in order to emphasize it – because it is so innocuous while so powerful. Cognitive behavior is a covert process in which we think about [assess, judge, attribute, value, compare, etc.] our perceptions and experiences.

Conversation or communication is the key interpretative device between two people. Language is the predominant method of sending messages. It tells the other person what we are thinking and how to respond. Unfortunately, it is quite an imprecise process with much ambiguity and often distorted receivers. Neurolinguistic programmers have posited some suppositions about communication that are worth considering [as reported by David Julian Xanatos].

The Meaning of Your Communication is the Response it Elicits.

If you compliment someone and they turn around and slap you, it is more intelligent to remember that this is the way to insult them, and try something else if you want to make them feel good.

Resistance is a Comment about the Communicator

It’s up to the communicator to be flexible enough to get the message across that they want, and be sensitive enough in their observation to notice if their communication is having the desired response. Otherwise…

If what you’re doing isn’t working, Do Something Else.

If you try one key in a lock and it doesn’t fit, you wouldn’t just try it harder, now would you. You’d get another key. People often to just try the same thing over and over, harder, louder, meaner. It’s easier to just calmly get another key, and another.. until you find the one that fits the lock, smoothly unlocking what you’re seeking.

So this communication behavior is powerful stuff and yet few of us are mindful of what we say – and often blame the recipient for not understanding.

The Initial Inquiry of the FCBA is a dialogue with the child and the significant people in the child’s life about who, what, when and where problems in living occur. This can be done individually, but it can also be done in a group, which has in this opinion, more opportunity for feedback and improvisation. Caretakers feed off each other and expand the observations about the child situation and external and internal contexts. Internal contexts are determined by the ‘leakage’ from self-talk – judgmental commentary made about events and experiences, from which we can begin to infer the core belief system. Core beliefs generally are thought to include thoughts about self, others (including what the person thinks others think about them), future prospects and the attributions of cause for success and/or failure. From the leakage [what the child says about these contexts in times of stress] the assessment specialist can begin to infer the child’s ‘theory of meaning’ [the way the child interprets events and experiences through the attribution of meaning]. Of even more importance, perhaps, is that the assessment specialist can gain an understanding of the ‘inner logic’ not only of the child, but of each of the caretakers as well.

If we recognize that the communication is the key to the messages sent and received, it is apparent that understanding the ‘inner logic’ of a child manager who acts atypically toward a child is every bit as important as understanding the ‘inner logic’ of the child.

This FCBA process can be implemented, with parent permission, in a Home, School & Community Council meeting that includes representatives of the Office of Mental Health and could involve a representative from the county/MCO. From the FCBA Initial Inquiry a process of hypothesis and plan development should ensue which would identify potential interventions with:

• child
• parents
• siblings
• peers
• teachers
• other natural supports

The reason for the secondary and tertiary clients is that we view the child as a system within a system. While it is true that individual work with the child can achieve effective outcomes, it is important to consider interventions with those who provide incentive for and maintain the child’s maladaptive thoughts and behaviors. This plan might include interventions that would normally only be implemented in the present system by medical necessity, and from that standpoint would constitute a recommendation for clinical evaluation OR implementation would be assumed by the public school. For example: a one on one support is recommended in the classroom to mentor the child in regard to his/her thoughts and resulting behavior. This is not for purposes of academic support, but is focused on the child’s attitudes and behaviors. This does not preclude that a teacher, guidance counselor or school social worker might not be able to provide these clinical supports and do so at more reasonable costs and less intrusively than if a clinical staff person from a provider agency were to do so.

Step 2. DISTRIBUTION

Depending upon the disposition of the clinical evaluation for medical necessity, the services could be financially supported through regular or special education, educational ACCESS [Educational Rehabilitation Agency – Provider 47] or through the Office of MH/MCO and community providers. We may even want to consider the development of an intervening financial category in which the local education authority puts up 50% of the funds and the MCO puts up 50% of the funds to cover special cases. Thus the range would go from full educational funding to full mental health funding; but the services would be coordinated.

The sorting process would include at least the following variables:

• the clinical evaluation and recommendations
• the child’s Medicaid eligibility
• the degree of need [scope, intensity, etc.]
• who is best able to provide the service
• who should fund the services

If the child is prescribed these services through the clinical evaluation and becomes Medicaid eligible, it would be natural to assume that the BRS would provide the services. However, if the clinical evaluator is using a defining line of the medical necessity, s/he may define a child who has, or a child who is at serious risk of developing an emotional or behavioral disturbance. This presents two very different categories: 1) a child who needs intervention to remedy an existing condition, and 2) a child who needs intervention to avoid the development of a condition. While it is unlikely that all evaluators will or can be precise about which position they are taking, such a variance offers up some possibilities¹ . We could, for example, suggest that any child who has a condition warranting intervention is a clinical issue and should be addressed through BRS funding. On the other hand, a child could potentially be served in a variety of ways.

• through direct education intervention [counseling, classroom management, school culture approaches, etc]
• though special education [emotional support developmental programs]
• through special education ACCESS [emotional support plus special programs from the ACCESS menu]
• through Medicaid [BHRS]

The development of decision points that help to sort these options would help to solidify the way the county seeks to serve its children. However, such decision points cannot be accomplished without a clear agreement on a fundamental assumption and a theory of change. To attempt to do the decision points without agreement is likely to prove futile. It also would be better if the interventions ranging from culture restructuring to cognitive restructuring were coherent in their approach. This would require that a consistent point of view and oversight be developed.

Another consideration, of course, is the fact that educational staff might be in the best position to provide clinical support and clinical staff may need to support educational interventions as well. The separation of who would pay and who would provide would be drawn across a decision point of practicality and utility, not jurisdiction. From this perspective, educational funds could be used to pay clinical staff to carry out educational functions and OMA/Medicaid funds could be used to pay educational, correctional or protective staff [or even natural supports] to carry out clinical functions².

Step 3. MONITORING

Once a child is receiving services, whether it be through education or clinical auspices, there needs to be an assurance that a) the services are being rendered, b) the services are being rendered correctly, and c) the service is having a positive impact on the life performance of the child. Presently such monitoring is rather ‘hit or miss’, with most providers of services [educational, clinical, protective and correctional] monitoring their own performance. Further, this monitoring is rarely focused on substantive outcome in life performance. In fact, most interventions are not able to identify any changes in life situation after implementation. Several factors are involved in correcting this aspect. First, there must be something clear to measure against. Nothing is more unfair than to have someone measure your performance while using a yardstick that is not appropriate. Yet the yardstick of children’s services seem by and large to only measure how well the intervention is able to stop the child from doing whatever s/he is doing that caused the referral. This is generally referred to as the ‘dead man test’.

Even if there is substantive improvement in the quality of life, we may not really be aware of how and why this effect occurred. Many procedures may be false and yet produce an approximately correct answer. Human services are at special risk of committing the fallacy of affirming the consequent. Thus, we may see evidence of positive change in a child’s life and assume that this is the ‘real’ thing because we were involved.

Several aspects should probably be addressed:

• monitoring should be separated from service delivery
• monitoring should be measuring provider performance against an established and agreed upon performance standard [baseline to benchmark]
• outcome expectation should be clear and measurable
• outcomes should be verified in vivo, meaning in home, school and community

We have modeled such a process in our recommendation for the Council to serve as the managing entity. Since it includes home, school and community members, there is a broad perspective that can be used to establish the ‘reality’ of change in life performance. With the addition of a Plan Manager (account broker), a person who acts as the eyes and ears of the Council, there can be an intensity of involvement – focusing on the implementation, outcome and satisfaction of all parts of the system. Since child serving public agencies and their contracted providers have their own internal quality control processes, the Council can maximize the leadership understanding of the problems and the solutions. Positing the Council as the ‘gatekeeper’ into the system and the manager of care while in the system provides a meaningful way for communities to care for their own children.

Step 4. Secondary clients

“Approximately two thirds of all children referred to mental health agencies [who] are labeled conduct disordered or oppositional” (Kazdin, 1985). Serious antisocial behavior in children and adolescents constitutes a significant problem in children’s mental health services and may be one of the most serious public health challenges in American society (Earls, 1989; Prinz & Miller, 1991).

Among the most well documented precursors and covariates of conduct disorders are parent and family characteristics and behaviors, particularly in the area of child management and monitoring. In addition, researchers have convincingly demonstrated that parent and family characteristics such as marital distress, spousal abuse, lack of a supportive partner, maternal depression, poor problem solving skills, and high life stress [socioeconomic disadvantages and a lack of social support for the mother outside the home (e.g., few positive social contacts with family or friends)] are likely to lead to serious defects in child and family management practices. Attempts to address the issues of child management, therefore, cannot be expected to achieve success, unless some of these issues are directly addressed. A Social Learning Family Intervention therefore, is a comprehensive approach that combines training with clinical intervention and enhancement of natural supports. This approach is specifically important for the families of children with Conduct Disorders.

• Child Management Training: the parents are taught a step-by-step approach where each newly learned skill forms the foundation for the next skill to be learned. Nine child management practices form the core content components of the program.
  • they are taught how to pinpoint problem behaviors of concern and to track them at home [e.g., compliance versus noncompliance];
  • they are taught social and tangible reinforcement techniques [e.g., praise, point systems, privileges, treats]. Over time, the tangible reinforcers are replaced by the parents’ social reinforcement;
  • they are taught discipline procedures, focusing on discipline as a noun instead of as a verb. Discipline is seen as a method of teaching the child how to discipline him/herself and take responsibility. When parents see their child behave inappropriately, they learn to apply a mild consequence such as a five-minute time out combined with a learning experience [either written (Individual Behavior Learning Packet), or in discussion about what constitutes appropriate behavior]. Response costs and work chores are advocated for older children;
  • they are taught to ‘monitor’ their children, even when the children are away from home. This involves parents knowing where their children are at all times, what they are doing, and who they are with and when they will be home;
  • they are taught how to set up a time and area for homework and the best methods to help their children finish homework assignments. They are taught how to contract with the school to receive daily notes regarding assignments and completion;
  • they are taught problem solving and negotiation strategies and become increasingly responsible for designing their own programs;
  • they are taught how to play with their children in a non-directive way, and how to reward children’s prosocial behaviors through praise and attention. The objective is for parents to learn to break the coercive cycle by increasing social rewards and attention for positive behaviors and reducing their commands, question and criticisms;
  • they are taught how to communicate transactionally, adult to adult; and
  • they are taught ways to communicate direct, concise and effective directions for mastery.

Training methods include role-playing, modeling and coaching. Homework is assigned in the form of daily ten-minute practice sessions with the child using the strategies learned. Based on Bandura’s modeling theory, the program utilizes video-tape modeling methods. Efforts are made to promote the modeling effects for parents by creating positive feelings about the models shown, using models of differing sexes, ages, cultures, socioeconomic backgrounds and temperaments so that parents will perceive the models as similar to themselves and their children. Video tapes show parent models in natural situations [unrehearsed] doing it right and doing it wrong in order to demystify the notion that there is ‘perfect parenting’ and to illustrate how one can learn from one’s mistakes. After each session, the trainer leads a family discussion of the relevant interactions and encourages parent ideas.

The process takes a minimum of thirty hours with additional time for follow-up and reinforcement.

Modifications for adolescents include targeting behaviors believed to put the adolescent at risk for further delinquency [e.g., curfew violations, drug use, time with ‘bad company’]; emphasizing the importance of parental monitoring and supervision especially with respect to school attendance; and using punishment procedures such as work details and restriction of free time. Parents also are asked to report legal offenses to juvenile authorities and then act as advocates for their children in court.

These trainings can occur in a classroom environment, perhaps run by teachers provided appropriate training and guidelines, or with a clinical staff person in support. Locating movable classes in elementary schools helps to alleviate transportation issues and to build a sense of community. Community leaders could be involved in the process and the whole process could be opened up to the ‘public’ to reduce the stigma for families with problems in living. In fact, there is the potential to ‘charge’ families to attend. Parents who are being encouraged to participate in this way might be given ‘scholarships’ to attend.

For families with severe and persistent problems in living the training may need to be more individualized and require more clinical attention. Family Based Rehabilitation Services or Mobile Family Specialists could provide these services in the home.

Specific Clinical Interventions: The literature is clear that families with severe and persistent problems in living have characteristics that need to be addressed and many of these are listed above. Where necessary, individual or family clinical or remedial interventions will take place with sufficient intensity to at least prepare the individual and/or family to take the initiative to address the problems on their own. Such interventions will be cognitive behavioral in nature, and consistent with the principles of social learning, teaching the individual specific skills which will enable them to take responsibility for their own lives.

This is clearly a clinical responsibility and is not, under normal circumstances a children’s service. However, as a support to the psychological fitness, it should be a mandated part of the child’s Plan of Change for those families in which the primary caretakers problems are directly connected to the child’s problems in living. This would include addressing parent and family characteristics such as marital distress, spousal abuse, lack of a supportive partner, maternal depression, poor problem solving skills, and high life stress [socioeconomic disadvantages and a lack of social support for the mother outside the home (e.g., few positive social contacts with family or friends)], which are likely to lead to serious defects in child and family management practices

BHRS may reduce costs for some of these services by providing a clinical presence in the elementary schools at night, so that several parents with severe and persistent problems in living can be seen in succession without additional travel.

Step 5: Tertiary Clients

Adults, other than the parents who provide natural supports and peers who relate or refuse children with problems in living, are another point of interest if we are to help children with problems in living change.

Supporting Adults:

People who provide natural supports such as relatives, friends, neighbors, crossing guards, teachers, etc., may need to be trained in new child management strategies and understand how to coordinate their advice with the Plan of Change. This objective can be met through individual or group training in cognitive behavior management strategies to which clinicians provide support. It may be worthwhile to consider other professionals who intervene as well, since the JPO or CY&F case manager can provide key supports to the thinking changes by merely learning language and concepts and perhaps even through scripting by the clinical staff.

Peers

There are essentially two broad clusters of childhood disorders:

• Over-controlled or internalizers

This group contains children with social anxieties and withdrawal

• Under-controlled or externalizers

This group contains children who are identified as having a conduct disorder, oppositional defiant disorder or attention-deficit hyperactivity disorder. The under-controlled child lacks or has insufficient control over behavior that is expected in a given setting.

Social competence is defined as capacity to expectation. The ability to draw upon a varied repertoire of socially appropriate behaviors pursuant to goal attainment may be considered an important feature of social competence. Because the behavior of externalizers are so critical to schools, our focus is drawn to children whose behaviors are not socially competent and interfere with the ability of the child to develop mutually satisfactory relationships with adults and peers.

Kazdin [1987] has outlined several key facets differentiating conduct disorder from other problems of childhood behaviors [Short & Shapiro, 1993]. Of importance here is the impairment of functioning. These children exhibit antisocial behavior in sufficient frequency and intensity to affect significantly their education performance and interpersonal interactions. In addition, such children may also be deficient in problem solving skills, particularly in generating multiple and/or prosocial alternative solutions which results in rigidity of aggressive responses. These impairments generally remove the child from natural peer interaction.

Two subtypes of conduct disorder include.

• undersocialized-aggressive or solitary aggressive is characterized by difficulty in interpersonal areas and has been associated with peer rejection and poor social skills;
• socialized-aggressive or group aggressive is identified with delinquent behaviors carried out in a group context.

Cognitive factors also play an important and well-documented role in antisocial behaviors and conduct disorders. Antisocial children often exhibit a cognitive response bias in which they interpret ambiguous interpersonal stimuli as being hostile. This cognitive bias may result in and justify aggressive responses to the misperceived hostile stimulus and therefore reduce social interaction. Social relationships are always interactive. Socialization takes place in the interactive arena. Children who are either rejected, or reject their natural peer group are prone to miss out on normalized socialization and acquire increasing problems in living as a result.

Probably the most pervading and important of all the affectional systems in terms of long-range personal-social adjustment is the peer group [Harlow – 1974]. Rejection by the normal peer group not only deprives a child of such learning experiences, but often leaves the child only negative [deviant] peer groups within which to grow and learn social affiliation. Since children with antisocial behaviors are most often removed from valued settings and placed in special settings with other children with similar problems in living, this process is formalized by the helping systems. Group work with the natural peer group can help that group learn how to accept and socialize the antisocial child while helping the child deal with the need to belong and the change required. Work with the resultant group can help all members learn appropriate social interactions and identify their own underlying value systems.

Again, the implementation of group work with a tertiary client may not be seen as a cost effective way of expending Medicaid funds nor require a clinical staff. Social group workers [MSW] are required to provide such services. The best place for natural peer group support is in a neighborhood or community center, settlement house, boys club, etc. The development of clinical support for such work and the use of educational, correctional or recreational staff to accomplish these tasks is well within reason. Use of the school or other community facility as a site for implementation also makes it more like a ‘club’ and potentially saves cost.

A Circle of Friends entails the artificial development of a personal support network. The research shows that chronic mental patients tend to live in smaller networks, to have a greater proportion of their energies involved in kin relations, to have intensely negative or ambivalent kin relationships, to have few clusters and higher density in their networks and to have few long-term relationships except with kin [Cutler, 1983]. The development of such networks is of course, interactive, in that such people also provide little reciprocity to their network participants.

The availability of an effective personal support network can provide both personal support in times of distress and the opportunity for learning how to effectively relate to others. For children, such a network needs to make available on a regular basis not only supportive adults, but supportive peers. A circle of friends offers an opportunity for community people to offer natural supports in a formalized way. The Circle can be one way of assuring that the prosocial acculturation is carried out in the community and is not just in school.

• Through sociometry – define the present personal support network. Make sure that you include all life domains in the quest.
• Convene a meeting of the Personal Support Network [PSN]. Interview the child and the members about potential target members. Include in this process an examination of valued setting that the child would like to participate in – and seek candidates within these settings.
• Develop a specific job description for a friend. Identify roles, functions, time commitments, etc.
• Interview target candidates for the friend positions. Explain fully what you are asking and seek commitment of at least sufficient time to determine whether this may become a life role.
• Convene a meeting of the new PSN. Discuss activities and events in which each member might participate with the child. Make a schedule for both individual and collective meetings.
• Monitor progress.

A Circle of Friends can be developed for the child or the family and can be implemented by any group interested in its development. Initiation by the Home, School & Community Council is helpful for exploring the full range of life domains for potential participants. It is also helpful to have an institutional organization to provide support to the group.

SUMMARY

When I think about how our century may be remembered, I believe it will be for the gap between rhetoric and reality — for calling children “our future” and “most precious resource,” but caring for them more in slogans than in actions. Philip Coltoff

“Over the past twenty years, numerous reports³ have chronicled the lack of appropriate services to meet the needs of children and adolescents with serious emotional disturbances. These previous studies report that children in need of mental health care often do not receive it or receive care that is inappropriate or inadequate.”[Koyanagi & Gaines – 1993] Our continued failure to unify the various public child-serving agencies into a singular approach under the auspices of local community management is unacceptable. The combined resources of education and clinical emotional and behavioral health services provides a beginning way to unify the systems, change the locus of control, create effective and efficient services utilizing and allocating resources in optimal ways, and providing prevention, development and remedial services in a coherent way.

It is long overdue to have dramatic change in the way we do business. We are suggesting that local communities have the ability to generate change by following the steps.

1. Change paradigm [mission, focus, theory, assumptions, suppositions, nature and name of the system.

a) fundamental assumption
b) outcome expectations [organizational and individual]
c) theory of change

2. Develop a cadre of people, stakeholders, staff, who are oriented toward the new paradigm and ensure that they stay ‘on the same page’.

a) culture reconstruction
b) staff training

3. Design a model that reflects the new paradigm principles.

a) all children have thoughts about self, others and future prospects and are eligible to learn how to think in more effective and utile ways
b) all social problems related to behavior which is not specifically caused by an identifiable physical or traumatic incident is considered a thinking disorder ether of distortion or of lack of skill – e.g., mental health, delinquency and substance abuse are considered variations of the same thinking disorder.
c) children who have physical or trauma problems are prone to interpret these defects in maladaptive ways and need support to correct cognitive errors.
d) while other actions may need to be taken [e.g., incarceration for committing a crime, hospitalization for a physical illness] the cognitive behavior management interventions can be provided as long as the person is capable of conversing with others.
e) all social interactive environments are amenable to culture restructure
f) all individuals are considered to be a part of an interactive system which must be involved in thinking about thinking when thoughts processes are maladaptive.

We are not attempting to provide a specific model although we have outlined some specifics. But we believe that within certain parameters, each community can and should experiment on its own. What we are clear on, as established over a forty-year history, WHAT WE ARE DOING IS NOT WORKING.