Katie A. foster care case, part 1: Present and future of CA’s mental health mandate

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By John Kelly

In 2002, lawyers representing foster youth in Los Angeles sued the county and California over its failure to service the mental health needs of children in or at risk of entering foster care. For years the mental health issues that these vulnerable children face were often ignored. The children who did receive treatment were frequently hospitalized when outpatient services would have sufficed.

Twelve years later, the clock has nearly run out on the settlements that stemmed from Katie A. v Bonta. On December 1, 2014, separate court settlements with the state and Los Angeles County could end.

Following is our analysis of what has happened since the settlement and where the state and Los Angeles could go next with regard to providing quality mental health services to children in need.

How We Got Here
In 2002, Los Angeles County and the state of California became ensnared in a federal lawsuit. Lawyers represented a handful of children and youth, alleging massive gaps in mental health care services available to children in the child welfare system.

These children were either in foster care or at risk of placement into foster care due to a maltreatment report. Katie A., the lead plaintiff, had never received therapeutic treatment in her home. By age 14, she had experienced 37 separate placements in Los Angeles County’s foster care system, including 19 trips to psychiatric facilities.

Evidence strongly suggests that children in foster care deal with significant mental health issues at a much higher rate than the community at large. One study showed that foster youth in California experienced mental health issues at a rate two-and-a-half times that of the general population.

Los Angeles County settled with the plaintiffs in 2003 and accepted the oversight of an advisory panel. After years of litigation and negotiation, the state came to terms only in 2011. A “special master” was appointed to oversee compliance efforts.

The requirements are the same for both Los Angeles and the state, and they apply to certain children and youth who are in or at risk of entering foster care. These children are identified as the “Katie A. subclass.”

Eligibility for the subclass is tricky to explain. First, a youth absolutely has to be fully Medicaid-eligible, and meet the criteria for specialized mental health services set by the state. He or she would also need to be in foster care, or be at risk of entering foster care, because of a maltreatment investigation.

There is another hurdle. A youth can only be considered part of the subclass if one of the following two things is true:

  • A system is considering wraparound or specialized services for the child;
  • A child is currently hospitalized for a behavioral condition, or has been hospitalized three times in the past 24 months for behavioral issues.

If a youth meets those criteria, the settlement mandates that counties adhere to a “core practice model” for screening and treating foster youths. This

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Maine Resilience Building Network changes how people think about childhood trauma

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Sue Mackey Andrews will talk to anyone about adverse childhood experiences, or ACEs: Pediatricians. Early childcare workers. Parent advocacy groups. And those on the front lines who work with kids, like the longtime school bus driver from rural Maine, a gruff and taciturn man who insisted, during a half-day school district inservice, that trauma and resilience had nothing to do with his work.

The driver also told Andrews that he would not start the bus each day until he had made eye contact with every single child and greeted him or her by name. And that, Andrews responded, was exactly the relevance of his work to build resilience.

The tagline of the Maine Resilience Building Network (MRBN), which Andrews co-facilitates, is “Join the Conversation.” The

Sue Mackey Andrews, co-facilitator, Maine Resilience Building Network

Sue Mackey Andrews, co-facilitator, Maine Resilience Building Network

group, formed in the spring of 2012, brings together practitioners in medical care, education and behavioral health, along with those working in business, law enforcement, the military, juvenile justice and faith communities.

Since its early meetings, comprising a half-dozen people, all of them doing work based on research into childhood adversity, MRBN has grown to include 77 members, with reach into all of Maine’s 16 counties.

From the beginning, said Andrews and MRBN co-facilitator Leslie Forstadt, associate professor with the University of Maine Cooperative Extension, the group agreed that the message should focus on wellness and healing rather than illness and trauma.

The word “resilience” had to be part of the name because, said Andrews, “we talk about how it’s never too late to realize your ACEs and, through support and personal discovery, overcome them.” The term “building” captured the sense of a growing effort, and “network” aptly described how individual sites would function autonomously while sharing their innovations, challenges and questions.

The term “ACEs” has its origins in the CDC-Kaiser Adverse Childhood Experiences Study. The study revealed a direct link between 10 types of childhood adversity and the adult onset of chronic disease (cancer, heart disease, diabetes, autoimmune diseases, etc.), mental illness, violence and being a victim of violence. It showed that childhood trauma was very common — two-thirds of adults have

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Massachusetts “Safe and Supportive Schools” provisions signed into law, boosts trauma-informed school movement

Massachusetts Gov. Deval Patrick

Massachusetts Gov. Deval Patrick

Massachusetts Governor Deval Patrick today signed into law provisions to create conditions for “safe and supportive schools” intended to improve education outcomes for children statewide, and giving momentum to the state’s trauma-informed schools movement. They were included in The Reduction of Gun Violence bill (No. 4376). This groundbreaking advance was achieved when advocates seized the opportunity to add behavioral health in the schools to the options under consideration as state officials searched for ways to strengthen one of the nation’s more restrictive gun laws in the aftermath of the tragic shooting of schoolchildren in Newtown, CT.

House Speaker Robert DeLeo saw the connection between reducing gun violence and school achievement and was instrumental in the bill’s passage. When the original sponsor of a Safe and Support Schools Act, Katherine Clark, left the state legislature for the U.S. House of Representatives, some advocates were concerned the void would not be filled. Their fears were assuaged when Rep. Ruth Balser of Newton and Sen. Sal DiDomenico of Boston became lead sponsors.

The schools act supporters were jubilant that the legislation they labored on for years was incorporated in the gun violence bill now signed into law, and expressed deep relief and excitement about the achievement. They also said the hard work of statewide implementation now begins.

The law requires the state education department to develop a framework for safe and supportive schools, first developed by a task force established by the legislature in 2008, that provides a foundation to help schools create a learning environment in which all students can flourish. The framework is based on a public health approach that includes fostering the emotional wellbeing of all students, preventive services and supports, and intensive services for those with significant needs.

Within the framework, schools are encouraged, but not mandated, to develop action plans that will be incorporated into the already required School Improvement Plans. The law also provides a self-assessment tool to help in the creation of the plans.

Under the leadership of the Trauma and Learning Policy Initiative (TLPI), a coalition of the Massachusetts Advocates for Children and Harvard Law School, the “Safe and Supportive Schools Coalition” was formed to move the legislation

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Failing schools or failing paradigm?

Roberto is an eight-year-old, former student in my second-grade class.  (All names are pseudonyms.)  In his short life, he’s experienced at least five major life traumas. One: his mother abandoned him when he was a baby. Two: he was placed in foster care with strangers. Three: he joined his father, but shortly after, Daddy was sent to prison. Four: Roberto moved again to live with Grandpop. Grandpop was ill and on house arrest, unable to leave his home, so Roberto was essentially under “house arrest” too, except for school. Roberto came to school, walked the perimeter of the classroom staring out windows, distracting other children. Sometimes, he just walked out of the classroom. His father was eventually released from prison and came to live with Grandpop, but Grandpop soon evicted Daddy after a fight with him. Five: Grandpop died.

Ashley, a bright and engaging nine-year-old, witnessed her stepfather break her stepbrother’s leg with a baseball bat last night. The police were called, invaded her home about 1 a.m., and took her stepfather away. This morning, she came to school as usual, but in a trance, unable to focus.

Jasmine responds much more aggressively. When she is off her medications, and her traumas are re-triggered, her tiny, wiry 45-pound frame can muscle a chair over her head. She screams and curses in guttural tones while heaving the chair at a classmate. She’s being raised by a hesitant uncle in place of her deceased parents.  Jasmine goes home to a darkened row-house, with ”illegal smoke” wafting out the front door that hangs wide open to the street.

Jamar’s been absent from school. After several suicide attempts, he’s at the Crisis Center. Jamar suffered brutal beatings from Mom’s boyfriend, who stuffed a sock in his mouth to muffle his screams. He will come back directly to my classroom from the Crisis Center, without the dedicated adult support he is due.

Ashley, Roberto, Jasmine and Jamar had at least eight other classmates with similar stories in our one classroom at the same time. These four real vignettes are hard to read. They’re tragic. Yet these kids are only a small portion of my class (see “Danny Goes to School).  For the last 13 years, one-half to two-thirds of the students in my urban, public school classrooms have experienced similar lives.  These children are only four of the thousands across only one city: Philadelphia.

Theirs is not a deficit issue. They’re not “sick” or “bad” children; they’re injured.

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What’s missing in climate change discussion? The certainty of trauma…and building resilience

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This spring, a group of more than 160 mental health professionals, resilience-building specialists and mindfulness teachers officially launched the International Transformational Resilience Coalition. Their goal is a challenging one: to raise awareness of how climate change traumatizes communities around the world. The group’s mission is to not only educate the mental health field about this threat, but to also provide preventive solutions before disaster strikes.

The initiative was first envisioned by Bob Doppelt, executive director of The Resource Innovation Group, an BobDoppelt2Oregon-based nonprofit that works across the U.S. to develop new approaches to social-ecological problems, including climate change. Doppelt said that efforts to mitigate climate change have focused on external aspects like fixing and improving infrastructure and developing new forecasting models.

“And throughout all of that work,” he said, “it dawned on me that we were missing what is likely to be the most important issue facing us, and that is the human response to climate change.”

Doppelt said he’d seen this firsthand after Hurricane Sandy devastated communities in southeast Florida, a region where The Resource Innovation Group played a key role in helping the government address climate change readiness. Trained as a counseling psychologist, Doppelt decided that it was essential to develop programs for teaching people how to become resilient as they faced the acute trauma and chronic stress brought on by climate change.

A year-and-a-half ago, The Resource Innovation Group launched its own program to teach mindfulness skills to individuals, organizations and community leaders across the country. The premise is that everyone will need coping techniques as climate change disrupts communities in both profound and subtle ways.

Yet, resiliency is a word that Doppelt uses carefully. “We came up with the term transformational resilience because in many cases the impacts of climate change mean there is no going back to pre-crisis conditions,” he said.

Doppelt also realized that this approach needed an entire network of dedicated mental health and mindfulness professionals – not just one organization like his championing the cause. That’s when he helped organize nearly two dozen founding members, including Dr. Sandra Bloom, co-creator of the Sanctuary Model, and Elaine Miller-Karas, executive director and co-founder, Trauma Resource Institute.

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How childhood trauma could be mistaken for ADHD

 

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[Photo credit: woodleywonderworks, Flickr]

Dr. Nicole Brown’s quest to understand her misbehaving pediatric patients began with a hunch.

Brown was completing her residency at Johns Hopkins Hospital in Baltimore, when she realized that many of her low-income patients had been diagnosed with attention deficit/hyperactivity disorder (ADHD).

These children lived in households and neighborhoods where violence and relentless stress prevailed. Their parents found them hard to manage and teachers described them as disruptive or inattentive. Brown knew these behaviors as classic symptoms of ADHD, a brain disorder characterized by impulsivity, hyperactivity, and an inability to focus.

When Brown looked closely, though, she saw something else: trauma. Hyper-vigilance and dissociation, for example, could be mistaken for inattention. Impulsivity might be brought on by a stress response in overdrive.

“Despite our best efforts in referring them to behavioral therapy and starting them on stimulants, it was hard to get the symptoms under control,” she said of treating her patients according to guidelines for ADHD. “I began hypothesizing that perhaps a lot of what we were seeing was more externalizing behavior as a result of family dysfunction or other traumatic experience.”

Considered a heritable brain disorder, one in nine U.S. children—or 6.4 million youth—currently have a diagnosis of ADHD. In recent years, parents and experts have questioned whether the growing prevalence of ADHD has to do with hasty medical evaluations, a flood of advertising for ADHD drugs, and increased pressure on teachers to cultivate high-performing students. Now Brown and other researchers are drawing attention to a compelling possibility: Inattentive, hyperactive, and impulsive behavior may in fact mirror the effects of adversity, and many pediatricians, psychiatrists, and psychologists don’t know how—or don’t have the time—to tell the difference.

Though ADHD has been aggressively studied, few researchers have explored the overlap between its symptoms and the effects of chronic stress or experiencing trauma like maltreatment, abuse and violence. To test her hypothesis beyond Baltimore, Brown analyzed the results of a national survey about the health and well-being of more than 65,000 children.

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Echo Parenting & Education rides the trauma wave

Changing the Paradigm keynote speakers Dr. Janina Fisher and Ruth Beaglehole, Founder of Echo Parenting & Education

Sometimes we don’t notice when history is being made. We ride a wave of logical progression and don’t even notice when it peaks – that snapshot moment when we are lifted, arms outstretched, into the waiting air and remain suspended for one glorious second before the wave breaks and pushes powerfully to shore.

What the heck am I talking about? Our Changing the Paradigm conference. Last month, 120 participants, 22 speakers and a slew of volunteers gathered at The California Endowment for our two-day conference on developmental trauma. Everything went off perfectly. The evaluations were glowing (apart from the person who wanted avocado on the lunchtime sandwiches – I guess you can’t please everyone). But don’t take my word for it. Here’s what some of the speakers had to say:

“It was a deep honor and a pleasure to be part of such a wonderful and inspiring exchange of hearts, minds

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