Children’s Mental Health Crisis Services

The topic of mental health crisis services specific to children and families has received increased attention throughout the state.

In January 2015, a consortium of mental health advocacy organizations issued a white paper titled “Kids in Crisis: California’s Failure to Provide Appropriate Services for Youth Experiencing a Mental Health Crisis.” This paper served to spotlight the challenges faced by children, youth and their families when attempting to access appropriate crisis services who often must rely on law enforcement intervention followed by hours or even days spent in noisy and chaotic emergency rooms that are frequently ill equipped to adequately meet the needs of child

Since the release of the paper in January, 2015, a bill, AB741 (Williams) was introduced to address a gap in the children’s crisis continuum of care: crisis residential programs. Also, the Mental Health Services Oversight & Accountability Commission (MHSOAC) initiated a project to understand the state of children’s mental health crisis services, document challenges, identify effective service delivery models, and advance specific policy, funding and regulatory changes to improve service quality and outcomes. Currently, various state departments and advocates are considering options to address the needs of children and families in crisis.

The attached article will provide information about the specific needs of children and families when a crisis occurs, identifies effective models, and provides recommendations for improving crisis care across the state.

Defining a mental health crisis for children and youth

Public systems and private insurance use the terms “mental health crisis” and “danger to self or others” interchangeably. A narrow focus on dangerousness is not a valid approach to addressing a mental health crisis. To identify crises accurately, we must have a much broader understanding and a perspective that looks beyond whether an individual is dangerous or immediate psychiatric hospitalization is indicated. (SAMHSA 2009).

While behaviors that represent an impending danger certainly indicate the need for some sort of an emergency response, these behaviors may well be the conclusion of a crisis episode, rather than the episode in its entirety. Situations involving mental health crises may follow paths that include intense feelings of personal distress (e.g., anxiety, depression, anger, panic, hopelessness), obvious changes in functioning (e.g., neglect of personal hygiene, unusual behavior) or catastrophic life events (e.g., disruptions in personal relationships, support systems or living arrangements; loss of autonomy or parental rights; trauma victimization, or natural disasters).

Crisis needs in those under the age of 18 is often more complicated than it is in the adult population. Multiple studies have indicated that over 20% of children and youth have a mental health need. A lack of awareness of mental health needs and stigma results in significant delays in the identification of these needs and in accessing appropriate treatment. Children and youth often exhibit increasing mental health needs by changes in appetite, sleep patterns, social activities, and academic performance. Multiple studies have shown that children report more intense levels and natures of mental health symptoms than do their caregivers. Changes in these patterns of behaviors should be a red flag to the caregivers and supports for these children. If adults in the child’s life sees a change in behavior, they should not wait to get help, at the needs are likely to be more severe than they suspect.

The National Alliance on Mental Illness (2010) identifies the follow examples of situations or stressors that can trigger a mental health crisis in children and youth:

Home or environmental triggers

• Changes to family structure – parents separate, divorce or remarry
• Loss of any kind – family member or friend due to death or relocation
• Loss of family pet
• Transitions between mom’s and dad’s home
• Strained relationships with step-siblings or step-parents
• Changes in friendships, boyfriend, girlfriend, partners
• Fights or arguments with siblings or friends
• Conflict or arguments with parents
• Family poverty
• Trauma or violence

School triggers

• Worrying about tests and grades
• Overwhelmed by homework or projects
• Feeling singled out by peers or feelings of loneliness
• Pressures at school, transitions between classes and school activities
• Bullying at school
• Pressure from peers
• Suspensions, detentions or other discipline
• Use of seclusion or restraints
• Misunderstood by teachers who may not understand that the child’s behavior is symptom of their mental illness
• Children’s perception that they are being culturally disrespected and they are being discounted
• Perceived or real discrimination

Other triggers

• Stops taking medication or misses a few doses
• Starts new medication or new dosage of current medication
• Medication stops working
• Use of drugs or alcohol
• Pending court dates
• Being in crowds or large groups of people
• Changes in relationship with boyfriend, girlfriend, partner
• Community violence or trauma

NAMI’s guide to children’s crisis services also provides the following example of warning signs for children and youth experiencing a mental health crisis:

Inability to cope with daily tasks

• Doesn’t bathe, brush teeth, comb or brush hair
• Refuses to eat or eats too much
• Sleeps all day, refuses to get out of bed
• Doesn’t sleep or sleeps for very short periods of time

Rapid mood swings

• Increase in energy
• Inability to stay still, pacing
• Suddenly depressed, withdrawn
• Suddenly happy or calm after period of depression

Increased agitation

• Makes verbal threats
• Violent, out-of-control behavior
• Destroys property
• Cruel to animals
• Culturally inappropriate language or behavior

Displays abusive behavior

• Hurts others
• Cutting, burning or other self-injurious behaviors
• Uses or abuses alcohol or drugs

Loses touch with reality (psychosis)

• Unable to recognize family or friends
• Is confused, has strange ideas
• Thinks they are someone they are not
• Does not understand what people are saying
• Hears voices
• Sees things that are not there

Isolation from school, family, friends

• No or little interest in extracurricular activities
• Changes in friendships
• Stops attending school, stops doing homework

Unexplained physical symptoms

• Facial expressions look different
• Increase in headaches, stomach aches
• Complains they don’t feel well

Best practice models:

SAMHSA (2009) identifies the following best practice values and principles for crisis service programs.

Essential Values:

1. Avoid harm
2. Intervene in person-centered ways
3. Share responsibility
4. Address trauma
5. Establish feelings of personal safety
6. Base on strengths
7. Treat the whole person
8. The person and family are credible sources
9. Recovery, resiliency and natural supports
10. Prevention

Principles for Enacting the Values:

1. Access to supports and services is timely
2. Services are provided in the least restrictive manner
3. Peer support is available
4. Adequate time is spent with the individual in crisis
5. Plans are strengths-based
6. Emergency interventions consider the context of the individual’s overall plan of services
7. Crisis services are provided by individuals with appropriate training and demonstrable competence to evaluate and effectively intervene with the problems being presented
8. Individuals in a self-defined crisis are not turned away
   Interveners have a comprehensive understanding of the crisis
9. Helping the individual to regain a sense of control is a priority
10. Services are congruent with the culture, gender, race, age, sexual orientation, health literacy and communication needs of the individual being served
11. Rights are respected
12. Services are trauma-informed
13. Recurring crises signal problems in assessment or care
14. Meaningful measures are taken to reduce the likelihood of future emergencies

The most comprehensive crisis continuums of care for children identified to this point have been found in the states of Massachusetts and Washington, and in Wraparound Milwaukee. These models demonstrate the ability to decrease the need for institutionalized crisis settings through the use of an integrated care models. The essential common elements in all three examples are:

• Multiple system collaboration and integration
• Community based services delivered by a team familiar to the child and family.
• Family and youth driven
• Inclusion of natural supports

Opportunities and Recommendations:

Addressing the needs of children in crisis is much more complicated than it is in the adult population. The recognition that crisis needs, best practice models, training of staff, location of services, state and federal entitlements, and inclusion of natural supports when meeting the needs of those under the age of 18 is unlike those in the adult system of care. California lacks consistent statewide access, quality, coordination, accountability, and family engagement related to the children’s mental health services in general and the crisis continuum of care specifically. These gaps lead to unnecessary suffering and at times the death, of California’s children. This section will outline the opportunities currently available throughout the state, and recommendations on how we can take advantage of these opportunities.

Opportunities

• Funding exists currently
• Models and data exist in other states
• Diverse stakeholder groups have come together to address this gap in services (January 2015 crisis paper and OAC Children’s Crisis Advisory Group).
• Avoidance of the litigation, which limits stakeholder involvement, and incurs significant costs (financial, time, and manpower).
• The rapidly changing landscape of health care delivery may allow for new, creative solutions.

Recommendations:

Standardization and Accountability of Quality Services:

• Set a standard of care for the state; provide leadership by mapping out ways to achieve the standard, both structural and financial.
  • Develop data systems to provide local program and quality management capabilities by tracking and reporting location, type, amount, recipients, quality, and other appropriate parameters of service delivery throughout the state, using a comprehensive minimum data set.
• Assist small rural counties in developing regional collaborative efforts to ensure all crisis services are available locally throughout the state.

Funding:

• Ensure financial efficiencies by leveraging federal funding for entitled services.
• Utilize uncommitted funding to develop programs replicating proven models existing in other states.
• Use a portion of the behavioral health subaccount growth funds to incentivize counties to implement the children’s crisis continuum of care.
• Blend funding across child serving systems

Coordination and Access:

• Improve access to preventative and early intervention services to decrease the need for crisis services.
• Increase community education and outreach efforts in all child and family serving systems.
• Create statewide training collaborative for various stakeholders.
• Integrate services across child and family serving systems to ensure that services are provided in the least restrictive location and include natural supports.

During the 2016 conference there will be many opportunities to discuss children’s crisis and crisis services. These opportunities include:

Plenary Speaker – Kappy Madenwald
Achieving the Promise of Family-Centeredness in Care Delivery
Wednesday, May 11^th, 2:15 in Merrill Hall

We have used the term for years, but what is family-centeredness about at its finest? What is it like to experience? If a program STARTS to deliver family-centered care, what must it necessarily STOP doing? How can we use the treatment experiences of youth and their families to realign how we think about and build effective systems of care and deliver services? Kappy will lead us through a thought-provoking and immersive journey as we consider when care is productive and when it is counterproductive; when it helps and when it harms; and ultimately, whether family-centeredness is about being nice or about getting results.

Kappy has extensive experience in mobile community-based and hospital-based crisis intervention services, specializing in the design, implementation and evaluation of person-centered service delivery systems, including comprehensive state or community crisis systems that are integrated at a systems and direct care level, are delivered in a way that promotes self-direction and recovery, are least restrictive/least intensive in nature, and designed to assure timely and purposeful movement through care. Kappy has worked directly on state level service planning and implementation initiatives in Massachusetts, Maryland, and Iowa and at a regional/local level in Oregon, Pennsylvania and California. She has also provided technical assistance to numerous county, regional, and local authorities or nonprofit organizations throughout the U.S. She is Director of Operations for the Annapolis Coalition on the Behavioral Health Workforce for the recruitment, retention, and training of the prevention and treatment workforce in the mental health and addictions sectors.

Directing Change

7:30 pm Thursday night, after dinner and before the dance, Directing Change will present a screening of student films in Fred Farr Forum
Directing Change Films: A statewide student film contest to promote suicide prevention and ending the silence about mental illness

Directing Change is part of statewide efforts to prevent suicide, reduce stigma and discrimination related to mental illness, and to promote the mental health and wellness of students. These initiatives are funded by the Mental Health Services Act (Prop 63) and administered by the California Mental Health Services Authority (CalMHSA), an organization of county governments working to improve mental health outcomes for individuals, families and communities.

Students throughout California were invited to Direct Change by submitting 60-second films in two categories: suicide prevention and ending the silence about mental illness. Winners were selected to move onto a second, statewide round of judging to select the statewide winners in each category.

This special screening of Directing Change Films will feature films in the statewide student film contest and explain how this project aims to further school-based prevention programs.

Workshop A3   School District Mental Health Services: Trauma

Intervention and Suicide Preventionm 10:30 – noon Located in Dolphin

Every year students in the Hemet community experience trauma, including sudden student and staff deaths due to suicides, traffic accidents, domestic disputes, drug overdose, peer/gang conflicts, and criminal assaults. The impact of these trauma events often result in both short and long term mental health issues if not addressed in a therapeutic manner. Three years ago the school district’s mental health team initiated a Crisis Response Team based on the NASP PREPaRE model, which can be rapidly deployed to a school site, and systematic suicide prevention services. This workshop will outline program services and provide participants with techniques and tools that can be implemented in their school district.

Workshop B 12 Self-Harming versus Suicide: Understanding the Difference
1:30 – 3:00 Location: Scripps

This workshop will outline the major differences between self-harming behaviors and suicide. Participants will learn how to identify warning signs of both and how to respond effectively. Discussion regarding how both are portrayed in the media will be covered. Specific interventions will be taught to use for children and adolescents who are in different degrees of self-harm and/or suicidal ideation. Participants will also learn what questions to ask someone who is self-harming and/or showing signs of suicidal behavior. Participants will learn how to identify warning signs of self-harming behaviors and suicide and how to respond effectively as well as what questions to ask someone who is self-harming and/or showing signs of suicidal behavior.

Workshop C8 Children’s Mobile Crisis Teams: A closer look at community-based services for children and adolescents in crisis and their families                                          

3:30 – 5:00 Location: Triton

Appropriate psychiatric services for children in crisis are woefully inadequate. The number of children with mental health problems in crises has increased but the capacity of inpatient and outpatient community-based services has declined. Children are being seen in the Emergency Rooms for a behavioral health crisis, a situation that can increase fear and stress of both the child and their caregivers. This need for increased crisis services for children has led several community-based agencies and partners to work closely to meet the needs of children while maintaining placement in the community. Highlighting crisis services in two California counties where mobile crisis teams devoted exclusively to children/youth work closely with community providers, schools, law enforcement and Emergency Rooms, this session will present an effective service delivery model and provide practical collaborative strategies for assessing risk and implementing interventions that stabilize and reduce further risk of crises such as suicidal behaviors, aggression and/or psychotic symptoms. This session will identify and discuss the ongoing needs and recent developments in California to address unmet needs of children in the continuum of crisis care.

See you at the conference!