CWW Vol 23: Recommendations and Solutions

This issue of the Watch focuses on the city’s youngest residents: babies and toddlers. We explore the impact of chronic stress on young children’s brain development and present national research around interventions aimed to buffer that effect and to better support the parents of young children. More than 6 percent—or 518,000—of New York City’s 8.1 million residents are under 5 years of age. A handful of local programs work with the families of young children who are affected by poverty, chronic stress and trauma, including some innovative programs for the child welfare involved parents of young children. We highlight the need for more of this type of expertise and illuminate the dearth of government funding and services targeted for caregivers seeking help for young children. Following are recommendations and solutions proposed by the Child Welfare Watch advisory board: The New York State Office of Mental Health (OMH) and the city’s Department of Health and Mental Hygiene should provide consistent, adequate funding for early childhood mental health treatment, and for professional training.

Providing early help to infants and toddlers who need it can prevent more costly, intensive and potentially invasive interventions later in life. Nobel prizewinning economist James Heckman has demonstrated that investing in effective early childhood interventions can yield huge cost savings—and that there is a steep decline in the value of these savings as early as the end of a child’s third year of life. However, state and city government funding for treatment is very limited and few professionals are trained to provide treatment to this age group. A 2012 analysis by the Citizens’ Committee for Children estimated that state-licensed mental health clinics had treatment spots for only 1 percent of children age 0 to 4 who needed them in three of New York City’s boroughs. Slots were most scarce in community districts considered high risk due to factors such as economic poverty and safety. Government and society are missing the opportunity to provide young children with appropriate treatment before their needs and symptoms compound. Some clinics and organizations providing early mental health treatment are reimbursed a small amount through Medicaid or, in some cases, by their referring foster care agencies. Many families are not eligible for these funds, or are served outside of clinics. Today, the City Council is one of the few sources of government funding for community-based early mental health treatment, but its support is not solely for treatment or for training clinicians to work with infants and toddlers; it must also cover the cost of screenings and evaluations. What’s more, this modest support of $1.25 million is not “baselined” into the mayor’s budget and is therefore at risk of elimination each year. We urge the city and state to recognize the need for more treatment options—including intensive, dyadic therapy, which is most lacking—for this vulnerable group of New Yorkers. There is also a great need to build a viable workforce able to work with children under 5 and their parents.

The city, state, and nonprofit organizations should co-locate infant and toddler mental health services in the places where young children and their parents already go: pediatric clinics, foster care and preventive agencies, family court, homes, community centers and child care programs.

Parenting young children while living in poverty or with other sources of chronic stress is taxing. Parents and young children who could benefit from treatment will be far more likely to find help if it is located in the places where parents already go. This makes services easier to access, reduces the stigma frequently associated with mental health treatment and allows infant mental health specialists to educate other professionals who work with babies—such as child care workers, judges, pediatricians, home visiting nurses and preventive workers—about the social and emotional development of young children.

The State Department of Health should provide professionals in the Early Intervention Program with comprehensive training in the social and emotional development of young children.

Early Intervention is the city’s largest, most comprehensive program for treating kids under 3. In theory, Early Intervention can work with children under 3 whose only issues are social-emotional. In practice, the program largely focuses on addressing developmental delays and disabilities, making it a missed opportunity to help the families of babies who are struggling with the effects of trauma or chronic stress. To help nudge Early Intervention closer to becoming a system able to address early childhood mental health, Early Intervention professionals should receive comprehensive training around the mental health needs of young children, with a focus on how to address and recognize the effects of trauma in this age group.

The state OMH should track the number of state-licensed mental health clinics—also known as Article 31 clinics—that have the capacity to treat infants and toddlers.

Few clinics have the capacity to provide mental health treatment to infants and toddlers. No government agency tracks the number that do serve very young children and their families. This makes it extremely difficult to address the citywide gap between treatment need and capacity.

The state OMH and the city’s Human Resources Administration and Department of Health and Mental Hygiene should collaborate with parents and community organizations to create an advertising campaign that promotes positive, supportive parenting of young children.

A growing body of research suggests that “supportive parenting”—a reflective, child-centered approach to parenting that stresses sensitivity, warmth, and responsiveness—is a key to buffering the potentially lifelong toxic effects of a childhood marred by stress, violence and trauma. New York should mount a campaign dedicated to educating parents about the benefits of supportive parenting and provide powerful examples of what it means to be responsive to the developmental needs of infants and toddlers.

The Administration for Children’s Services (ACS) should require foster care agencies to ensure that babies and toddlers in foster care are screened for mental health impairments, in addition to standard developmental evaluations.

Last year, there were more than 3,050 children under age 5 in New York City foster care. Young children often come into care with tumultuous histories that put them at high risk of medical, emotional and developmental problems. Once in the system, many of them continue to experience turbulence, moving from caregiver to caregiver while being separated from their families. When foster care is necessary, it should be maximized as an opportunity to nurture children’s developmental health. In the past decade, ACS has made great progress in the effort to ensure that children receive developmental screenings when they enter care. These screenings focus primarily on cognitive and physical delays, rather than on the more subtle impacts of disrupted relationships and stressful experiences that threaten babies’ emotional wellbeing. Unfortunately, mental health assessments often don’t happen until children are older and demonstrate obvious behavioral symptoms of emotional distress. Some agencies have developmental specialists on staff to ensure that developmental screenings take place, and to follow kids who demonstrate special needs. This systematic approach should be instituted at all agencies, with a similar level of attention paid to mental health screenings for children of all ages.

ACS and the state Office of Court Administration (OCA) should routinely train frontline staff and contract employees on the developmental needs of infants and very young children.

Removing babies and toddlers from their homes disrupts their attachments to caregivers and can have lifelong negative consequences. Frontline workers at foster care agencies, as well as child protective specialists and key Family Court staff, attorneys and judges, should be regularly trained in the particular developmental, emotional and mental health needs of infants and very young children—including the damage that can be caused by repeated disruptions in care. I n the past, a privately funded court commission ran an initiative that educated court staff about infant development, while also providing guidelines and checklists to help judges and attorneys make sure that babies received appropriate care. In the absence of outside funding, ACS and the courts should continue these practices. OCA should consider designating social workers to follow infants’ cases in court, ensuring that they receive developmentally appropriate services. Along with frontline case workers, Family Court judges should consider conducting analyses of babies’ existing attachments before making placement decisions. OCA should also consider the feasibility of creating specialized court parts for babies and very young children, staffed by judges with particular training in early childhood mental health, and who are fully informed of resources in the community for infants and their parents.

ACS and nonprofit family support organizations should ensure that parenting classes engage in active skillbuilding, supporting parents to understand and nurture their children’s development.

Too often, parenting classes are didactic exercises in compliance, instructing parents in basic skills they may already know. These classes—in conjunction with family visits—should be used as an opportunity to support parents’ meaningful interaction with their children, building skills that encourage nurturance and children’s secure attachments. With the recent introduction of its ChildSuccessNYC initiative, ACS has taken steps toward incorporating a focus on children’s developmental and emotional needs, and on the positive, crucially important role a parent plays in her child’s development. Under the initiative, parents participate in facilitated groups that promote both instruction and discussion, including concrete information about strategies to support infant brain development and mitigate the potential harm caused by trauma or neglect. The implementation of ChildSuccessNYC should not preclude parents and foster care agencies from pursuing alternative approaches, however. Specifically, there ought to be more opportunities for parents to learn about child development in environments where they can interact with their children, supported by facilitators who help them build understanding of real-life issues in real time. The ‘Baby & Me’ program at SCO Family of Services is one example of this kind of program. Parents and their children participate in a structured playgroup, in which facilitators discuss elements of development, demonstrate strategies to support that development, and then provide opportunities for parents to interact one-on-one with their children. Support groups and instruction are both valuable, but they should be closely connected to visitation experiences for parents and their children in foster care—and parents themselves should have both the information they need and the freedom to choose the most appropriate programs.

Upcoming Event: Poverty, Chronic Stress, and New York's Youngest Children

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Center for New York City Affairs at The New School presents

a Child Welfare Watch forum:

Baby Steps: Poverty, Chronic Stress, and New York's Youngest Children

 Friday, October 4, 8:30-10:30am

 Tishman Auditorium

Alvin Johnson/J.M. Kaplan Hall, 66 West 12th Street, Ground Floor

Chronic stress and early trauma shape the brain development of very young children. Increasingly, research shows that innovative, early-life work with infants, toddlers and their parents can help prevent the need for much more costly interventions later on. Can we reduce the likelihood of abuse, neglect and mental illness in stressed-out, low-income families? What kinds of targeted interventions are working? And how should government and nonprofits respond? A conversation with experts in the field, and the release of the latest edition of Child Welfare Watch.

 Keynote remarks by

Jack P. Shonkoff, M.D., the Julius B. Richmond FAMRI Professor of Child Health and Development at the Harvard School of Public Health and the Harvard Graduate School of Education; Professor of Pediatrics at Harvard Medical School and Boston Children’s Hospital; and Director of the university-wide Center on the Developing Child at Harvard University.

 Followed by a conversation with

Linda Lausell Bryant, executive director, Inwood House

Susan Chinitz, professor of clinical pediatrics, Albert Einstein College of Medicine

Piazadora Footman, parent; editorial assistant at Rise, a magazine written by and for parents in the child welfare system; and Chances for Children participant

Benita Miller, deputy commissioner of family permanency services, NYC Administration for Children's Services

 Moderated by

Andrew White, director, Center for New York City Affairs at The New School

 Admission is free, but you must RSVP.

The Child Welfare Watch project is made possible thanks to the generous support of the the Ira W. DeCamp Foundation, the Child Welfare Fund, the Viola W. Bernard Foundation, the Sirus Fund, the Pinkerton Foundation, the Prospect Hill Foundation and the Milano Foundation.

A First in NY: Residence for Young Offenders with Mental Illness

Last week marked the opening of the first psychiatric residence for juvenile delinquents in the state's custody. Most of the handful of young people who have moved into the new home in Brooklyn are transferring from juvenile justice facilities upstate. Some have been waiting for weeks or even months to move in, says Michael Pawel, who runs the August Aichhorn Center, which operates the new residence. These young people are among the 50 percent of young adults in state-run juvenile correctional facilities who have been diagnosed with a mental illness, according to the Office of Children and Family Services (OCFS), which runs the New York State juvenile justice system. Child Welfare Watch has previously reported on how difficult it is to find appropriate placements for court-involved youth with mental illness.  A 2009 federal Department of Justice investigation found that state-run juvenile justice facilities were woefully lacking in the treatment of mental illness. As we reported in 2009, state-licensed residential treatment facilities, which are designed to work with mentally ill young people, are notorious for screening out children known to be aggressive or violent.

When Pawel visited some of the juvenile justice facilities to let them know about the new residential program in Brooklyn, he says many staff told him they had long given up on trying to get young people moved to residential treatment facilities. Pawel hopes the new Brooklyn home, which will house 24 young people, will change that.

The new facility has a psychiatrist and therapists on staff. It is overseen by the Office of Mental Health and is not part of the new system the city is building for local juvenile delinquents.

Rather, it is part of a larger reform effort to house young people with mental illness in homelike, therapeutic facilities located in the five boroughs. The building was formerly a children’s psychiatric hospital with seclusion rooms and a 100-foot steel fence separating it from the community. Aichhorn has spent the better part of the last year renovating the building to be more welcoming and better integrated in the surrounding neighborhood of Weeksville.

The building now has direct access to the street with an unlocked gate, and no seclusion rooms. Aichhorn revamped what had been 72 identical bedrooms in the children’s hospital to allow for a new entry and lobby, and suites of eight bedrooms each, which will be co-ed, something that is unusual in the juvenile justice world but that Pawel says creates calmer dynamics among residents.  You can download a slideshow of the building before and after renovations through a link here.

The residence will continue to admit youth until it reaches capacity, with the hopes that it will serve an equal number of young women and men, says an OCFS spokesperson. Pawel hopes and expects the state will find a way for residents to be sent to the Brooklyn home directly after being sentenced in court.

His one gripe is that despite Aichhorn’s track record of working with young people with mental illness, the Office of Mental Health’s Bureau of Inspection told him to change the building’s carefully chosen bathroom fixtures as a suicide prevention measure. The new toilet paper dispensers cost $250 each, he says, and are ugly. “It’s totally crazy to be telling us what we need for security,” he says. “But if you don’t open the bathrooms, it looks really nice.”

Brooklyn's Home for Juvenile Justice

New York State is moving forward with plans to open its first psychiatric residence for kids with mental illness in the juvenile justice system. The planned facility, which will take over the site of a soon-to-close Brooklyn psychiatric hospital, is part of a large-scale reform effort to keep kids close to their homes and in community-like settings. But the state's first job, according to the director of the organization recently chosen to run the facility, is to overhaul the building so it doesn't feel like a prison. The building sits on a campus filling several blocks of Bergen Street in Brownsville. It's a sprawling, two story, L-shaped structure enclosed by a high iron fence with a sliding electric gate overseen by a guard booth. "They're acting like this is either a medium security prison or a target of terrorism," says Michael Pawel, who runs the August Aichhorn Center for Adolescents. "It's the antithesis of a community facility."

The state's Office of Mental Health Services (OMH) expects the new residential treatment facility (RTF) to be up and running by the end of the year, housing city teens who would otherwise be sent upstate to juvenile lockups. Though the residence will house only 24 young people, its opening reflects a critical shift in how the state aims to treat and house children with mental illness who wind up in the juvenile justice system.

Some 50 percent of young people in juvenile correctional facilities have been diagnosed with a mental illness, according to the Office of Children and Family Services (OCFS), which runs the New York State juvenile justice system. Advocates place that percentage even higher. The state has a long history of providing inadequate psychiatric care to these young people. A 2009 Department of Federal Justice investigation of four state juvenile justice facilities found that cases of children with mental illness were mishandled; young people were given powerful psychotropic medications without proper monitoring; and staff at the facilities used excessive force and restraints. Shortly after the investigation, the Department of Justice threatened to take control of four state juvenile facilities unless, among other requirements, children needing more services than the facilities could provide were transferred to more appropriate settings.

But appropriate settings for court-involved youth with mental illness have been hard to find. While some adolescents are sent to residential treatment centers funded through the city's foster care system, they rarely have the level of clinical supervision required for court-involved young people with mental illness.

State-licensed residential treatment facilities, which are funded by OMH, typically have lower staff-to-child ratios and richer clinical services than the residential treatment centers. However, they are also infamously difficult to be admitted to.Only one in New York City accepts children who are violent: Michael Pawel's Aichhorn Center.

It's one of the reasons OMH and OCFS selected Aichhorn over much larger social service agencies to run the new RTF. "This new program will really be able to manage some of the behavioral disruptions that the other RTFs aren't equipped to do," says Susan Thaler, director of children's services at OMH's New York City field office. "There is some expectation that these kids have histories of violence and running away and haven't been able to manage or receive treatment in other kinds of settings."

Thaler says the new program's Brooklyn location will make it easy for teens to visit with their families and will allow for a more natural transition when it's time to return home.

Pawel's plans for the residence, which he presented to OMH this month, are modeled after Aichhorn's adolescent psychiatric facility in Harlem, which currently houses some juvenile offenders. He proposed to break down the tall fence surrounding the building and add an entrance to the street to connect it to the neighborhood. On the inside, he wants to add carpeting and comfortable living room spaces and ditch the locks on the outside of bedrooms as well as the building's electronic "panic system," which staff at the psychiatric hospital now use to alert help with the touch of a button.

The building's living space will be divided into apartment-like units each housing a co-ed group of 8 young people."Having units co-ed is very unique and normalizing and helpful," says Pawel. "People tend to be calmer in co-ed groups."

Each unit will share meals in their own kitchenettes, family-style. And just like at the Harlem residence, mental health services will be folded into most every aspect of the young residents' lives, both while they're living in their units and in school. The site will have the equivalent of one full-time psychiatrist, three unit leaders, and two other therapists.

Pawel believes the program's most important challenge will be getting away from the idea that "might makes right."

"My understanding is that particularly mentally ill youngsters in OCFS facilities are being managed primarily by a lot of physical force," he says. "If you can get a group like this which is a very unhappy, very angry, very violent group and more or less eliminate the incidence of violence while they're being supervised, that's very good and I think that's going to be clear very quickly. And I think we can pull it off."

One internal Aichhorn study compared the outcomes of young people admitted to the organization's Harlem program with other teens who met the same admission criteria but were rejected because beds were not available. Using state court data, the study found that 39 percent of Aichhorn's alumni were subsequently arrested, compared to 60 percent of the group that was not admitted to the program.

Pawel hopes he can produce similar or better results at the new residence. Advocates are optimistic too, but say the new program should be only the beginning. "For far too long, the juvenile justice system has been used to warehouse children with mental illness; an approach that fails both children and the public," Gabrielle Prisco, director of the juvenile justice project at the Correctional Association of New York, said in a written statement. "We hope that this is only one part of a larger transformation from a punitive juvenile justice system to one that meaningfully serves the needs of children, builds upon their strengths, and maintains their connections to their families and communities."

Photo: Sandeep Prasada

A Need for Correction: Reforming New York's Juvenile Justice System

Half the children housed in New York State's juvenile correctional facilities suffer from mental illness, yet there is not one psychiatrist or psychiatric nurse on the staff of the state Office of Children and Family Services (OCFS), which runs the facilities.

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Half Full, Half Empty: Children and Families with Special Needs

The Winter 2006/2007 issue of Child Welfare Watch describes the impact of a longstanding dispute that has left children and families without the respite care, in-home assistance and other family supports that can help make it possible for young people with disabilities to live healthy and more fulfilling lives.

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