Mary I. Armstrong

Patterns of service use, individual and contextual risk factors, and resilience among adolescents using multiple psychosocial services

BACKGROUND Very little research has examined the relationship between resilience, risk, and the service use patterns of adolescents with complex needs who use multiple formal and mandated services such as child welfare, mental health, juvenile justice, and special educational supports. This article reports on a study of 497 adolescents in Atlantic Canada who were known to have used at least 2 of these services in the last 6 months. It was hypothesized that greater service use and satisfaction with services would predict both resilience, and better functional outcomes such as prosocial behavior, school engagement and participation in community. METHODS Youth who were known to be multiple service users and who were between the ages of 13 and 21 participated in the study. Participants completed a self-report questionnaire administered individually. Path analysis was used to determine the relationship between risk, service use, resilience, and functional outcomes. MANOVA was then used to determine patterns of service use and service use satisfaction among participants. RESULTS Findings show that there was no significant relationship between service use history and resilience or any of the three functional outcomes. Service use satisfaction, a measure of an adolescents perception of the quality of the services received, did however show a strong positive relationship with resilience. Resilience mediates the impact of risk factors on outcomes and is affected positively by the quality, but not the quantity, of the psychosocial services provided to adolescents with complex needs. CONCLUSIONS Results show that resilience is related to service satisfaction but not the quantity of services used by youth. Coordinated services may not increase resilience or be more effective unless the quality of individual services is experienced by an adolescent receiving intervention as personally empowering and sensitive to his or her needs.

Family-centered intensive case management: A step toward understanding individualized care

New York States initial attempt at individualizing services occurred within the context of an experiment. We randomly assigned children 5–12 years old who were referred for out-of-home placement in treatment foster care to either treatment foster care, Family-Based Treatment (n=15), or to Family-Centered Intensive Case Management (FCICM) (n=27). FCICM used teams of case managers and parent advocates to provide in-home services. Flexible service dollars, respite care, and behavior management skills training were available to assist teams in individualizing care. Preliminary outcomes indicate that children in FCICM are doing as well or better than children assigned to FBT in their functioning and symptom reduction. Parents of children in FCICM have made gains, although not at a statistically significant level, in behavior management skills and family strengths that allow them to provide care for their children at home.

An experimental study of the effectiveness of intensive in-home crisis services for children and their families: Program outcomes.

In this article, we describe the outcomes associated with a 3-year research demonstration project. It is the second of a two-part article concerned with this research conducted in the Bronx, New York, to examine the efficacy of three models of intensive in-home services—Home-Based Crisis Intervention (HBCI), Enhanced Home-Based Crisis Intervention (HBCI+),and Crisis Case Management—as alternatives to hospitalization for children experiencing a psychiatric crisis. In Part I (Evans, Boothroyd, & Armstrong, 1997), we described the features of the three program models, the research design, data collection measures, and the presenting characteristics of the children and families. In Part 2, we describe the success of maintaining children at home (82%) and the increases in family adaptability, childrens self-concept, and parental self-efficacy both at discharge and at 6 months postdischarge. Enrollees in two of the models (HBCI and HBCI+) experienced a significant increase in family cohesion,although this was not maintained at 6 months postdischarge. While enrollees in the enhanced program showed significant increase in social support at discharge, all enrollees experienced this at 6 months postdischarge.

Development and Implementation of an Experimental Study of the Effectiveness of Intensive In-Home Crisis Services for Children and Their Families.

This article describes a 3-year research demonstration project originally funded by the National Institute of Mental Health and now funded in part by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. This project, which was conducted in the Bronx, New York, examined the efficacy of 3 models of intensive in-home services as alternatives to hospitalization for children experiencing serious psychiatric crises. All programs were 4- to 6-week interventions. The first, Home-Based Crisis Intervention (HBCI), was modeled on the Homebuilders model of family preservation; the second, Enhanced HBCI (HBCI+), added respite care, flexible service money, parent advocate and support services, and additional staff training in cultural competence and violence management. Crisis Case Management, the third model, used case managers to assess child and family needs and link them to services, as well as respite care and flexible money. The specific features of the 3 program models, the research design, and data collection measures are described. The intake data on the children and families are presented, and implications for providing services and for future research are discussed.

Children placed in out-of-home care: risk factors for involvement with the juvenile justice system.

In previous research, child maltreatment has been associated with several negative outcomes, including delinquency. This study uses administrative data to examine risk factors, including the severity and chronicity of maltreatment, for juvenile justice involvement among children, ages 7 to 17, who were placed in out-of-home care in Florida (N = 13,212). The results of multivariate Cox regression analysis indicated that among specific types of maltreatment, sexual abuse was associated with the risk of faster placement only in a detention center. Additionally, findings from this study suggest that maltreatment chronicity but not maltreatment severity increases the chances of earlier involvement with the juvenile justice system among children who were placed in an out-of-home care. Implications of these findings are discussed.

Contextual and individual-level predictors of abused children's reentry into out-of-home care: A multilevel mixture survival analysis

OBJECTIVES This study examined the effects of individual and contextual factors on reentry into out-of-home care among children who were discharged from child protective services in fiscal year 2004-2005. The objectives were to: (1) examine individual and contextual factors associated with reentry, (2) explore whether there are meaningful groups of youth who differ in terms of risk for reentry, and (3) determine whether relatively homogeneous clusters of child welfare agencies, based on contextual characteristics, differ significantly in terms of the reentry rates of the children whom they serve. METHOD The study design involved a multilevel longitudinal analysis of administrative data based on an exit cohort. Two Cox proportional hazards multilevel mixture models were tested. The first model included multiple individual level predictors and no agency level predictors. The second model included both levels of predictors. RESULTS The results of multilevel Cox regression mixture modeling indicated that at the individual level, younger age, being placed in out-of-home care because of neglect and having physical, health problems corresponded to a decreased likelihood for reentry. At the agency level, lower average expenditures per child and contracting out case management services were associated with faster reentry into out-of-home care. CONCLUSIONS This study demonstrates that children who reenter out-of-home care appear to be a homogeneous population and that reentry is associated with both contextual factors and individual characteristics. PRACTICE IMPLICATIONS The most important implication that can be drawn from the study findings is that reentry may be most effectively prevented by focusing on such factors at the organizational level as contracting out case management services and funding allocation. Child welfare agencies that are responsible for an array of services and decide to contract out case management should consider the use of performance-based contracts and emphasize and strengthen quality assurance approaches for contracted services. In addition, to compensate for lower funding allocated for children served in out-of-home care, child welfare workers should become more familiar with community resources and help connect families to these supports.

Predictors of Emotional Well-Being in At-Risk Adolescent Girls: Developing Preventive Intervention Strategies

This article examines the degree to which various demographic characteristics, personality traits, and environmental factors are associated with overall emotional well-being of 125 adolescent girls whose mothers were involved in welfare reform. Daughters participated in a 4-year, mixed method study and annually completed a structured interview protocol and a sub-group also completed a qualitative interview. The quantitative findings from the study suggest that daughters having an internal locus of control, experiencing fewer negative life events, and reporting stronger parental and teacher social support had enhanced emotional well-being over the 4-year study compared to daughters without these factors. The findings were further elaborated with examples from qualitative interviews conducted with the daughters. The findings were used to propose prevention activities using a tertiary mental health preventive intervention framework.

Child Welfare Privatization: Quantitative Indicators and Policy Issues

The purpose of this study was to demonstrate the development of safety, permanency, and child well-being indicators by using administrative data sets as well as by using these indicators as tools for evaluating Florida’s Community-Based Care (CBC) initiative. Longitudinal data from 37 counties including 4 counties that implemented community-based care were examined in this study. The results of the study indicated that the overall performance of CBC counties is at least as good as the performance of their comparison run by the state counties. The findings that emerged from this study may provide important lessons for developing a performance measurement system in the child welfare field.

Outcomes associated with clinical profiles of children in psychiatric crisis enrolled in intensive, in-home interventions

Little is known about the characteristics of children and youth presenting at emergency settings in psychiatric crisis, and virtually nothing is known about their outcomes. The purpose of this study is to describe the clinical profiles of 238 children presenting at two psychiatric emergency settings and enrolled in a randomized controlled trial of three intensive in-home interventions. A second purpose is to examine child mental health outcomes, based on clinical profile and to suggest the utility of using a clinical-profiles approach.

The Impact of Managed Care on Systems of Care That Serve Children With Serious Emotional Disturbances and Their Families

A qualitative case study approach was used to evaluate the impact of managed care reforms on a select sample of systems of care funded by the Comprehensive Community Mental Health Services for Children and Their Families Program. Analyses indicated that the system-of-care philosophy and approach could be maintained in a managed care environment under the right circumstances. These circumstances include (a) the preexistence of a system-of-care philosophy prior to the integration of managed care, (b) stakeholder involvement in managed care planning and implementation, (c) use of a broad array of providers and sufficient support for case management and care coordination activities, (d) identification and support of high utilizer groups within the managed care system, and (e) financial compatibility between managed care and systems of care.