A Successful Public/Private Partnership in Children?s Protective Services:::::: Welcome to Child Trauma Academy :::::::::::

A Successful Public/Private Partnership in Children’s Protective Services:
The Children’s Crisis Care Center

David Conrad, LMSW-ACP*
Christine Dobson, Ph.D.**
Stephanie Schick, M.Ed*
Duane Runyan, Ph.D.*
Bruce D. Perry, M.D., Ph.D.*

Presented at the Twelfth International Congress on Child Abuse and Neglect, Aukland, New Zealand, 1998.

*The ChildTrauma Programs
A Partnership between
Baylor College of Medicine
and Texas Children’s Hospital
Houston, Texas

**Children’s Crisis Care Center of Harris County
Harris County Child Protective Services
Houston, Texas

BACKGROUND

Scope of Maltreatment

In 1995, nearly 3 million children were exposed to traumatic abuse and neglect in the United States, a 42% increase from a decade earlier (Petit & Curtis. 1997). Thirty-three percent of these children were under the age of 6. In 1995, on any given day, 486,000 children were placed in out-of-home care—a 74% increase from 1986 (Petit & Curtis. 1997).

Child Protective Services: Overburdened and Unprepared

Children’s Protective Services (CPS) has the responsibility of finding suitable (if not optimal) placement for the children removed from parental care. These children are all at risk for a host of emotional, behavioral, cognitive, social and physical problems related to abuse and neglect. Yet each of these children will have unique combinations of strength and vulnerability; and each deserves the opportunity for placement and services that match their needs. This is a challenge under optimal situations, but particularly for the overburdened and unprepared CPS system. Few CPS systems have proactive, multidimensional evaluations that provide information to decision-makers during the first weeks in the CPS system (Urquiza, Wirtz, Peterson, & Singer. 1994).

INTRODUCTION

Formation of the Task Force: Pre-pilot phase

In 1993, the Harris County Children’s Protective Services Fund Board, a private organization founded by the corporate community in Houston commissioned a Task Force to help Harris County (greater Houston) CPS develop an innovative program that would reduce placement disruptions and the length of time children spent in shelters. Following much discussion, the Task Force recommended the development and testing of a proactive, cost-effective assessment to identify high-risk children entering the CPS system.

Creating the Public/Private Partnership: The Children’s Crisis Care Center

The primary partners in the project were Harris County Child Protective Services, the Texas Department of Protective and Regulatory Services and the CIVITAS ChildTrauma Programs (now known at the ChildTrauma Academy). Harris County CPS was assigned overall administrative responsibility for the project while the CIVITAS ChildTrauma Programs was selected to develop and implement the proactive assessment process.

METHODS

The CIVITAS/CCCC Core Assessment Process

The central concept of the Core Assessment Process is to obtain an accurate and useful "snapshot" of the child’s strengths and vulnerabilities in six major domains: (1) physical/medical; (2) family/social; (3) life history/traumatic life events; (4) emotional/behavioral; (5) cognitive/academic and (6) developmental.

The CIVITAS/CCCC Core Assessment: Domains of the Multidimensional Evaluation. The Core Assessment is designed to provide subjective and objective data from each of these six critical domains in a cost-effective and practical fashion. Rather than providing a comprehensive and exhaustive evaluation of one domain (i.e., filling in only one piece of the pie), the selective administration of quantitative measures in each domain provides a useful initial understanding of the child and family. If the initial CIVITAS/CCC Core Assessment demonstrates the need for more intensive or targeted evaluation, this can be recommended. With this multi-dimensional and standardized format, rapid decision-making can take place, guiding better initial placement recommendations, targeted services and expedited evaluation of ultimate placement decisions.

Components of the Pilot Phase CIVITAS/CCCC Core Assessment

Domain	Developmental *(0-6 Years)*	Child/Adolescent *(6-17 Years)*
Physical	Height Weight Blood Pressure Pulse FOC (frontal-occipital circumference) Historical Physical Information Active Problems	Height Weight Blood Pressure Pulse FOC (frontal-occipital circumference) History of Physical Problems Active Problems
Life Events	Trauma Inventory	Trauma Inventory
Family/ Social	Family Inventory of Life Events Family Adaptability and Cohesion Scale	Family Inventory of Life Events Family Adaptability and Cohesion Scale
Cognitive/ Academic	Not Applicable	Beery Visual-Motor Integration Test Wide Range Achievement Test Kaufman Brief Intelligence Test
Developmental	Caregiver Interview Denver II	Not Applicable
Emotional/ Behavioral	Caregiver Interview Conner’s Parent Rating Scale Child Behavior Checklist 2-3 Child Behavior Checklist 4-18	Structured Clinical Interview (Child) Conner’s Parent Rating Scale Child Behavior Checklist 4-18 Youth Self Report Children’s Depression Inventory Feelings, Attitudes and Behaviors Scale for Children State-Trait Anxiety Inventory for Children Millon Adolescent Clinical Inventory Children’s Perceptual Alteration Scale Child Post-Traumatic Stress Disorder-Reaction Index Trauma Symptom Checklist for Children

Key Differences:

CIVITAS/CCCC Core Process vs. CPS-Standard Approach to Assessment

	CIVITAS/CCCC	CPS-Standard
Primary Model	Proactive	Reactive
Nature of Evaluation	Multi-dimensional (including Family )	Focused, typically psychological
Assessing young children (0-6)	Developmental	None
Psychometric Instruments	Quantitative measures with known validity and reliability	Minimal standardization and little cross-clinician consistency
Report Format	Graphical, structured, standardized with subjective and objective data	Narrative, primarily subjective interpretation
Report Availability	Reports available for early decision-making	Evaluation data rarely available at 10 d, 30 d or other proceedings
Information Management	Data stored on electronic database; available for multiple appropriate users	No electronic record of evaluations or primary test data
Communication with CPS	Clinicians participate in interdisciplinary teams with CPS	Rare participation by contract clinicians in CPS staffing
Outcomes Evaluation	Follow-up assessment is part of the process; quantitative measures allow outcome evaluation for "fit" of placement and efficacy of services	None
Relationship with CPS	True public/private partnership with distributed leadership and shared responsibility	Contract clinicians with limited investment in CPS systemic issues
Program Development	Continual self-evaluation and correction; integration of program or process innovations	None

RESULTS

The Children’s Crisis Care Center Pilot Project operated for two years, from March 1, 1996 until March 1, 1998. Two units of CPS were attached to the CCCC (pilot units) and all children removed by these two units (n=400) participated in the initial assessment process. Two comparison units were followed to aid in program outcome evaluation. In the pilot units, the assessment was repeated at six-month and yearly intervals.

Direct Economic Impact to Child Protective Services

Utilization of the CIVITAS/CCCC Core Assessment has a direct immediate impact on CPS as is illustrated in the Table below. More specifically, the proactive assessment allows more rapid decision-making; therefore, fewer days in CPS care, fewer days in shelter care and fewer disrupted placements. The cost savings from these factors alone could save the CPS system in Texas over 25 million dollars per year.

CIVITAS/CCCC Process: A Dramatic Improvement over the Current CPS System

Children in CPS custody participating in the Children’s Crisis Care Center process typically benefited in many ways. Examples include receiving a multi-dimensional evaluation by a multi-disciplinary team, spending less time in shelter care and experiencing fewer placement disruptions. Caseworkers, clinicians, attorneys and judges made more rapid and informed decisions about placement and services.

Key Findings: Children Removed from Caregivers by the CPS System

Young children (0-6)

23 % of young children were "un-testable" due to significant behavioral problems

80 % of the remaining children have some form of developmental delay or problem

Number and severity of developmental delays increase with age (i.e., more maltreatment = more delay)

The prevalence of asthma was higher in these children than in the general pediatric population

Few of these children would have been evaluated or referred for services in the standard CPS model

Children (7-17)

86 % of the children (7-17) had clinically significant post-traumatic stress (PTSD) symptoms

50 % of children (7-17) had some form of academic problem

36 % of children performed higher in non-verbal than on verbal; while only 3 % performed higher on verbal rather than non-verbal tasks

Economic Analysis of CCCC Pilot Project: Year One

	CIVITAS/ CCCC	CPS- Standard	Savings/ difference	Net Gain
Cost of Assessment
Cost of assessment/child	350	550	200
Percent of children assessed	100 %	25 %	-75 %
Cost/100 children	35,000	13,750	-21,250
Cost/12,000 children *	4,200,000	1,650,000	-2,550,000	-2,550,000
Benefits: Rapid Decision-Making
Days in shelter care	31 d	49 d	18 d
Cost of shelter care/child ($91/day)	2821	4459	1638
Cost of shelter care/ 100 children	282,100	445,900	163,800	142,550
Texas costs (12,000 children in care)	33,852,000	53,508,000	19,656,000	17,106,000
Benefits: Fewer Days in Care
Level one foster care: per diem	16	16
Annual cost of 1 children in care	5240 **	5840
Annual cost of 100 children in care	524,000	584,000	60,000
Annual cost Texas (12,000 children)	62,880,000	70,800,000	6,720,000	7,920,000
Potential Annual Savings for Texas CPS System				25,026,000

* 12,000 is an estimate based upon the number of children removed from parental care and entering CPS foster-care system in Texas over during a one-year period

** Figures based upon differences in percentage of children in CPS care in Year One of the CCCC pilot project.

CONCLUSIONS: The Key Role of Process

Rapid and cost effective assessment of children and families in CPS care is feasible

Use of quantitative measures and modern information management technologies are required for efficacy

Effective program implementation was dependent upon process more than the "content" of the evaluation

Selecting, training and supporting the staff was essential to success

Cross-institutional and interdisciplinary functioning was dependent upon creating and maintaining "process"

Key process issues were:

Inclusion of all partners in key decision-making
Distributed leadership
Mutual respect
Resource and professional support
Structured mechanisms for continuous communication
Interpersonal dynamics of key staff

From Pilot to Systemic Program: Next Steps

Harris COUNTY CPS and Texas Department of Protective and Regulatory Services (TDPRS) recognized the success of the pilot phase of the CCCC. At present, the CIVITAS/CCCC Core Assessment process is being taken "to scale" in Harris County. An expanded version of this proactive assessment model will include the investigative phase of the CPS process. The use of objective, multi-domain assessment of family and children being investigated by CPS may help reduce subjective and inconsistent removal decisions and better target limited in-home services.

Both of these efforts face significant obstacles. These include resource depleted public systems, poorly trained and under-supported staff and, in some cases, passive supervision and leadership. Despite this, the experience of the CCCC primary partners suggests that careful attention to group and system dynamics (i.e., process) can overcome these limitations. Other systems or organizations interested in systemic change to help improve services for children must pay close attention to, and directly address "process" issues such as staff selection, training, support, morale, communication and the organizational "environment" (Glisson & Hemmelgarn,1998).

REFERENCES

Glisson, C. & Hemmelgarn, A. (1998) The effects of organizational climate and interorganizational coordination on the quality and outcomes of children’s service systems. Child Abuse and Neglect, 22, 401-421.

Perry, B.D. Conrad, D.L., Dobson, C., Schick, S. & Runyan, D. The CIVITAS/Children’s Crisis Care Center model: A proactive, multidimensional child and family assessment process for child protective services, submitted.

Petit, M.R., & Curtis, P.A. (1997). Child abuse and neglect: A look at the states. CWLA Press. Washington, D.C.

Urquiza, A., Wirtz, S., Peterson, M., & Singer, V. (1994). Screening and evaluating abused and neglected children entering protective custody. Child Welfare, 73, 155-171.

Abstracts