Approved by Council January 2002

Preamble

In the past few years, significant attention has been given to the growing number of children who suffer needlessly because their emotional, behavioral, and developmental needs are not being met. All of us are being urged to take seriously the task of preventing mental health and/or substance use problems and providing services and supports for treating mental illness and/or substance use in children.

Over the last few years, the Surgeon General's Report on Children's Mental Health and the UN Convention on the Rights of the Child have emphasized that treatment should be considered a basic right for children who suffer from an emotional/mental health/substance use problem and their families. This year, President Bush issued an executive order, the "New Freedom Initiative" (NFI) of June 18th, 2001, to identify and remove existing barriers to community living for persons with disabilities, including children with severe emotional disturbances. The NFI highlights the importance of "no wrong door" for accessing services and creating opportunity for children to receive community-based services within their local service systems. The President's announced plan to establish a National Commission on Mental Health will further support addressing the unmet emotional/mental health needs of children.

Children served by the foster care system are coping with the events that precipitated their coming into care, while enduring the personal grief and trauma that accompany the loss of a family. Currently, over 500,000 children reside in foster care in the United States, and 85% of them are estimated to have an emotional disorder and/or substance use problem. Recognizing our common interest, the American Academy of Child and Adolescent Psychiatry (AACAP) and the Child Welfare League of America (CWLA) began an initiative in March 2001, to improve the design, delivery, and outcomes of the mental health and substance use services provided to children in foster care and their families. AACAP and CWLA have been joined by over 30 consumer and professional organizations, which have contributed their expertise and resources to this initiative.

Our examination of the problem and the seriousness, intensity, prevalence, and urgency of the unmet needs of these children and their families substantiates our commitment to this initiative. Drawing on the values and principles already developed through such efforts as the systems of care, which focused on service delivery to children with serious emotional disturbances, the values and principles delineated in this document will guide our efforts to improve policies and practices in the various child-serving systems that serve children in foster care and their families. We believe such values and principles will drive practice in addressing the mental health and substance use needs of children and their families. This in turn will lead to other reforms in how local communities and the formal systems intersect around mental health, substance use, and child welfare issues to ensure and promote the well-being of children in foster care and their families.

Our mutual interest is the emotional/mental health of children and their families. We must develop innovative and evidence-based assessment tools to identify children's emotional and/or behavioral problems as early as possible and to ensure that all children and their families have access to and receive evidence-based, effective mental health and substance use prevention/treatment services, and supports. We believe it is our professional responsibility to provide the most timely, appropriate, and effective prevention/treatment services and supports to children and their families to ensure the best outcomes. Key strategies for accomplishing these goals are:

• keeping children and their families involved whenever possible;
• providing the children with services and supports in their own community;
• responding to their needs with staff who understand their culture and programs that are culturally relevant to children and their families; and
• treating their mental health and substance use needs in a timely manner with professionals trained in the most effective prevention/treatment approaches.

To this end, we agree to support and advocate for providing mental health and substance use prevention strategies, assessments, treatments, services, and supports designed for children in the foster care system and their families that abide by the following values and principles:

1. Values
   Overarching Discussion Points:
   
   • Values are infused into a piece of work; principles are the key points that support the infused values.
   • Values are what drive the process. Principles result from the values; they make the process operational.
   • Values are the "why"; principles are the "how."
   • The values focus should be on mental health and substance use issues of children in foster care and their families.
   1. Suggested value concepts should support a child-focused approach to ensure that mental health and substance use services and supports are an integral component within foster care.
      
      Value: Child-Focused Mental Health and Substance Use Services and Supports
      Discussion Points:
      • Issues of attachment are considered significant to the emotional/mental health of children in all placement decisions.
      • The trauma children endure when moved from placement to placement is not conducive to normal development. It can adversely impact children and families.
      • When children are placed outside of the home it is important for services and/or supports to be provide not only to the child but also to the family of origin.
      • When placing children outside of the home, it is essential to help them create developmentally meaningful new attachments, while at the same time maintaining existing attachments whenever possible.
      • Children's view of how their emotional/mental health will be impacted by placement decisions should be represented (either by the child through their words or behavior or through representation by an adult whose primary role is to offer the child's perspective) in all proceedings in keeping with the age and maturity of the child.
      • The current child welfare system tends to be focused initially on the physical safety of the child while not adequately considering the impact of removal and placements on the child's emotional/mental health. To do so could prevent further emotional/mental health problems.
      • Practice Guidelines must be established to address not only the safety issues but also the emotional/mental/behavioral health need of children.
      • Foster care providers need information and resources to address the mental health and substance use needs of the children they serve. A process for monitoring that services are delivered in a timely and appropriate manner is necessary.
      • It is important that, while in care, the child and the birth family maintain contact. Assessment decisions need to be made to determine if the birth family can be in immediate and continuing contact (face to face visitation and/or by telephone) in order to decrease the severity of separation trauma. In addition, whenever possible, the birth parents and foster parents and/or other agency caregiver(s) should communicate with each other to maximize continuity and mutuality in accomplishing therapeutic goals.
      • Providing mental health intervention at the time of the initial placement and while in care is a means of preventing attachment disorders and/or the progression of already existing mental health and substance use problems. To ensure the child's emotional well-being, assessments should be performed at regular intervals to determine if there are attachment issues emerging to be considered while the child is in care, when moving to another placement and/or moving to their permanent placement (i.e. home, adoption, long-term foster home).
      • Reunification with the family of origin may not always be the best option for the child and other options must be considered to ensure the physical and emotional well-being of the child.
   2. Suggested value concepts should support a family-driven approach to ensure that mental health and substance use services and supports are an integral component within foster care.
      
      Value: Family-Driven Mental Health and Substance Use Services and Supports
      
      Discussion Points:
      • For child welfare services, a family-driven policy that does not compromise the child's safety is necessary.
      • The foster care system is currently focused on the child. To really meet the needs of the child, it should place greater emphasis on the family of origin. This family-centered approach could result in a major change of cultural/mindset within the current child welfare system.
      • The child welfare system is concerned with safety, permanency, and well-being. Every child should have a safe home as soon as possible preferably, but not necessarily with the family of origin.
      • To every extent possible, the biological family should be involved even when it is not the custodial family.
   3. Suggested value concepts should support a community-based approach.
      
      Value: Integration, Collaboration and Coordination of Community-Based Mental Helath and Substance Use Services and Supports with the Foster Care System
      
      Discussion Points:
      • Mental health and substance use (behavioral health) services and supports should be readily available to children in foster care and their families.
      • Identify best practices in providing mental health and substance use services and supports to children in foster care and their families.
      • Health and behavioral health care providers must have a clear and defined role, driven by professional expertise and values, in treating children in foster care and their families.
      • To ensure child safety and achieve quality services and supports for children and their families, it is crucial to expand and increase the input of both community members and expert professionals.
      • In the child welfare system, the child is placed in a foster care environment, which is expected to address the child's safety and well-being. There may be difference in how states define safety. How local communities participate in setting the community standards further impacts the differences in definition.
      • The child's comprehensive health assessment must include the elements of the EPSDT screening and assessment, such as physical, dental, substance use, and mental health evaluations. It must also address issues of co-morbidity.
      • Foster parents must be informed of the mental health and substance use needs of the child that they are caring for. They must also be provided with education and information as to effective ways these needs can be met to support the key role foster parents have addressing the mental health and substance use needs of the child.
   4. Suggested values concepts should demonstrate sensitivity to cultural competency issues
      
      Value: Culturally Competent, Sensitive, Relevant, and Strength-Based Mental Health and Substance Use Services and Supports that are Provided by Knowledgable and Skilled Staff and Service Providers Who are Aware and Understand the Cultural Diersity of that Community
      
      Discussion Points:
      • It is crucial that assessment tools and mental health and substance use services and supports be not only culturally competent, but also culturally sensitive and relevant to children and their families.
      • Assessments and mental health and substance use treatment/service/support planning should take into account the strengths of the children and their families.
      • Assessment and mental health and substance use treatment/services/supports should take into account the cultural status, economic status, and the diversity of the community and the population being served.
      • There should be culturally competent policies and professional competence in procedures, outreach, advocacy, and training throughout the service delivery system.
      • To facilitate rapport and successful outcomes, the team engaging and delivering services/supports to children and their families should, to the extent possible, represent the diversity of the community and the population served.
      • Cultural competence, sensitivity and relevance is demonstrated through the array of services, the design and delivery system, and by recognizing the importance of existing community-based, informal support networks such as churches, extended kinship networks, and social organizations.
   5. Suggested value concepts should support timely access to effective evidence-based quality services and supports
      
      

      Value: Timely, Effective, Evidence-Based, Outcome-Driven Mental Health and Substance Use Services and Supports

      Discussion Points:
      • The grief and trauma children experience when they are placed into and within the foster care system must be taken into account when assessing their needs and providing services and supports. An initial mental health and substance use screening should be done within 24 hours of placement. The mental health and substance use screen is intended to identify children in urgent need of emergency mental health and substance use services. This screening would also assess the internalized and externalized levels of distress in the child regarding the separation from their family of origin. A triage intervention to address the child's feelings regarding the separation and help the child cope should be provided as quickly as possible based on the severity and intensity.
      • All children in foster care and their families must have a comprehensive mental health and substance use assessment once the child is stabilized but minimally within the timeframes of EPSDT. The assessments should always address the attachment issues for the child as long as the child is in care and be done in a timely fashion especially when there is transition from placement to placement.
      • The child welfare system must take into account the difference between a child having a mental disorder and/or substance use problem and a child requiring mental health and substance use intervention to prevent a future disorder and address both. Currently, a mental health and/or substance use assessment is often not done until there is a crisis.
      • Just as it is necessary for periodic reviews to be done on individual case plans, it is necessary for systems and providers to perform effective, evidence-based, outcome-driven reviews of results to demonstrate progress in achieving the goals for the children and their families.
      • To provide compassionate, relevant services it is essential to reach for and use feedback from the children and their families about the effectiveness of the services offered to address their needs and goals.
2. Principles generated by the above values
   The principles outlined in this section are infused by the core values mentioned above and provide greater detail for how they are to be implemented.
   1. Service coordination and case/care management
      • Coordination/integration among mental health, substance use, physical health, developmental disabilities, legal services, educational services, and child welfare services is essential.
      • Children in the foster care system deserve coordinated mental health and substance use services that are designed, screened, assessed, and delivered as part of their foster care services plan.
      • Coordination at the systems level can ensure the most appropriate use of limited resources and eliminate the fragmentation currently experienced with different funding streams for the needed services and supports.
      • Many children and youth coming into foster care have co-occurring mental health and substance use issues. Service coordination should be provided to ensure that their substance use needs are assessed and treatment services and supports are provided concurrently with the mental health services and supports.
      • Coordination must also include the services children are receiving and the services the family member(s) are receiving.
      • Coordination should take place to ensure that family members who require services/supports are receiving them.
      • Information must be shared on a regular basis among organizations/agencies providing services/support to the child and/or their family. Every effort must be made to eliminate barriers, while complying with the confidentiality requirements in HIPAA. This information should follow the child from placement to placement.
   2. Prevention and early identification
      • Prevention and early identification programs and supports for potential mental health and substance use issues are vital to children in the foster care system and their families.
      • Young children (0-3yrs) are of particular concern given they make up a significant percentage of the population of children who are placed in the foster care system. Evidence-based prevention and early intervention programs should be targeted to this population.
      • Assessments for children entering the foster care system should include screening for potential mental health and substance use issues.
      • While in foster care, children should be reassessed for potential mental health and substance use problems at specific intervals (minimally EPSDT timeframes) or as indicated, so that prevention and/or treatment services and supports can be provided as early as possible. It is recommended that a referral be made for a mental health and substance use assessment by an appropriately trained professional.
   3. Planned and coordinated transitions among agencies and providers and between children, families, and adult systems
      • Children and their families can suffer significant negative impact when transitions and/or discharges are not successful. Therefore, coordination, communication, and effective planning are necessary whenever children are involved in one of the following: changing providers and/or agencies, returning home, changing levels of care, changing placements or moving to their permanent placement, and/or transitioning to self-sufficiency or being transferred to another service system.
      • Youth in care making the transition to self-sufficiency may need services provided by the adult system, such as mental health and/or substance use services and housing, financial, health, dental, and educational and/or employment assistance. It is therefore important that effective coordination take place between these child and adult systems.
      • Key to ensuring successful transitions and discharges are early planning, ongoing coordination of services to address all needs, effective monitoring of plan implementation, and appropriate sharing of the case record information at the time of transition/discharge.
      • Each child leaving the child welfare system must have a developmentally and age appropriate transition and/or discharge plan. Such planning must provide the skills, information, services, and supports that allow young people to successfully transition to adulthood, where they can provide for their own permanency, safety, and well-being.
      • Transition can have a significant impact on the child and their family. Therefore, to ensure successful transitions, it is important that the child's needs and wishes (expressed either verbally or through behavior) be considered and take precedence over the system's needs whenever possible. If a child experiences more than two placements, the child welfare system should have a process in place to review the reasons and the impact to the child to ensure attachment issues and the child's mental health and substance use needs are being adequately addressed/considered.
      • To minimize the potential negative impact of changes/turnover in workers, it is recommended training be provided to workers on such issues as the impact of removal from home and/or transitions on children and their ability to form attachments, assessing the trauma of removal/placements on the child, effective interventions for dealing with attachment trauma, and signs for when a child should be referred for mental health and substance use treatment/services/supports.
   4. Human rights and responsibilities regarding protection and advocacy
      • All children in foster care have the right to have their views expressed directly through their words and behavior to the extent that is developmentally and age appropriate or have representation by an adult whose primary role is to offer the child's perspective for the following:
        1. Have access to and be provided with quality mental health and substance use services and supports.
        2. Have a say in which mental health and substance use services and supports will be of assistance to them based on their own strengths and needs.
        3. Have a say in the development, monitoring, and revision of their mental health and substance use treatment plan, which is in keeping with their permanency plan and the family service plan.
        4. Have a say in what mental health and substance use services and supports are or are not working for them.
        5. Refuse mental health and substance use services and supports unless their refusal would put them at risk of harm.
        6. Be provided mental health and substance use services and supports in the least intrusive community-based environment that is possible.
        7. Retain their constitutional rights when placed in foster care.
        8. Have input into the impact of placement decisions on their emotional/mental health.
        9. When very young or developmentally immature, have representation to ensure consideration of the impact of placement decisions on their emotional/mental health.
        10. Maintain frequent and regular, ongoing contact with sibling(s) and other family members when the family cannot be maintained as a single unit.
      • All families with children placed in foster care (except when parental rights are terminated or other legal decisions take precedence while weighing the best interests of the child) have the right to:
        1. Have a say and participate in which mental health and substance use treatment services and supports will be of assistance to them and their child based on their strengths and needs.
        2. Have a say and participate in the development, monitoring, and revisions of their child's mental health and substance use treatment plan, which is in keeping with their child's permanency plan and their own family service plan.
        3. Have a say and participate in decisions about what mental health and substance use services and supports are or are not working for them.
        4. Refuse their own mental health and substance use services and supports, when their refusal would not put their child at risk of harm.
        5. Have access to and be provided with quality mental health and substance use services and supports.
        6. Be provided mental health and substance use services and supports in the least intrusive environment possible.
        7. Retain their constitutional rights when their child/children are placed in foster care.
      • Through a release of information form, emancipated youth and family members can provide consent on who gets what information.
      • Children and their families have the right to be treated in compliance with federal, state, and local policies and standards.
      • Children and their families have the right to seek advocacy support.
      • Children and their families have the right to make complaints/raise concerns about the mental health and substance use services and supports that they are receiving without retribution. All agencies/providers should have a defined process for how such complaints/concerns can be raised and addressed.
      • Children and their families have the right to receive services that are culturally competent/relevant and to choose providers who respect and value their language, culture, and spiritual beliefs.
      • Children and their families have the right to access to the courts to address any concerns they might have about the mental health and substance use services they are receiving or believe they should be receiving.
   5. Nondiscrimination in access to services for children in care
      • Discrimination in the provision of services on the basis of race, religion, ethnicity, language, gender, age, sexual preference, marital status, national origin, or disability whether or not illegal.
      • Providers should deliver mental health and substance use services and supports to children and their families in compliance with the Americans with Disabilities Act.
      • Families can choose mental health and substance use service providers who respect and value their language, culture, and spiritual beliefs.
      • As emphasized in the Surgeon General's Report on Children's Mental Health, it is important for public and private providers to ensure services are provided and accessible without any discrimination, including interpreters when necessary.
   6. A comprehensive and accessible array of services
      • Given the complexity of serving children and their families, it is crucial to have a comprehensive array of services available. This would include traditional, faith-based, and non-traditional mental health and substance use services and supports as well as formal and informal supports and services.
      • This service array should be appropriate to address the circumstances and treatment needs of children and their families.
      • Services chosen from the array should be age and developmentally appropriate.
      • This service array should support children and their families in the community whenever possible.
      • This service array should take into account the ongoing developing strengths of children and their families.
   7. Individualized service planning
      • Service planning to address the mental health and substance use needs of children should be individualized and include the following:
        1. mental health and substance use services and supports focused on the strengths, desires, interests, values, and goals of the child and the family,
        2. an assessment of the specific and particular mental health substance use needs of the child and the services/supports the family requires to deal with and support a child with these mental health and substance use needs,
        3. measures to address issues of emotional distress arising as a consequence of all placement transitions,
        4. consistency with the permanency plan for the child and the family service plan,
        5. informal as well as formal mental health and substance use services/supports, and
        6. goals articulated in such a way that one can measure progress towards the goals identified by the child and family.
      • This individualized service plan should include the continuation of treatment when the child is reunified with his or her family. If a child is not receiving treatment services/supports at the time of reunification then it is an important time to initiate any treatment services that are needed as part of the reintegration process.
      • This individualized service plan should be developed in partnership with the child and family and other professionals working with them.
      • This individualized service plan should be regularly reviewed and updated to reflect the progress of the child or lack thereof, with input from the child and family when appropriate.
      • This individualized service plan should include the discharge and transition plans.
   8. Services in the least intrusive community-based environment
      • Service planning to address the mental health and substance use needs of children should focus on providing these services and supports for children and their families at the appropriate level and intensity and in the least intrusive environment to increase the child's functioning and physical stability.
      • Every effort should be made to keep children in their home community whenever possible. Issues of risk to the child take precedence over the placement that is least intrusive/restrictive even if that means removing a child from their home.
      • When services are being designed and developed there should be an easily accessed array of community-based services that support children receiving treatment in the least intrusive manner. Sometimes this might be over a widespread region, in particular in rural areas where it is not financially feasible to have all services in each local community.
      • When services are being designed and developed there should be family and community input into the planning process.
      • When children need to be placed outside the home community, it is essential that treatment/services/supports be provided to maintain the family connection when there is no indication to the contrary.
   9. Family participation in ALL aspects of planning, service delivery, and evaluation
      • Family is defined (using the Federation of Families definition) as including biological, foster, and adoptive parents, grandparents and their partners, as well as kinship care givers and others who have primary responsibility for providing love, guidance, food, shelter, clothing, supervision, and protection for children and adolescents.
      • It is important for the family to be actively invited as part of the engagement process at ALL levels of planning, service delivery, and evaluation: e.g., the system level, organizational level, and individual child level.
      • It is important for the family to be appreciated and involved in activities involving the child whenever possible.
      • Families should be given the choice as to whether or not they participate.
      • The family preference(s) and choice(s) should be considered in all planning for their child outside of situations, which might put the child at risk of harm.
      • Families should be provided with advocacy and representation that increases education/communication to families.
   10. Integrated services with coordinated planning across the child-serving system
       • Children in the foster care system with mental health and substance use issues and their families are often involved with multiple child-serving organizations and systems. They require and deserve well coordinated planning and integration of services to address their complex needs.
       • To ensure the most appropriate and effective integrated service delivery for children in the foster care system with mental health and substance use issues and their families, services should be planned and coordinated across the child-serving systems.
       • Often children in the foster care system initially access services through primary care. The EPSDT screening process should facilitate integration and coordination of services to meet the identified needs.
       • Even when funding streams can not be combined, there is greater potential for integrating services when planning is coordinated across the child-serving systems. Such integrated planning would make better use of limited dollars and reduce the potential duplication of services while increasing the availability of services and supports for the child and family.
       • When there are multiple systems involved, it is important for there to be consistency in planning across the various systems to ensure the child and/or family does not hear conflicting messages or has treatment approaches that are counter-indicated. It is the responsibility of all systems to work to mitigate the burden caused by uncoordinated planning between agencies and families.
       • The goal is for there to be one document where the plans of various other child-servicing systems are incorporated into the foster care system case plan. The plan should be reasonable, useful, and respectful

Glossary of Terms

Child - Refers to any child placed in out of home care.

Child Focused - A system is child-focused when both the physical and emotional well-being of the child is central to all levels of decision-making, and a process is in place for resolving conflicts between these two domains. The child's own views expressed, where possible, directly through the child's words and behaviors or, as required, through representation by an adult whose primary role is to offer the child's perspective should be represented along with the viewpoint of members of the child's family (as defined in this document).

Child Safety - A child is considered safe when an analysis of all available information leads to the conclusion that the child in his of her current living arrangement is not in immediate danger of serious harm, and no safety interventions are necessary.

Cultural Competence - A system is considered culturally competent when there is professional and formalized competence throughout the system in: policies, procedures, outreach, and advocacy efforts, and training. Cultural competence, sensitivity and relevance is demonstrated through the array of services, delivery, framework, and the recognition of the importance of existing community-based, informal support networks such as churches, extended kinship networks, and social organizations. Cultural Competence is demonstrated when there are knowledgeable and skilled staff and service providers who are aware of cultural issues within the diversity of the community and who reflect and understand the diversity of that community.

Family - Families can include biological, foster and adoptive parents, grandparents and their partners, as well as kinship care givers and other who have primary responsibility for providing love, guidance, food, shelter, clothing, supervision, and protection for children and adolescents. It is the extent of daily interaction and responsibility for a child, not a legal construct that identifies an individual as a family member.

Family-Driven - A system is family-driven when the family (kin and extended) is involved in all levels of decision making. Identification, outreach and engagement of the family receiving services in the foster care system is required so that family experiences and perspectives collectively drive the planning, work and outcome for the foster child.

Prevention and Early Prevention - Is inclusive of the following three components:

Primary Prevention: Efforts to avert mental health and substance use problems altogether. For children these efforts include interventions directed at parents and educators and/or other professionals involved with children.
Secondary Prevention: Efforts to detect mental health and/or substance use problems in their early stages of development and to apply techniques to reduce the severity and duration of incipient problems.
Tertiary Prevention: Attempts to arrest further deterioration in individuals who already suffer from severe mental health and/or substance use problems (disorders). Treatment can be considered tertiary prevention.¹

System of Care - A system consisting of mental health, substance use, social services, education, medical, physical health, primary care, juvenile justice, and other professional organizations and other formal and informal services/support that work together with the family to meet the child's needs.

Substance Use - Refers to the use of alcohol, illicit drugs and the misuse of prescription drugs.

¹ Basis of definition derived from: "Children's Mental Health: Problems and Services." The Congress of the United States, Office of Technology. Washington D.C., 1986. Pg. 151-152.