Use and predictors of out-of-home placements within systems of care.(Report)

This article examines out-of-home placements for youth with mental health problems in community-based systems of care. Longitudinal data come from the national evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program. One third of youth residing at home when they enrolled in the system of care were placed out of home during the 2-year follow-up period. As expected, youth who were placed out of home displayed more problems, fewer strengths, and more risk factors than youth who remained at home. However, results suggested few differences between youth placed in foster care and those placed in more restrictive settings. In addition, there was increased placement instability for Hispanic and older youth. Findings suggest that out-of-home placements remain a common component in systems of care. This suggests the immediate need for additional work on effectiveness of these settings for youth within systems of care.

Keywords: child mental health; community-based mental health; community-based services

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During the past two decades, tremendous effort and resources have been devoted to disseminating and implementing principles of a system of care for serving youth with serious mental health problems (Kutash, Duchnowski, & Friedman, 2005; Lourie, Stroul, & Friedman, 1998; Pumariega & Winters, 2003). The system-of-care principles were developed in response to concerns about existing children's services at the time. Knitzer's (1982) work alerted the field and the nation to the fact that youth with mental health problems were being inadequately treated by either receiving no care or by being served in overly restrictive settings. Additional work at the time pointed to the lack of communication and coordination among various service systems and providers (e.g., mental health, child welfare, juvenile justice, education, primary care medicine; Stroul, 1996) and placing youth in residential settings that were geographically removed from their family and community (e.g., Burchard, Burchard, Sewell, & VanDenBerg, 1993). The resulting approach, based on the Child and Adolescent Service Systems Program (CASSP) principles (Stroul & Friedman, 1986), emphasizes the importance of providing child-centered, family-focused, community-based, and culturally competent care with an emphasis on individualized and least restrictive services. In the decade that followed, resources from a variety of public and private sources came together in an attempt to help communities build systems of care that included both a well-developed continuum of services and increased collaboration and communication between service sectors (Sondheimer & Evans, 1995).

During the late 1980s and 1990s, both the federal government and private foundations provided resources to develop these systems of care throughout the nation (e.g., Bickman et al., 1995; England & Cole, 1992; Saxe, Cross, Lovas, & Gardner, 1995). The largest of these nationwide capacity-building and dissemination projects included grants by the Center for Mental Health Services' (CMHS) Comprehensive Community Mental Health Services for Children and Their Families Program (CMHS, 2001). To date, 126 grants and cooperative agreements have been funded to states and communities across the nation, more than 70,000 youth have been served, and CMHS has funded a national evaluation of these demonstration sites (Brannan, Baughman, Reed, & Katz-Leavy, 2002; Holden & Brannan, 2002; Manteuffel, Stephens, & Santiago, 2002; Stephens et al., 2005; Stroul, Pires, Armstrong, & Zaro, 2002).

At present, the effects of these system-of-care initiatives are somewhat unclear and controversial. There is little doubt that the system-of-care principles have created a paradigmatic shift in children's mental health services that has changed views about appropriate provision of services for children with mental health problems (Burchard & Clarke, 1990; Rog, 1995; Stroul, 1996). Most of the early initiatives focused on changing system-level factors (availability of a full continuum of services, communication and coordination among providers, capacity building). Evaluations of these efforts suggested that focused system-level efforts could achieve desired system-level changes, including increased access to services, more interagency collaboration, and decreased costs (e.g., Burns, Farmer, Angold, Costello, & Behar, 1996; Rosenblatt, 1998). However, results have been less clear for child- and family-level outcomes. While numerous studies have shown positive pre-to-post changes for youth in systems of care (e.g., Burns et al., 1996; Rosenblatt, 1998), comparison-group studies have been less convincing about the benefits of systems of care (e.g., Bickman et al., 1995; Bickman, Lambert, Andrade, Penaloza, 2000; Bickman, Summerfelt, & Noser, 1999; Burns et al., 1996; Clarke, Lee, Prange, & McDonald, 1996).

While outcomes have been promising but equivocal, the philosophy of a system of care has taken root. This is particularly seen in an emphasis on family-centered and individualized services and in a priority for treating youth in the least restrictive appropriate setting (Kutash et al., 2005). Data have shown that systems of care could result in fewer out-of-home placements for youth and that youth who had previously been sent to out-of-home and often out-of-state placements could be successfully maintained in their homes or, at least, in community-based placements (e.g., Burchard et al., 1993; Chamberlain, 1994; Henggeler, Schoenwald, Borduis, Rowland, & Cunningham, 1998).

There has been considerable attention to out-of-home placements in contemporary literature on children's services (e.g., Barber, Delfabbro, & Cooper, 2001; Chamberlain et al., 2006; Farmer, Wagner, Burns, & Richards, 2003; Fisher, Burraston, & Pears, 2006; Holden et al., in press; James, Landsverk, & Slyman, 2004; Knitzer, 1982; Palmer, 1996; Rosenblatt, 1998; Staff & Fein, 1995). However, much of this work has used foster care as its frame of reference and has not explored these concepts within established systems of care. Many system-of-care sites work diligently to avoid out-of-home placements whenever possible, and when placement is necessary, seek the least restrictive appropriate option for such placement. How successful they are at following these principles and the factors associated with placements within these systems is currently not known. The current work uses data from the CMHS demonstration sites to help fill this gap by examining patterns and predictors of out-of-home placements within these systems of care.

Existing literature on children's mental health services and out-of-home placements provides a backdrop for the current work. Youth served by systems of care display a wide range of individual and family risk factors and problems (Walrath & Liao, 2005). There has been considerable concern about rates of out-of-home placements and of placement instability among such youth (e.g., Blankertz, Cnaan, & Freedman, 1993; Chamberlain, 1994; Clarke, Hawkins, Murphy, & Sheeber, 1993; Farmer, Burns, et al., 2003; Teare et al., 1999). In addition, there have been findings from various studies on factors related to out-of-home placement. Behavior problems (particularly externalizing behavior problems) are consistently linked to increased probability of out-of-home placement, restrictiveness of placement, and likelihood of disrupted placement (e.g., Barth et al., 2007; James et al., 2004, 2006; Reid et al., 2000). Less consistent effects have been shown for race, sex, and age. Some studies have suggested increased rates of placement and/or more restrictive settings for minority youth (Bums et al., 2004; Smith, Stormshak, Chamberlain, & Bridges-Whaley, 2001; Walrath & Liao, 2005). Some have found increased rates of placement and instability for older children (James et al., 2004; Walrath & Liao, 2005), whereas others have shown more placement instability for younger …