For a long time, children and youth in Alaska with severe emotional disturbances (SED) and challenging behaviors had few in-state options for treatment. They were most often sent to a residential psychiatric treatment facility (RPTC) outside of Alaska. A child experiencing a severe emotional disturbance (SED) has been diagnosed with a mental, emotional, or behavioral disorder that results in significant functional limitations in daily life. (See Alaska Administrative Code 7AAC 70.990(10) for a complete definition.)
The situation improved dramatically with the advent of the Alaska Youth Initiative (AYI) in the 1980s and the creation of more community-based services in the state. But by the late 1990s, the number of children sent out of state for treatment was on the rise again due to a variety of circumstances. The Bring the Kids Home Initiative (BTKH) was launched in 2004 to address these circumstances and to develop a more cohesive system of in-state services. Services improved under BTKH leadership and the number of children sent out of state for treatment declined dramatically. However, late in 2010, the numbers stopped decreasing and began fluctuating. This article looks briefly at the history of the Bring the Kids Home Initiative and describes the program's response to the increase in out-of-state residential psychiatric treatment center placements and its current strategies and goals to address remaining challenges.
The Alaska Youth Initiative (AYI) was instituted in the 1980s and became a trailblazer among states in the U.S. striving to keep severely emotionally disturbed children and youth in their family homes. This was done by creating a network of community-based services and strategies. AYI was successful for a number of years, but then encountered several difficulties. For example, one challenge came with increased Medicaid funding. In 1999 Medicaid funds, with attendant funding restrictions, became a larger part of the pool of money available to pay for care. With this increase in Medicaid funding, parents of children who had severe emotional disturbances but who previously had not been able to access care, began to seek assistance from behavioral health service providers. However, providers found that in-state treatment strategies that had been allowed under grant funding were more difficult to implement with Medicaid funds. The number of children being sent out of state for treatment started to climb once more. (In 2002, the Alaska Department of Health and Social Services eliminated AYI as a separate program, and AYI funding was added to the pool of grant money for providers serving children and youth with severe emotional disturbances.)
From about 1998 to 2004, Alaskan children with severe emotional or mental disorders requiring intensive and comprehensive services were once again increasingly sent to residential psychiatric treatment centers outside the state. Some in-state residential psychiatric treatment center beds were available, but many youth with more difficult behavior issues were sent for out-of-state treatment. Most of these children and youth were in the custody of their families-rather than in the custody of the Department of Health and Social Services (DHSS), Office of Children's Services (OCS), or Department of Juvenile Justice (DJJ). Children had to leave their family and community, and parents and relatives were rarely able to visit them. Many parents asked why the resources their children needed were not available in the state.
In 2003, DHSS examined the high number of Alaskan children being placed in out-of-state psychiatric residential treatment centers and recognized this was a significant problem. Program officials recall that at any one point in time, an average of 450-500 children were in out-of-state placement. During fiscal year (FY) 2003, 637 Alaska children were in out-of-state residential psychiatric treatment centers. Because of the way treatment options and payment were structured at that time, children were being sent out of state and after 30 days became eligible for Medicaid. Medicaid then retroactively paid for the first month of care. Most of these children were in the custody of their families, and DHSS was not involved until the Medicaid billings were received for the youth. Medicaid costs for out-of-state treatment were soaring. The Medicaid funds were paying for treatment outside of Alaska, and were not being used to develop treatment options in-state, and infrastructure in Alaska for families was not being built. The high out-of-state placement numbers garnered the attention of policy makers and funders and there was a movement to explore how to better provide treatment in-state and keep children in Alaska and in their own homes and communities. The goal was to evaluate each case and ensure that only children who needed out-of-state treatment that was not available in Alaska were sent to out-of-state facilities.
Bring the Kids Home
The Bring the Kids Home Initiative was established in 2004 by the Alaska Department of Health and Social Services and the Alaska Mental Health Trust Authority (The Trust) to address this problem and to provide resources for in-state treatment of severely emotionally disturbed youth. DHSS and The Trust worked with parents and state and local providers to find and develop resources in Alaska to meet children's mental health treatment needs. The focus of BTKH was and is on "Alaskan children with, or at risk for, severe emotional disorders." Children with such disorders are Trust beneficiaries and it is part of The Trust's mission to provide resources to assist their beneficiaries. Alaska Mental Health Trust beneficiaries are described on The Trust website and include "the following broad groups of individuals: People with mental illness, People with developmental disabilities, People with chronic alcoholism and other substance related disorders, People with Alzheimer's disease and related dementia."
Starting in 2005, as part of the Bring the Kids Home Initiative, The Trust was able to provide funding to increase the treatment capacity in Alaska. In addition, State General Funds and funds to match Medicaid dollars were also used to support BTKH efforts to develop needed services. Other key continuing partners in these efforts are state planning boards, family and youth advocates, providers, tribal entities, Native health service providers, the Alaska Department of Education, school districts, and social service agencies. Collaborative planning has been critical to BTKH progress.
BTKH's goal was to develop and use community-based services so that children could remain in their homes, or as close to their own homes as possible. Some children might still require the level of care of a residential facility, but the objective was to help them get the care they needed in Alaska. The program was a success and the number of residential placements both in and out-of-state dropped from 965 in FY 2004 to 605 in FY 2010. These numbers include both children and youth in custody of the state (Office of Children's Services or Division of Juvenile Justice) and in custody of their parents. But a later review of figures for 2010 showed that the total number of children served in residential psychiatric treatment centers increased from 605 youth in FY 2010 to 623 youth in FY 2011. (See Figure 1.) The number of children and youth admitted to out-of-state residential psychiatric centers also increased-from 90 in FY 2010 to 96 in FY 2011 (See Figure 2.) Bring the Kids Home stakeholders have been reviewing data about the youth being sent out of state to better understand what is driving this increase, and to refocus projects and efforts.
How many children in Alaska are in need of treatment for severe emotional disturbances? The 2006 Behavioral Health Prevalence Estimates in Alaska: Serious Behavioral Health Disorders by Household study estimated that from a total state population of 647,894 persons, 51,430 individuals-7.9% of the population-had a serious behavioral health disorder. From the total youth population of 177,558 (ages 0-17), an estimated 12,725 youths had a serious emotional disturbance-7.2% of the entire state youth population.
To develop strategies for this new initiative in 2004, Bring the Kids Home examined data about the numbers of children in the custody of the state and those still with their families. BTKH also looked at the range of needs of these individuals, the treatment options currently available and projected needs, resources and treatment providers, and sources of funding. Transferring children to out-of-state facilities also means transferring funds that pay for treatment. Keeping children in-state for appropriate treatment means that Medicaid funds or other sources of payment stay in Alaska.
Bring the Kids Home tracks out-of-state and in-state care admissions, total number of clients served, and expenditure data. A point-in-time count of children sent out of state is done weekly, which allows DHSS to track trends during the current fiscal year. As of July 2012, the point-in-time count of youth in out-of-state residential psychiatric treatment centers was 117: 80 non-custody and 37 custody youth. (See Figure 3.) Although the number of children sent for care outside of Alaska has dropped significantly from 2003 and earlier, there are still challenges in ensuring that all children can receive appropriate treatment and services in Alaska. A recent strategy BTKH has identified is to decrease the number of children needing care by establishing early childhood programs and comprehensive planning. The goal is to intervene when children are young and to intervene earlier to assist children with special needs. To achieve this, more trained professionals are needed to 1) mentor and assist parents, 2) identify and train foster parents, and 3) provide services to the children themselves.
The FY11 DHSS [Alaska Division of Health and Social Services] Budget Overview noted the "service gaps for young children with behavioral health problems and their families: few clinicians are qualified to work with young children and early learning settings often expel children with behavioral challenges." The Overview also referenced the Centers for Disease Control and Prevention "Adverse Childhood Experiences Study" (ACES) which has shown that traumatic events in early life can result in increased risk behaviors for individuals and a greater likelihood of experiencing mental illness and other disease. Bring the Kids Home is supporting several projects to provide early intervention services for children and families, and partners with people and programs already doing this type of work. One partner is the Alaska Office of Children's Services and the "Early Childhood Comprehensive Systems Project" which strives to provide children (prenatal to eight years of age) a "culturally responsive, comprehensive and accessible service delivery system that links service providers, empowers families, and engages communities." Early intervention and workforce development are strategies that Bring the Kids Home will be supporting over the next few years.
Tracking the Numbers
As noted above, between FY 2010 and FY 2011, DHSS noticed that the numbers of out-of-state admissions to residential psychiatric treatment centers began to increase. Which children did these numbers represent? Data analysis found that many of the severely emotionally disturbed children in out-of-state placement had what is termed a developmental or intellectual disorder, as well as a severe emotional disorder/behavioral disorder. (See Figure 4.) This distinction affects availability of funding and treatment options as these youth require a greater intensity of treatment and individualized treatment strategies. (See Tables 1 and 2.)
In order to obtain appropriate assistance for these children, behavioral health workers must navigate a complex system that makes clear distinctions between certain types of diagnoses and which diagnoses qualify for funding and services. A child may be diagnosed with an emotional/behavioral disorder and/or a developmental disability-such as autism, mental retardation, or Down's Syndrome. In the developmental disability system, children do not have the option of receiving services in a group home setting. This can result in youth with complex needs moving into the behavioral health treatment system where residential services are available, including treatment in a residential psychiatric treatment center. However, many residential providers in Alaska exclude children with intellectual disorders from treatment, and these youth may be sent outside of Alaska for treatment.
A developmental disability according to Alaska Statue 47.80.090(7) is a "severe, chronic disability that is attributable to a mental or physical impairment or combination of mental and physical impairments; is manifested before the individual attained age 22; [and] is likely to continue indefinitely." Some children have Fetal Alcohol Spectrum Disorder (FASD) or another developmental disorder that affects daily functioning and this may qualify them for a "developmental disorder waiver" which allows them access to funding for services. However, this does not include services in a group home or residential setting. In this scenario, a child who also has a severe emotional/behavioral disorder may be placed in a residential facility outside Alaska. Often this is necessary because long-term services in Alaska, especially in a village, may not be available. Depending on the disorder, the child may not experience significant improvement in his/her condition or may show improvement while in the treatment setting, but have a difficult time maintaining improvement when in a community setting. In mental health rehabilitation, there is the expectation of improvement over time. For developmental disorders, the approach is habilitation in a community-that is, the problem will be life-long, the individual will not improve significantly, and will likely need long-term on-going services. Bring the Kids Home is seeking to develop integrated and coordinated services for individuals who have both habilitative and rehabilitative needs. The challenges in developing appropriate in-state services are ongoing.
Children in Rural Alaska
Alaska Native children are overrepresented among the group of children needing treatment services. Since 2009, DHSS and Bring the Kids Home have been working on a Tribal- Rural Logic Model with Tribal Behavioral Health Directors. When a tribal provider delivers the services for a child who is a Medicaid tribal beneficiary, the costs are fully covered by the federal government, rather than being split 50/50 between the state and federal government. The goal is to expand use of Medicaid funding to increase services by tribal providers. This will assist in making more culturally-competent services available to Native children. Under Medicaid, the tribal provider is responsible for supervision of services and administrative matters, and can actively track services that its members are receiving.
In Alaska, parents do not have to give up custody of their child in order to access Medicaid funded services, but there are still barriers to treatment. Community mental health resources are limited, especially in rural areas. Often private insurance will not pay for outpatient services. If rehabilitative services are required, Medicaid may cover this, but private insurance covers little.
Types of Services Needed
All of the children needing assistance are severely emotionally disturbed. Some have a co-occurring diagnosis of Fetal Alcohol Spectrum Disorder (FASD) or another developmental disorder, or have been identified with sexual behavior problems. Therapeutic foster care may be required, but access to foster homes is limited. Bring the Kids Home has resulted in new funding for services such as Individual Services Agreements (ISAs) that are not covered by other sources. ISAs are developed for a child and outline what services are best for that individual and family to keep the child in a community-based setting. A spectrum of care needs to be developed that includes community, regional, in-state, and out-of-state treatment. Some of these services may fall outside the care parameters of Medicaid and family income. For example, a child diagnosed as having a severe emotional disturbance may love piano lessons, and piano lessons help the child's condition remain more stable. Piano lessons are not covered by Medicaid, and in most cases the family cannot afford the lessons. In such a case, an Individual Services Agreement can pay for the costs of the lessons to help maintain the child successfully in a community setting.
Services for Families
As Bring the Kids Home and the Division of Behavioral Health saw the numbers of out-of-state placements for children rise in late 2010, they began to increase emphasis on developing services for families, not just the individual child, and to look at the family system. (See Tables 3 and 4.) They found high levels of trauma in families, family disruption due to parental mental illness, substance abuse, and other factors. Few in-home services and services such as therapy for the entire family were being delivered. In FY 2012-2014, family services will be a major focus of Bring the Kids Home. Two projects are moving forward. One is a pilot program, "Parenting with Love and Limits" (PLL), currently operating in six locations in the state. The program concentrates on parents and youth ages 10 to18 who have severe emotional or behavioral problems and combines parenting education and family therapy. The other is an in-state model of technical assistance being developed by DHSS. The goal of the model is to improve and expand family therapy services statewide.
The Family Voice Program was instituted to give family and youth more involvement in actual planning, system development, and services. Family Voice assists youth and their family in learning ways to participate in planning and in overseeing the delivery of their needed services. A peer navigation system has also been created to provide non-clinical support, parenting skills development, and help with maneuvering through the treatment system. Parents who have been through the system assist parents who are new to the process.
The Division of Behavioral Health also implemented a model last year for children that is based on a multi-pronged model for assisting adults with a developmental disability. The model uses individualized consultations and adapts an individual's living space as needed. The Division will be adding more services to this model for children. This type of complex behaviors collaboration could help children stay in their family home.
Another population that Bring the Kids Home serves is transition-aged youth and young adults ranging from 14 to 21 years old who have a significant emotional disorder. One tool BTKH service providers use for these youth is the Transition to Independence Process (TIP). TIP is a nationwide program to assist youth and young adults "with emotional and/or behavioral difficultiesâ€¦as they move in and out of our community child and adult serving systems (e.g., schools, foster care, mental health, detention, corrections)." The program is a training model for personnel dealing with youth with significant emotional disorders and includes the goals of actively engaging youth and their families in the process of preparing and planning for the youth's future and working with the community for support.
Who are these transition-aged youth in Alaska? In 2010, the UAA Institute for Social and Economic Research (ISER) released a report in collaboration with Covenant House Alaska titled, Youth in Crisis: Characteristics of Homeless Youth Served by Covenant House Alaska. Covenant House Alaska (CHA), based in Anchorage, is a crisis center and service provider for homeless, run-away, and at-risk youth. Since 1999 Covenant House Alaska has assisted close to 400 youth each year. Researchers found that "[in] 2009, 80% of youth at Covenant House were identified as Trust beneficiaries, which means they have one or more of: mental illness, substance abuse, developmental disability or traumatic brain injury." From 1999 to 2008, an increasing number of youth being served by the Covenant House Crisis Center were from rural Alaska and from out of state. Many youth originally from rural parts of Alaska had been in residential treatment centers outside of the state and were now returning to Alaska. Transition-aged youth have become a major focus for future BTKH efforts.
Bring the Kids Home has been requesting money each year from the Alaska Legislature and has also been receiving funds from The Trust. The budget in the state general fund for FY13 is about $13 million. The staff for Bring the Kids Home includes a full-time coordinator who is the liaison between the Department of Health and Social Services, The Trust, and stakeholders. BTKH's budget has been helped by the decrease seen in Medicaid costs. Medicaid expenditures for out-of-state residential psychiatric treatment center placements have gone from $40 million in FY06 to $12.5 million in FY11. This Medicaid saving has been reinvested in building treatment capacity in-state and improving in-state delivery of services. For FY2014, Bring the Kids Home is asking for new funding to focus on early childhood needs, family therapy provision, and transition-aged youth. Early intervention appears to be key to improving outcomes for children with emotional disturbances. Bring the Kids Home has found that many of the families of children and youth receiving treatment services have high levels of trauma, sometimes multi-generational. Early intervention and family therapy, as noted earlier, are critical to helping both the children and their families. These types of early intervention and prevention services can help decrease the need for residential psychiatric treatment care and other residential treatment services-either in-state or out-of-state.
Strategies for Change
Bring the Kids Home has identified seven strategies for change to enhance its overall work. These strategies are outlined on their website:
- Theory of change. Articulate and communicate a formal theory of change and continue ongoing communication.
- Strong family voice. Develop a strong family and youth voice in policy development, advocacy, family education and support, and quality control/assurance and evaluation.
- Examine financing and policy issues.
- Performance and QA [quality assessment] Measures. Ensure that strong performance measurement/continuous quality improvement procedures are in place.
- Home and Community-Based Services (DBH SED Youth [Division of Behavioral Health Severely Emotionally Disturbed]). Develop a wide range of accessible home and community-based services that reduce the need for kids to enter residential care and ease transition back into the community for those in out of home care.
- Workforce Development. Build the capacity and core competencies of in-state providers to provide services that meet the needs of kids with severe behavioral health disorders.
- Assessment and Care Coordination. Develop "gate keeping" policies and practices and implement regional networks to divert kids from psychiatric residential care.
Implementation of these strategies is in various stages. One example is in the area of workforce development where progress is already being made. Increasing the number of Alaska-based behavioral health workers is critical to meeting the goals of Bring the Kids Home. Formal education opportunities, such as partnering with the University of Alaska Anchorage (UAA) through the Colleges of Health, Arts and Sciences, and Education, are a significant part of BTKH's plan.
Bring the Kids Home and The Trust are supporting work at UAA to prepare professionals in an interdisciplinary manner to meet the complex needs of children and families in-state. Bring the Kids Home through The Trust has provided grant money to UAA for the development of a Graduate Certificate in Children's Mental Health. The certificate program has been approved by the UAA Board of Regents and welcomed its first cohort of five students in 2011. The program takes a minimum of 2 years to complete. A candidate for the certificate must be currently enrolled in a Master's program or already have completed a Master's degree in social work, psychology, counseling, special education, or a related field. The certificate program is a multi-disciplinary effort of the UAA School of Social Work, College of Health; Department of Special Education, College of Education; and Department of Psychology, College of Arts and Sciences.
Another major workforce development effort is the proposed Partnership Graduate Certificate in Marriage and Family Therapy. The UAA School of Social Work, Department of Special Education, and Department of Psychology are collaborating with Alaska Pacific University Department of Psychology and the University of Alaska Fairbanks Counseling Education Program to expand expertise in the state for counseling couples and families. The proposal is currently pending with The Trust, and the partnership group continues to meet regularly. This will be the first consortium-type of certificate to be granted in Alaska.
Other Alaska groups and agencies have also increased funding to focus on trauma-informed services. In the future, more trained professionals will be available to provide appropriate and trauma-informed services to Alaska children and their families.
What Next for Bring the Kids Home?
Bring the Kids Home has made tremendous progress over the past 8 years. But there are a number of areas that BTKH hopes to address in the future. Although there have been great strides in training, workforce partnerships are just beginning. Also, the separation between residential service systems for children in state custody and for children in parental custody often complicates placement of individuals. DHSS is considering bringing these residential services together within the Division of Behavioral Health which will allow consistency in structure, standards, and expectations. There is also a long-term shortage of approved therapeutic foster homes and trained foster parents. And Bring the Kids Home strives constantly to improve needs assessment to ensure consistent placement and appropriate level of care. A study is currently underway looking at this issue.
Families remain a central concern for Bring the Kids Home and the need for high quality engagement with family members. Perhaps one of the most complex issues is how to work across the variety of systems-providers and agencies-that impact the children Bring the Kids Home serves. The continuum of care required by children served by Bring the Kids Home is often provided by a mix of private, local, state, federal, and tribal entities. Integrating and implementing the policies and requirements of these varied agencies is a formidable task. Bring the Kids Home and its partners remain committed to seeking what is in the best interest of the children and families they serve.
For more information on Bring the Kids Home and the Alaska Mental Health Trust Authority, see "Resources" on page 6.
Barbara Armstrong is the editor of the Alaska Justice Forum.