REPORT by Narell C. Joyner
October 19, 2004
Rosie D. v. Romney
- Overview:
I was retained by the Center for Public Representation to serve as an expert witness in the Rosie D. v. Romney litigation. Specifically, I was asked to review a sample of class members. This class action lawsuit was filed on behalf of children with behavioral health disabilities or serious emotional disturbance who are in need of intensive home-based services, in order for them to remain with their families and in their home communities. The complaint filed in Rosie D. alleges that at least 3,000 children in Massachusetts are not receiving medically necessary services and, as a result, are inappropriately placed in psychiatric facilities or other residential care settings. State officials freely admit that there are at least 100 children in psychiatric facilities or other residential programs due to a lack of in-home and community based services. Other children with acute psychiatric needs are being turned away from these more structured settings because the beds are filled with children who do not need this level of care. Other children with serious emotional disturbance and their families are waiting for a case manager to be assigned to initiate, coordinate and monitor mental health services.
The purpose of the client review was to complete an in-person and record review of a sample of children with serious emotional disturbance who have been placed in psychiatric or residential facilities or had received crisis services while living at home. The focus of the client review process was to examine the history, needs and service needs for the clients, including their need for in-home services.
The following three activities were part of the client review: 1) record review of available treatment records; 2) interviews with each child and family, to the extent available; and 3) interviews with various service providers.
After I was retained to work on this case, I was informed by Marci White and Marty Beyer that they and other of the plaintiffs’ experts had worked together to develop the definition of home-based services that we used in the review. I agree with this description, as it is consistent with my experience and expertise working with child mental health services. I understand that the defendants in the case have insisted on a single definition to describe this treatment; therefore, for the purposes of this review. I used the description for in-home services that the plaintiffs’ experts developed:
Home and community-based services, sometimes referred to as wraparound services, are well established behavioral health intervention for children designed to meet the child’s needs in his/her home and home community. They may be provided in the child’s natural or foster home or in the community where the child lives. The planning and provision of home and community-based services require a specific, individualized process that focuses on the strengths and needs of the child and the importance of the family in supporting the child. Home and community-based services incorporate several discrete clinical interventions, including, at a minimum, comprehensive strength-based assessments, crisis services, case management, clinical teams, and individualized supports including behavioral specialists. These services must be provided in a flexible manner with sufficient duration, intensity, and frequency to address the child’s needs.
This description of home and community-based services incorporates an individualized planning process that focuses on the strengths and needs of the child while including the family as a full partner in supporting the child. This approach focuses on an individualized coordinated and service delivery process and is often referred to as “wraparound” services.
II. Background and Experience:
I have twenty-eight years of experience working with children and adults in the human services field. The past sixteen years has been in the area of mental health. This focus has included looking at the process for strength-based needs assessments, planning and service delivery for children with serious emotional disturbances. During this period, I have participated in several thousand record reviews, interviews with families and children and service planning in a variety of states including North Carolina, Missouri, Florida, Arizona, New York and Chicago. I worked extensively work in the Willie M. lawsuit filed and settled in North Carolina. This work included the identification, assessment and service planning for the children in the class as well as securing the necessary community resources required to address those needs. I also have consulted extensively with other professionals on program development and evaluation. I have also conducted numerous staff training events in wrap around components including strength-based assessments, service planning and systems development.
I retired from my position with the State Department, Division of Mental Health in North Carolina approximately two years ago. I am self-employed and I provide consultation and training to several states or programs including the Arizona Department of Behavioral Health, the Durham Mental Health Center, Alexander Youth Network, and the Mecklenburg Child and Adolescents Mental Health Program regarding the System of Care/Wraparound Practice.
- Structure of the Review:
Marci White and Marty Beyer designed the client review process and Marci White served as the client review coordinator. Their respective roles are described in their expert reports.
IV. Implementing the Process:
I was assigned a sample of 10 children to review and completed an analysis of their history, needs and services including their need for home-based services. I was provided with a variety of available records, including those made available by the Department of Social Services, hospital records, residential records as well as assessments, evaluations, service plans and progress notes. I also interviewed each client,their family, to the extent they were available, and a variety of their assigned service providers to assist in determining my opinion.
SAMPLE SUMMARIES
Ralph B.
Ralph B. is a 14-year-old boy (DOB 4/16/90) whose life has been scarred by abandonment and neglect. He has been in the custody of the Department of Social Services for most of his life. He recently stepped down to a group home - his 21st placement - after spending the last four-and-half years in a residential program, the Riverside School. He sums up his needs with one sentence: “I need a family.” In recent years, therapists and social workers have advocated for Ralph’s placement with a skilled foster family that receives effective community supports. However, the current long-term plan is for Ralph to remain in the group home until he is 21, or is able to live independently. He continues to attend Riverside as a day student.
His current diagnoses are post-traumatic stress disorder, depressive disorder and ADHD. He has been prescribed Wellbutrin, Trileptal and DDAVP. His therapist describes Ralph as being very young emotionally, clingy, hyperactive and demanding. Ralph continues to have incidents of bedwetting and difficulty sleeping at night.
In my opinion, Ralph would benefit from specific home-based services. In addition to existing clinical supports, such as counseling and medication management, he needs a comprehensive assessment that includes an evaluation for reactive attachment disorder. His inability to attach seems to be the root of the behaviors that have jeopardized potential family placements. Case management also would be beneficial in providing oversight and coordination of services and supports as Ralph transitions from his long-term residential placement to the community.
In addition, DSS and Ralph’s current caregivers should link him as soon as possible with a family that is committed to maintaining a long-term relationship with him - a family that will help him develop as an adult, a family that will introduce him to the community and bolster his social skills, a family that will maintain ties with him when he is a man, living independently on his own. At present, Ralph continues to have day visits with a family that since March 2002 has been a visiting resource for him at Riverside. Nothing in the record or information obtained from the agency indicates that this family will ever be anything more than a visiting resource. Ralph needs more.
Ralph was removed from his natural home as an infant because of abuse and neglect, and was subjected to eight different placements until June 1993, when he returned to his mother’s care. Again, due to neglect and abuse, in March 1994 he was removed from his mother’s care, and placed in foster care. All told, between the ages of two month and 6 years, Ralph experienced fifteen substitute care placements. Most of his placements were disrupted due to his frequent and intense crying and night terrors. Early behaviors included enuresis, feces smearing, hyperactivity, and frequent tantrums. Between 1996 and 1999, Ralph was placed in three more settings.
In September 1998, he entered specialized foster care with the goal of adoption. Ralph moved into a specialized foster care home in Brockton on November 1, 1998. His behavior at school and at the home improved, though he was described as being more attached to things than people in the home. On December 12, 1999, Ralph set fire to the foster home. No one was hurt, but the house was destroyed. He was taken to Westwood Lodge and remained there until he was placed at Riverside School on March 22, 2000. While at Riverside School, Ralph completed the fire safety courses and participated in individual therapy and other psycho educational groups. In the on-site school setting, Ralph performed near his appropriate grade level.
Ralph’s step-down plan from Riverside school fluctuated between specialized foster care and group home settings. There was a lot of concern about Ralph's inability to form attachments and trusting relationships. An adoption assessment completed on August 2002 recommended that Ralph step down to specialized foster care. This plan was changed or at least suspended when Ralph lit a match and flushed it down the toilet at the home of his visiting resource in September 2002. Overnight visits with the visiting resource were discontinued until July 2003. In November 2003, four months after overnight visits were reinstated, it was reported that Ralph had inappropriate sexual contact with another resident of Riverside School. Overnight visits with the visiting resource were discontinued again and have not been reinstated. In January 2004, Ralph was reevaluated for specialized foster care, but rejected due to his history. Ralph transitioned from the Riverside School to the Littleton Group Home on June 14, 2004.
Ralph currently resides at Littleton Group Home with fifteen other children. He is in the eighth grade and attends school at the Riverside School. He expects to transition to public schools next year. Ralph is a very handsome young man with beautiful hazel eyes. He is quite active and most reports indicate that he enjoys one on one attention and constantly seeks adult attention. He loves animals, baseball, basketball, hockey and watching television. He plans to go to college and become a scientist. Ralph's number one desire is to have a family.
Ralph has numerous siblings, four of whom have been adopted. Ralph, in conversation with a social worker in August 2002, characterized himself as “an orphan,” and suggested that no one in his family would remember him. The social worker recommended that Ralph have at least limited sibling contact. “In its most concrete form, the benefit would ensue from Ralph seeing and hearing that his siblings are safe and that they are in the care of adults who are committed to them. … It would represent a powerful dose of reality to a child whose fantasies and real-life experiences involve the opposite condition, i.e., disconnectedness and abandonment.”
NEEDS
1. Ralph needs a family that is committed to a long-term relationship with him and will provide a home he can visit as an adult.
2. Ralph needs to establish a relationship with his siblings if possible.
3. Ralph needs a professional assessment by a specialist in reactive attachment disorder. His inability to attach seems to be the root of the concerns about any possible future placement with a family as well as the fire setting history.
4. Should a family setting become a real possibility for Ralph, it would be important that the family reside within reasonable travel proximity both to his current visiting resource and to the Riverside School where he has spent the last four years.
5. Ralph needs to refrain from fire setting and any behavior related to fire setting.
6. Ralph needs to begin to participate in activities (basketball games, hockey games etc.). with public school students to prepare for his transition to the public school system.
SERVICES
1. Continued individual therapy and group therapy.
2. Ongoing fire safety group.
3. A permanent visiting resource.
4. Transition plan developed for his transition to public school.
5. Reactive Attachment Disorder assessment.
6. A family that is committed to maintaining a long-term relationship with Ralph.
7. Case management to coordinate and oversee services and supports as he transitions to community-based programs, including public school.
Janice B.
Janice B. is an eighteen-year-old young woman (DOB 8-26-86) who for nearly 16 months has resided at the acute unit at the University of Massachusetts Adolescent Treatment Program at Westborough State Hospital. She has done well in the program, and is ready for transition, but she has no place to go; her therapist fears she will become one of the so-called “stuck kids” in the mental health system. Janice, who has been in the custody of the Department of Social Services for four years, was admitted to the U-Mass unit at the state hospital on July 7, 2003, following an extended history of hospitalizations, residential treatment and involvement in the youth correctional system. Born to drug-addicted parents, she was the victim of protracted abuse and neglect throughout her childhood. She was exposed to drugs, physical abuse and sexual abuse, and was herself engaged in prostitution by the time she was 14.
She is currently diagnosed with Post-traumatic Stress Disorder, Major Depression, Explosive Disorder (in remission), and Stevens-Johnson Syndrome, a serious systemic disorder with the potential for severe morbidity and even death that typically involves the skin and the mucous membranes.
Janice is in desperate need of case management services to assist her in the transition from the U-Mass unit to a community setting. Once placed, she will need intensive home-based services, including therapy and medication management, and a one-to-one behavioral coach to direct her and guide both in-home program staff and her father as she learns to re-connect with the community and to establish her independence.
Janice was born prematurely. Janice said she was born addicted to cocaine and weighed two pounds and four ounces. Janice is the second oldest of six children born to her mother with different fathers. Both of her parents have a history of addiction to cocaine. Janice’s developmental milestones per report occurred within normal range. She received her first core evaluation in elementary school and received a combination of resource classes and mainstream classes.
Janice was able to give a detailed account of her life. Some of the information that Janice reported was obviously information shared with her by others and some information is from her own recollection of events. Her father, whom she described as a caring parent when he was around, was in and out of her life throughout her childhood. Janice's memories about her mother are colored by abuse: She remembers her mother doing drugs, drinking, leaving the children unattended, and specifically treating Janice worse than her siblings.
As a toddler, Janice lived with her father and a paternal aunt; when she was three years old, her father returned her to her mother. She joined her mother and siblings at the home of the maternal grandmother, who died when Janice was four years old. Janice has fond memories of her grandmother. Following her grandmother’s death, the family moved into a shelter and later into their own home.
When Janice was in the fifth grade, a truck hit her as she was crossing the street. This accident (3/17/96) caused retrograde amnesia with serious head injury, onset of a seizure disorder and two hours of subsequent blindness as reported by Janice. She also reported she had Scarlet Fever that same year. When she was 12, she said her mother’s mistreatment escalated, and she started running away. She lived with friends and returned home occasionally. Between the ages of 12 and 14, she broke a girl’s nose and was placed on probation. By the time Janice turned 14, she was prostituting; she said she stopped when her best friend, also a prostitute, was murdered. In addition, she reported a cousin raped her when she was 12. She said an uncle raped her when she was 14, and she became pregnant but miscarried the fetus at five months.
The Department of Social Services took custody of Janice at 14, and placed her in the New Leaf Program in December of 2000. It was the first of many placements for Janice. Over the next few years, she experienced short-term hospitalizations, residential treatment and placements at programs run by the Department of Youth Services. She exhibited aggressive behaviors that included explosive and severe aggressions, flashbacks and self-mutilation. She reportedly tried to jump out of window, cut herself with glass and strangle herself at Valleyhead in Lenox. In March 2003, she moved from Valleyhead to Carney Hospital, where after three months she was diagnosed with Stevens-Johnson Syndrome.