REPORT by BETH C. WHITAKER
October 19, 2004
Rosie D. v. Romney
I. Overview:
I was retained by the Center for Public Representation to serve as an expert witness in a class action lawsuit filed on behalf of children with serious emotional disturbance who are in need of treatment in order for them to remain with their families and in their home communities. The complaint filed in Rosie D. reports that in Massachusetts at least 3,000 of these children are inappropriately placed in psychiatric facilities or other residential care settings or denied access to needed services. State officials indicate that on a daily basis at least 100 children remain in psychiatric facilities or other residential programs due to a lack of less restrictive in-home and community based services. While these children remain in these restrictive settings, other children with acute psychiatric needs are being turned away because the beds are filled. In the meantime, 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 this review was to complete a record and on-site review for 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. This review process focused on looking at the history, needs and services for the clients, including their need for in-home services.
The expert review focused on three areas:
-Review of available records
-Interviews with each consumer and family, if available
-Interviews with various service providers
When I was asked to be one of the expert reviewers for this case review sample, Marci White, Marty Beyer and several other experts in the case had worked together to develop the description we used in the review for intensive home-based services. I concur with this description, and 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 expression to describe this treatment; therefore, for the purposes of this review 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,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 includes an individualized planning process focusing on the strengths and needs of the child while including the family as a full partner in supporting the child. This process, sometimes referred to as a “wraparound” approach focuses on an individualized coordinated and service delivery process.
II. Background and Experience:
I have twenty-five years of mental health experience with the last eleven years being focused in the arena of child 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 and Arizona. My experience has covered a variety of private and public domains including extensive work in the Willie M. Lawsuit filed and settled in North Carolina. This work included the identification, assessment and service planning for client needs as well as ensuring the appropriate community resources to address those needs. I also have extensive experience in consulting with other professionals on program development and evaluation as well as training staff in a wrap around components including strength based assessments, service planning and systems development.
My current position is with the North Carolina Division of Mental Health where I am working with area programs as they move from being providersbeing providers to managers of service via system reform. I continue to serve on the Child Mental Health planning committee and I serve as the Principal Investigator for the System of Care Grant.
III. Structure of the Review:
The review was designed and structured by Marci White and Marty Beyer, as described in their expert reports.
IV. I Implementing the Process:
I was assigned a sample of 10 children to review with a focus on analyzing the history, needs and services including their need for home-based services. I was provided with a variety of available records by the defendants which included hospitalizations, residential placements, assessments and evaluations, service plans and progress notes. I also interviewed each client, their family if available and a variety of their assigned service providers to assist in determining my opinion.
I visited with the following clients, families and providers as set forth in the schedule attached to this report.
V. Summaries and Opinions on the Individual Children Reviewed
Emil M. (DOB 10/02/91)
Emil is a 12-year-old boy who was born in Puerto Rico and now lives with his mother and two brothers in Chelsea. Emil attends school in a self-contained classroom with an IEP and educational accommodations for his significant language deficit. Despite repeated difficulties in school and several short-term school suspensions, Emil recently did very well in his after school program learning appropriate interaction skills. Emil diagnoses include probable Bipolar Disorder, Learning Disorder and Oppositional Defiant Disorder. He was previously diagnosed as having a seizure disorder but has not had a seizure in the past four years. Emil’s current medications are Ritalin and Risperdal.
Since the age of seven, Emil has experienced multiple hospitalizations. As early as 1998, upon leaving the hospital for home, hospital discharge recommendations included certain home-based services. However, neither the services recommended nor the sporadic aftercare services provided were sufficient to address Emil’s mental health needs.
It is my opinion that Emil needed intensive home-based services in the past to address his mental health needs and to function in home, at school and in the community. It is also my opinion that Emil currently needs intensive home-based services as described below and that the current services he receives are not sufficient to meet his current needs.
Hospitalization and treatment history
At age seven, Emil was hospitalized three times within a two-month period (November 1998, December 1998) due to aggressive behavior in school and difficulties at home. Despite recommendations for family stabilization team services, outpatient treatment and educational support, Emil continued to behave aggressively at home and get into trouble at school resulting in several school suspensions. He was hospitalized again in February 2000 and again most recently in April 2003 due to abusive behavior, suicidal ideation and aggression toward his younger brother. During his last hospitalization Emil's medication was adjusted and it was recommended that he receive individual therapy, family stabilization team services and outpatient psychiatric follow-up.
He began the stabilization team services in May 2003; however, those services ended in July 2003 when Emil left Chelsea for a summer visit with his father in Connecticut. The Family Stabilization Team was not reinstated.
Currently Emil is living at home without services except for individual therapy 1 hour per week and medication monitoring. Emil's mother is actively involved in seeking assistance for Emil and advocating for the services and supports he needs. She is hopeful that during the coming school year Emil will be enrolled in an after school program with age-appropriate peers. Emil therapist’s observed that both Emil and his mother are at times easily overwhelmed. The therapist is concerned that without structure and consistency in the home, school and after school programs, Emil's frustrations will turn to more aggressive behavior toward his peers and other family members.
Emil’s need for home-based services
This young man and his mother need and can benefit from well-structured and consistent delivery of intensive home-based services.
Since 2003 and continuing to the present, Emil has had the following needs:
-Emil needs to learn alternative ways to deal with frustration related to changes in routines and schedules.
-Emil needs to learn how to negotiate difficult interactions with siblings and peers rather than reverting to aggressive behavior.
-Emil needs to learn social skills that will help him to develop safe independent community living while promoting his interests and ability to develop confidence.
-Emil needs consistent structure and behavioral support in both the school and home setting to ensure his successful placement in home and community.
-Emil needs to continue his educational progress so he can accomplish his goal of graduating from high school.
It is my opinion that Emil’s needs intensive home-base services to include the following::
-1 on 1 behavioral support in the school, home and community (2 to 3 x /week and on weekends).
-Ongoing medication management and consultation.
-Continue to utilize individual therapy
-An integrated team approach with strong case management coordination among the family, 1 on 1 behavioral support person, the individual therapist, the educational staff and psychiatrist with strong clinical oversight.
Forrest W. (DOB 01/13/89)
Forrest is a 15-year-old boy in DSS custody, currently in residential placement at Lakeside School in Peabody. Since 1997 when he was removed from his family and placed at the New England Home for Little Wanderers, Forrest has spent over seven years in residential placement. He has been institutionalized for nearly half of his young life. Forrest has a long list of psychiatric diagnoses including Post Traumatic Stress Disorder, Oppositional Defiant Disorder, Obsessive Compulsive Disorder, ADHD, Depression and Learning Disorder. His medications for these conditions include Wellbutrin, Concerta, Clonidine, Adderall and Zoloft.
Forrest had a number of significant losses in early childhood. His biological father died of AIDS and stepfather died from drug overdose. Until age 8, when he was removed from home to residential placement, Forrest lived in East Boston with his mother, sister and mother’s boyfriend. Forrest’s record in all residential placements is one of little to no progress. At age 15 he lacks basic self-help and survival skills. He is careless about his poor hygiene and continues to engage in destructive and aggressive behavior.
Forrest is a boy who is able to make connections and strike up friendships within his residential programs. He enjoys age-appropriate activities such as Pokemon and video games. He is able to talk some about adult life goals for himself such as working as a manager for Dunkin' Donuts. Unfortunately Forrest's various residential placements have not prepared him for any transition back to family or community life. Although his family remains involved, the distance from East Boston and transportation difficulties hamper participation and family contact with Forrest. Based upon my review of the limited records available and interviews with Forrest and his therapist Carrie Kelly at Lakeside School, it is clear the Forrest’s needs for transition from residential placement have not been addressed and there is no viable plan of any type of his return to a family and community. It is my opinion that Forrest needs home-based services that has not been addressed during his multiple residential placements. A transition plan that includes the services described below should be developed to meet Forrest’s mental health needs and enable him to transition to the community.
Placement and treatment history
Forrest at an early age presented behaviors that were very difficult for his mother to manage. He was verbally and physically aggressive toward others and threatened harm to himself, expressing suicidal ideation. Before his ninth birthday he was hospitalized on at least two occasions. In December 1996, DSS became involved with the family when reports of abuse and neglect of Forrest and a sister were substantiated. Forrest’s mother was unable to care for him and in September 2000 DSS assumed permanent custody of Forrest.
In June 1997 Forrest was removed from his home and placed at the New England Home for Little Wanderers. Over the year in this residential placement he made no progress. In November 1998 he was transferred to Dr. Frank Perkins School in Lancaster. Again, he spent a year making no progress. In October 2001 he was transferred to Lakeside residential program where he currently remains. Throughout the years in residential placement, Forrest’s behaviors have fluctuated somewhat but are most often characterized by his verbal and physical aggression, suicidal ideation and risk-taking behaviors such is running away. His poor personal hygiene is a continuing problem as are his episodic aggressive and destructive incidents.
Transition from residential care
Now with over seven years in residential placement that has been ineffective in terms of any positive treatment outcomes, Forrest is approaching adulthood. Apart from an aborted attempt to find a community group home placement in August of 2003, there has been no planning or activity related to Forrest’s transition from residential care and return to the community. Forrest does not have home visits now and has not been on a home visit for a long time. There has been minimal therapeutic work done with the family in East Boston. Very little has been done to equip Forrest with the basic survival and social skills he will need to interact in a family setting and with teen age peers in the community. There is no viable plan of any type for his return to community life. Forrest appears to be stuck in residential placement. Without a transition plan that includes home-based services, it is likely that he will remain in residential care until he eventually and inevitably ages out of DSS.
Forrest's needs for a transition plan for home-based services
It is my opinion that since 1997 and continuing to the present Forrest' needs include the following:
-Forrest needs to work on interpersonal skills including improvement of hygiene and keeping his room and personal belongings clean and tidy.