War and Peace: Training Fellows to Navigate Systems Pertaining to Child Protection

1. War and Peace: Training Fellows to Navigate Systems Pertaining to Child Protection May 12, 2017 AADCAP Charles H. Zeanah, M.D. Tulane University School of Medicine

2. Disclosures • Grant support • NIMH • SAMHSA • Lumos Foundation • Palix Foundation • Irving Harris Foundation • Royalties • Guilford Press • Harvard University Press

3. Background • 1994-2013 Infant Team • Young children in foster care (less than 60 months) • Jefferson Parish (population ~500,000) • ~50 children annually • Comprehensive assessments and treatment • 3 juvenile court judges • Located in Human Services Authority (mental health, substance abuse, developmental disabilities • Fellows involvement varied • none to elective to required

4. Administrative/Funding context • Core funding from state office of Child Protective Services (Federal money to states) • Contracted to Tulane Child Psychiatry • Supplemental Funding • SAMHSA (Early Trauma Treatment Network) • Irving Harris Foundation

5. Special Features • Comprehensive, multimodal services • Integrated treatment plans • Relational, infant mental health perspective • Naturalistic and clinic settings and structured and unstructured assessments • High intensity, low volume case load • Located in community mental health center • Systems focus • University/Public sector partnership

6. Goals of Intervention • Reduce the length of time in care • Reduce maltreatment recidivism rates • Improve psychological/developmental care to infants and toddlers • Improve the quality of information provided to courts regarding children, biological parents and relatives and foster parents. • Assist foster parents in management of young maltreated children. • Reduce longterm deleterious effects of maltreatment

7. Re-invention • 2013-present Family Resource Center • All children involved with CPS • foster care • family services • adoption • Orleans, Jefferson, St,. Bernard, Plaquemines Parishes, plus referrals from others (population ~1,000,000) • 350-400 children annually • Comprehensive assessments and treatment • 4 juvenile court judges, plus 6 other judges • Located at medical school

8. Personnel • Faculty (all part-time) • One psychiatrist • One social worker • 7 Psychologists • Staff (all full-time) • 2 social workers • 4 parent educators

9. Trainee involvement • 1st Year Categorical Fellows (2) • Year long rotation one day a week • 3rd Year Triple Board Residents (2) • ½ day rotation for 6 months • 2nd Year General Psychiatry Residents (8) • 2-3 month rotation one day a week • Psychology Post Doc • ½ to full-time all year • Psychology Interns • ½ time all year

10. Fellows schedule • 8:00 -- 11:45 assessments • 11:45 – 12:30 tape review • 12:30-1:00 lunch • 1:00-3:00 case conferences • 3:00 – 6:00 treatment

11. Student involvement • Medical students (10) • One month elective, one day a week • Graduate students in psychology • Tulane (0-1) • University of New Orleans (0-1) • Social work Interns • Tulane (0-1) • Southern University of New Orleans (0-1) • Undergraduate service learning students • Tulane (12)

12. Legal and CPS Systems Impacting Children Judge Protective Services Attorney Supervisor Caseworker Biological Parents Mother Father Others? Foster Parents Mother Father Children’s Attorney Parents’ Attorney(s) Child(ren) CASA

13. Goals of Systems Intervention • Change how the systems understand and deals with young children • developmental differences • time frame differences • importance of caregiving relationships • attachment • disruptions • Enhance access to services • Improve integration and coherence of services

14. Parenting Interventions • Nurturing Parenting Program • Effective Black Parenting • Circle of Security • Triple P • Trust Based Relational Intervention • [Video Intervention to Promote Positive Parenting]

15. Parent Child Therapies • Visit Coaching • Dyadic Psychotherapy • Circle of Security • Child-Parent Psychotherapy • Attachment and Biobehavioral Catch-Up • Parent Child Interaction Therapy • Individual Psychotherapy (e.g., TF-CBT) • Couples/Family Psychotherapy

16. Biological ParentTreatments • Substance Abuse Counseling • Substance Abuse Residential Placement • Psychopharmacology • Psychotherapy

17. Legal Silo Clinical Silo CPS Silo

18. Please read

19. System Challenges CPS • Underfunded • Unsupported work force • Lack of developmental focus • Policy favored over thinking • Lack of child focus Legal • Variability in decision making in different sites • Children’s attorneys • Ex parte communication • Clinical perspective vs. rights perspective

20. Cara • 12-year-old girl • Referred by CPS (depression) • Foster care 6 months • Reason for coming into care

21. Cara • Family • Dominican Republic • Mother • 26-year-old sister • Stepfather (out of country) • Foster Mother

22. Initial Events • Initial visit • FM and Elida • Follow-up visit • Elida • Emergency room x 2 • Hospitalization • Meetings with family • Preparing Elida for school • Talking about abuse • Phone taken away

23. Differing Views Cara Foster Mom Family CPS

24. Navigating countertransference Charybdis Scylla

25. Pre-meeting and meeting • Meeting with • worker, supervisor, manager, attorney and regional director. • Fellow, parent educator, faculty psychiatrist. • Questions: • Does mom accept responsibility?   • Understands that she cannot blame the agency for her family not being together? • Her understanding her role as the agency is trying to work towards reunification? • Understands how to help her daughter through this tragedy instead of playing mind games with her.

26. Post meeting • Psychiatric treatment • Family therapy • Mom IPV treatment • Transitioned home • Cara TF-CBT • School call

27. Systems Issues • Persistence • Probing the CPS hierarchy and accessing level necessary for clear thinking. • Knowing the appropriate level • The food chain • Relationships • Transparent communication and getting facts clarified. • Many heads are better -- managing countertransference. • Determination balancing humility • Accepting limits

28. Thanks!