On a Friday morning in 2013, Lori and Randy went to visit their adopted daughter, Shawna (named has been changed), at her residential treatment center—one of many she’d been in during the last two years. Shawna had experienced extreme neglect in the first years of her life and had inherited mental illness; her diagnostic acronyms had more letters than the alphabet. The treatment center was three and a half hours away from the family’s home, but after Shawna was expelled from other centers, there weren’t better options.
Shawna’s family sought treatment to protect her and those around her. She had been hurting herself and was threatening others. She had been consuming all the energy, patience, happiness, and love of everyone who cared for her. Her parents found it almost impossible to give attention to their other children or other parts of their lives.
Lori and Randy had been foster parents for nearly 30 years, and prided themselves on their ability to provide permanency for kids with really significant challenges. They had attended (and led) many trainings, deeply understood the effects of trauma, knew every innovative and proven parenting skill, had tried many types of therapy, and knew every service available. But they could not find a way to keep Shawna at home while also keeping the family intact.
During this visit with Shawna, the three went to a McDonald’s for lunch. Shawna was so over-medicated, she was lethargic and dizzy and fell and hit her head. Lori and Randy helped her to the car, and then Shawna threw up all over. These furious parents wanted Shawna out of the residential center, but knew she couldn’t come back home without supports to make it work.
The weekend that followed this visit was the worst Lori and Randy had ever experienced, as they worried that Shawna might be at risk of death due to overdose. They had to wait until Monday before calling the Children’s Division to demand that she be moved.
Many parents face similar dilemmas every day. Making the decision to place a child in out-of-home treatment is a gut-wrenching experience for any family, and typically one undertaken only because there are no effective community-based options that would allow them to safely maintain their child at home.
Fortunately, Lori is not just an adoptive parent, but is also founder and chief executive officer of FosterAdopt Connect, an agency that strongly believes that the best place for abused and neglected children who have been removed from their birth families to heal is with caring, skilled, and well-trained kinship, foster, and adoptive parents. Since she knew there was no effective program available to parents like her, Lori created an innovative approach to meeting the needs of highly challenging children at home.
The Need for a New Model
Unmet mental health needs are one of the greatest threats to stability and permanency for children in foster care and adoption. Children who have endured trauma tend to display a range of behaviors. They are often impulsive, hyper-vigilant, hyperactive, withdrawn or depressed, have sleep difficulties, and anxiety. They may show some loss of previous functioning or a slow rate of acquiring new skills.
Research findings on brain development have changed drastically in recent years. The past thinking was that damage due to trauma was permanent and unchanging. We now understand that brains do have the ability to rewire neurons and continue to heal with time and targeted activities. With the right supports, traumatized youth can move from a primal fight, flight, or freeze response to stress to a cognitive, more appropriate response.
But what’s the best way to provide those needed supports for children with serious challenges? Few options exist to support families when behavioral and emotional challenges become too great to handle in the home alone. Out-of-home care is typically the last resort. The cost of residential treatment is second only to inpatient psychiatric hospitals. According to the U.S. Surgeon General, inpatient treatment “was justified on the basis of community protection, child protection, and benefits of residential treatment. However, none of these justifications have stood up to research scrutiny. In particular, youth who display seriously violent and aggressive behavior do not appear to improve in such settings.” (Mental Health: A Report of the Surgeon General, 1999)
A study of children institutionalized for mental health problems in the U.S. found that seven years after discharge, 75 percent were back in institutions—they were in psychiatric centers or jails. (Greenbaum, 1996) Distance from home and lack of meaningful family involvement are frequently regarded as two of the biggest issues with residential treatment. (Jivanjee, 2002)
When compared to the outcomes associated with residential treatment, in-home behavioral modification treatment provides a viable alternative to what is often a relatively ineffective—yet extremely expensive—treatment option.
The Behavioral Interventionist Program Is Launched
Given the need and lack of effective in-home options, FosterAdopt Connect partnered with the Missouri Department of Social Services to implement the Behavioral Interventionist (BI) Program in 2013. The BI Program is an intensive, individualized, home-based approach to therapeutic treatment and support services to address the needs of children with severe emotional and behavioral issues. The program is designed to help children improve their behaviors while providing support and relief to parents, thus decreasing frustration and exhaustion.
Lori designed a program in which the crisis de-escalation, trauma-informed care, and structure that a residential treatment program offers can be replicated at home. Keeping children with their family reduces trauma and supports healing. Moreover, it ensures that the child has the best possible chance for a satisfying and successful adulthood, connected to people who love and care for them.
The program serves children ages 3 to 18 in foster care as well as children in all types of adoptive families and children in their birth families. Children must be regularly and frequently displaying behaviors that cause disruption or crisis in the family, with the behaviors being severe enough to potentially qualify the child for a residential facility, mental health treatment center, or hospital. In general, the program also seeks to determine that other community resources have not been successful or are not available to the family. In 2016, the program served 111 youth in Missouri and Kansas.
A strong partnership with the Missouri Children’s Division and other case management agencies is a cornerstone of the model. For youth in foster care, referrals for the BI Program generally come from case management agencies. Adoptive families typically refer themselves. The program also receives referrals from therapists, foster parents, guardians ad litem, CASAs, and family courts. Program services are funded for youth in care by their Children’s Division county-specific service funds, while adopted youth are funded through their adoption subsidy contracts. Youth who have no other source of funding are served using private grants received for the program.
Key elements of the program include:
- Trained in-home specialists—known as behavioral interventionists or BIs—work with families whose children exhibit significant behaviors that jeopardize the stability of their current placement. These specialists receive training in the program model, non-violent crisis intervention, conscious discipline, first aid, and the effects of trauma on the brain. Staff also receive ongoing monthly trainings and meet regularly to discuss barriers they are having with clients and brainstorm solutions.
- Staff work one-on-one with the child in the family home to intervene during periods of escalation and also to implement trauma-informed, neuro-stimulant activities to assist the brain in the healing process.
- Each child usually has only one assigned BI. In some cases, when more hours are approved, there may be two staff per home. The BIs are generally part-time staff and work with the child after school and on weekends, when the child is not in school.
The Behavioral Interventionists are trained to use neuro-stimulant activities with their clients, including movement, touch, music, anxiety reduction, and repetition. The activities are specifically designed for the child or youth being served, pairing their behavioral treatment goals with neural stimulation. Although options are endless with creativity, activities can include:
- interaction with other youth at a park to engage in peer relationships
- playing matching games
- turning chores into an activity (for example, placing the laundry basket in the middle of the room and “shooting baskets” with the dirty clothes)
- recreational outdoor activities
- learning songs by singing them repetitively
With these consistent and repetitive activities, staff work to heal and strengthen neural pathways that never had a chance to fully develop. The BIs and youth participate in at least three to five neuro-stimulant activities per shift, which supports helping the child to make decisions using the thinking part of their brain rather than their instinctual (fight, flight, or freeze) part. Over time, the interventions enable children and youth to begin to make choices and decisions more rationally.
The BI program also works to educate parents about trauma, brain function, and intervention techniques. One of the mantras program staff try to instill in the parents is QTIP—quit taking it personally. Parents need to know that their children are not trying to punish them with their behaviors; they physically cannot make better choices because of how their brain is wired. This dual approach can significantly reduce the feelings of frustration, hurt, and anger on the part of the parents, enabling them to better meet their child’s needs at the same time as they are able to more realistically adjust their expectations. This is a critical change, given the research that shows unmet expectations on the part of the parents is a key factor in adoption breakdowns.
The BIs also model crisis de-escalation techniques for caregivers and encourage the caregiver to be the de-escalator when possible. The model recognizes that parents are the experts on their children and their families, and that parents, even those with access to evidence-based training and therapy techniques, cannot be psychiatric hospitals or residential treatment centers. They still have to sleep, work, and care for other children in the home. For children to heal, parents must not be so drained emotionally and physically exhausted that they cannot nurture and connect with their children. The approach is very supportive of the family’s role in their child’s life.
Making a Difference
The BI program has greatly reduced entry into residential facilities for its clients. From July 2015 to March 2016, 100 percent of the 57 children served experienced a reduction in psychiatric hospitalizations and stays in residential treatment. During the referral and intake process, staff obtain the records of each client’s past stays in hospital settings and residential treatment centers. Using the information about the amount of time previously spent in congregate care, they can then determine if the program has reduced the use of congregate care. Other program outcomes are evaluated using daily living assessments, residential program needs assessments, and parent and family satisfaction surveys.
Parents and professionals have both expressed their gratitude for the Behavioral Interventionist Program:
- “FosterAdopt Connect’s Behavioral Interventionist Program has helped our son SO much. Also, it has kept him out of residential facilities. We don’t know what we would do without this wonderful program. It’s been a lifesaver!”
—Very grateful parents
- “During my last monthly home visit with Ashley’s* family, Ashley’s aunt [in this kinship placement] stated, ‘Your program saved our marriage. My husband and I were on the verge of a divorce when we started the BI program because of the strain of Ashley’s behaviors on our relationship. I would have been a single mom to my niece, who suffered so much physical abuse and unbearable trauma.’ The couple held hands through almost the entire visit, and then Ashley talked about everything she loves to do with her BI. Every activity she listed happened to be neuro-stimulant activity, reconnecting the brain pathways that were malformed from the trauma she endured and helping her to heal, and she doesn’t even know it! This program is amazing.”
—Ali Schnakenberg, Behavioral Intervention Program case manager
The Missouri Department of Social Services, Children’s Division has also seen what a difference the program makes. Tim Decker, division director, explains: “What makes the Behavioral Interventionist Program effective is that it promotes permanency, safety, and well-being as inter-connected and inter-dependent goals; increases placement stability by moving the resources to the child and family versus moving the child; effectively supports relative/ kinship placements and serves as an effective post-adoption support; reduces the impact of trauma and re-traumatization of the child and family; supports healthy brain development and normalized developmental opportunities for children and adolescents; and builds the capacity/skills of child and family by teaching, modeling, and reinforcing skills in areas such as self-regulation, communication, planning, emotional connection/support, and conflict resolution.”