Mental Health Services for Children

Mental Health does not provide the “minimum array of services” specified above. Response (Mental Health): Agree. Even though the Department has been aggressive in expanding services to outlying areas, it will never achieve the “minimum array of services” in all geographic locations of the County. Response (Board of Supervisors): The Board agrees in part with this finding. The law refers to providing the “minimum array of services” to the extent resources are available. The Mental Health Department has done a commendable job of expanding services to the outlying communities by making the best use of financial resources and inter-agency partnerships. a. Precrisis and crisis services are inadequate. 1) Parents and school counselors reported that children did not receive needed services when they were in crisis. Response (Mental Health): Disagree in part. There may be isolated instances of children not receiving crisis services, but many children do receive timely intervention. Response (Board of Supervisors): The Grand Jury did not provide enough information to agree or disagree with this finding. 2000-2001 Mendocino County Grand Jury Final Report 3 2) Mental Health Clinic Services Associate crisis workers screen children in crisis. The Clinic Services Associate position has no requirement for licensure or training in children’s services. Response (Mental Health): Agree. Response (Board of Supervisors): The Board agrees with this finding. The Board approved five new positions for Crisis Services, including one designated for a Children’s Services specialist. b. Even though Mental Health states assessments are being done, thorough assessments of children are not completed before treatment plans are developed. Response (Mental Health): Disagree. The standard practice is that three sessions are spent in assessment and by the fourth session the Managed Care Plan requires a treatment plan be in place. Staff is regularly instructed in this procedure. Response (Board of Supervisors): The Board disagrees with this finding, based on the explanation offered by the Mental health Department. c. Clients and parents testified that Mental Health provides no medication education. Mental Health states that this education is provided “in pamphlets handed out and available in the reception area, and through dialogues with psychiatrists and clinicians.” Some medication management is provided via telemedicine. Response (Mental Health): Disagree. Pamphlets and written materials are provided in the lobby and by staff. Education on the uses and effects of medications are routine parts of sessions with medical staff. Clinical staff appropriately refers such questions to medical practitioners. Excellent medication management with pediatric psychiatrists is provided via telemedicine. Response (Board of Supervisors): The Board disagrees with this finding. While the Grand Jury may have received such a comment, mental health staff work closely with medical practitioners regarding medication. Further, the Board commends the Department for implementation of its telemedicine program as a creative solution for rural areas without child psychiatrists. d. Mental Health provides case management for only the few children served through the System of Care (See System of Care, next page) Response (Mental Health): Disagree. Mental Health also provides case management for children with IEPs on school sites who have not necessarily 2000-2001 Mendocino County Grand Jury Final Report 4 been reviewed by IACMT. IACMT has reviewed a total of 206 children (unduplicated count) since its beginning in the Fall of 1998. There are currently 130 active CSOC files. Response (Board of Supervisors): The Board disagrees with this finding. The Board agrees with the Mental Health Department response. The Grand Jury appears to have out-of-date information. e. There are no twenty-four-hour treatment facilities for children in the County. Mental Health states, “We provide transport to these out of county services.” Response (Mental Health): Agree; there are no 24-hour facilities in the County to utilize. The Department provides transport to these facilities and pays for children to receive these services. Response (Board of Supervisors): The Board agrees with the Grand Jury and Mental Health Department. f. Mental Health provides rehabilitation and support services to a few clients. Mental Health states that these services “are provided by out- patient counseling, day treatment programs, CSOC programs such as the Family Strengths ‘Wraparound’ Program, Therapeutic Behavioral Services, and school based counseling services.” Response (Mental Health): Disagree. The unduplicated count of children seen as reported by the DMH has increased from 346 in 1998/99 to 383 in 1999/00 and 650 in 2000/01. The Children’s unit has provided a corresponding increase in the number of direct service and/or case management hours as follows: 1998/99 - 19,007 hrs. 1999/00 - 27,582 hrs and 2000/01 - 38,270 hrs. Response (Board of Supervisors): The Board disagrees with this finding. It is unclear what the Grand Jury means by “a few clients.” As is evident by the Mental health Department’s response, the number of children served has been increasing steadily since the inception of CSOC.

Mental Health does not have a staff child psychiatrist, even though the Compendium states that psychiatric services are provided. The County has no child psychiatrist present for diagnostic services for children. Response (Mental Health): Agree. There is a statewide shortage of Child Psychiatrists. 2000-2001 Mendocino County Grand Jury Final Report 5 Response (Board of Supervisors): The Board agrees with the Grand Jury and Mental Health Department. a. Child psychiatrists in Riverside, California prescribe medications for children in Mendocino County through telemedicine hookups, without in- person contact. Response (Mental Health): Agree. This program is seen as “cutting edge” elsewhere in the state, and is being widely replicated. Families and children have reported high levels of satisfaction with this program. (One study has shown a higher percentage of patients prefer telepsychiatry to meeting with an in-person psychiatrist.) It is accepted practice, and fully recognized as such by Medi-Cal and other third-party payors. Response (Board of Supervisors): The Board agrees with this finding. The Board commends the Department for implementation of its telemedicine program as a creative solution for rural areas without child psychiatrists. Mental Health does not employ a child psychiatrist to provide therapeutic services, including family interventions or behavior plans. Response (Mental Health): Agree. Even if Mendocino County did employ Child Psychiatrist, medical doctors would not typically provide these services Response (Board of Supervisors): The Board agrees with the Grand Jury and Mental Health Department response. b. Current and former Mental Health staff testified that there is a need for the services of an in-person child psychiatrist. Response (Mental Health): Department is unaware of staff responses to Grand Jury's inquiry. The Department has a Telepsychiatry program which provides a televised link to pediatric psychiatrists in Southern California. Response (Board of Supervisors): The Board does not have enough information to either agree or disagree with this finding. c. A local pediatrician told the Children and Families First Commission that stress symptoms in young children can be identified, but personally felt there were not resources to refer them to. The pediatrician stated that resources need to be in place before children can be diagnosed and referred. Response (Mental Health): Disagree. Mental Health assessment and diagnosis falls into the scope of practice of licensed clinicians. There are over twenty clinicians who work full time in the County system that can provide assistance. 2000-2001 Mendocino County Grand Jury Final Report 6 There are also many competent private providers who treat mental illness in children. There is no reason why a child should not be diagnosed and treated in Mendocino County Response (Board of Supervisors): The Board disagrees with this finding. The Board agrees with the response presented by the Mental Health Department. d. Mental Health staff suggested that the services of a Mental Health staff psychiatrist for children could be available to the Superior Court, Department of Probation, and the Department of Social Services. Response (Mental Health): Agree in part. All the children of Mendocino County should receive treatment. As per (d) above Mental Health does not have a pediatric psychiatrist and has been unable to successfully recruit for all psychiatric positions available. Response (Board of Supervisors): The Board agrees in part, as explained by the Mental Health Department response.

Mental Health does not provide services for pre-school children who are experiencing psychosocial problems. Response (Mental Health): Disagree in part. Mental Health screens every referral that comes in. The fact is not many preschool children are referred. Mendocino would benefit from proactive screening for preschoolers. Staff experience shows that there is a huge reluctance to identify very young children with mental health problems. Children’s Services Staff serve on interagency preschool collaborative teams and provide consultation and strategies to partner agencies. Response (Board of Supervisors): The Board disagrees in part with this finding. The Board agrees with the response presented by the Mental Health Department and encourages staff to continue working with interagency collaborative teams regarding preschool age children.

Even though Mental Health states that the Patients’ Rights Advocate represents all clients of its department, all parents and most staff, including parent advocates, interviewed stated that they were unaware of the existence of a Patients’ Rights Advocate for children. Response (Mental Health): Agree in part. The Patients’ Rights Advocate has focused most of her attention on the Adult System of Care. The Children's services staff has discussed specific children’s issues with the Patient Rights Advocate, but there have not been many instances of this. 2000-2001 Mendocino County Grand Jury Final Report 7 Parent Advocates are on CSOC staff and assist with advocating for appropriate services to children. They have responded to virtually every request from parents/providers and/or partner agencies. PAN representatives have functioned as surrogates on behalf of schools for local Group homes, have attended court with families, have met with families referred from AODP regarding CPS issues (in Ft. Bragg) have traveled with parents to out of county IEP’s, have traveled with families in the process of interviewing residential group homes for their children. Department policy has been to respond to every request and to offer Parent Advocate availability to every family the CSOC comes in contact with. Response (Board of Supervisors): The Board agrees in part and has a solid record supporting the establishment of Parent Advocate positions within the Children’s System of Care.

Mental Health has no system for evaluating the outcomes of services provided. Response (Mental Health): Disagree. Every family who remains in the system and has either a year of service or a planned discharge receives an assessment tool called a Client Satisfaction Questionnaire developed by the University of California in San Francisco. The PACE program has been evaluated by the State for recidivism and school progress and has shown progress in both areas. Every family who enters the system is evaluated by five standardized instruments adopted by the State; YSR, CBCL, CAFAS, CSQ8 and CLEP. Response (Board of Supervisors): The Board disagrees with this finding. The Board agrees with the response presented by the Mental Health Department. System of Care (SOC) Background Information The State Department of Mental Health made funds available for promoting interagency coordination of services for severely emotionally disabled children at risk of out-of home placement with the intent of providing services in the community, reducing costs of placements, and keeping children in their own communities whenever possible. In 1997, Mental Health applied for and received 3-year State grant of $750,000 to implement the System of Care. Mental Health, the Department of Social Services, the Department of Probation, Alcohol and Other Drugs Prevention, and the 2000-2001 Mendocino County Grand Jury Final Report 8 Mendocino County Office of Education collaborated to provide individual case management for severely emotionally disabled children at risk of out-of-home placement in facilities that offer extensive supports. Mental Health states that the County will now receive from the State an on going $313,000 annually to continue System of Care. The SOC Director is a Department of Social Services employee who works under the director of the Mental Health, Children’s Services Program Manager. Out-of-home placements in group home settings by the Department of Social Services, Probation, and Mental Health were as follows: (cid:1) In 1996-97, 52 children, (cid:1) In April, 2001, 79 children. The Compendium, p. 16 states: “Mission/goal(s) of program: Treatment of children deemed severely emotionally disabled [SED] and their families; reduce need for hospitalization or placement out-of-home in the SED population. Description of program/activity: Evaluation/Referral/Treatment (cid:3) Short-term outpatient family therapy (cid:3) Coordination of services with other System of Care partners. (cid:3) Case management for student in residential treatment or other placement. (cid:3) Referral Criteria: Families, school personnel, probation officers, police, social workers and individuals who contact the department all make referrals. All request for services are handled by the CSOC process.” Findings

Mental Health has focused on System of Care as the primary provider of services to children. Responses to questions posed to Mental Health about services for all children are answered in System of Care jargon and signed by the System of Care Director. Mental Health staff responsibilities are blurred. Response (Mental Health): Disagree. There are three “intake teams” in the County; Ukiah, Willits and Fort Bragg. These teams meet weekly or more often if necessary to triage and assign new referrals. This process is a combined effort of both Children’s Mental Health and System of Care. This is a common practice through out the State. If responsibilities appear blurred, it is because there is so much teamwork occurring it is not necessary to remind each other of roles. Each staff person has a specific written job description as outlined in the children’s procedure manual. In a collaborative effort it often appears that responsibilities are blurred. They are in fact shared. 2000-2001 Mendocino County Grand Jury Final Report 9 Response (Board of Supervisors): The Board disagrees with this finding. The Board agrees with the response presented by the Mental Health Department.

System of Care provides services to a small percentage of the reported number of children receiving services. Response (Mental Health): Agree. Children’s Mental Health does serve more children than the CSOC. The CSOC is multi-agency effort to reach out to families with children with most severe disturbances. The Mental Health Department has dramatically expanded services to all children both in scope and in numbers. The children in CSOC represent a small proportion of reported services. Response (Board of Supervisors): The Board agrees in part with this finding. The Board agrees with the response presented by the Mental Health Department, pointing out that CSOC deals with the most severely emotionally disabled youth. a. Mental Health staff report that approximately 300 children are receiving services from its department. Response (Mental Health): Disagree. This past year the department has served more than 650 children. The complete year’s data was not available at the time of the interviews with the Grand Jury. Response (Board of Supervisors): The Board disagrees with this finding. The Board agrees with the response presented by the Mental Health Department. b. System of Care is intended for a limited number of children who are at risk of out-of-home placement in facilities for children with severe psychosocial problems, not the broader population of children who may be in need of Mental Health services Response (Mental Health): Agree. The goal is to focus on the most severely disturbed children and then reinvest savings into earlier interventions. Response (Board of Supervisors): The Board agrees with this finding. The Board agrees with the response presented by the Mental Health Department. c. Through the System of Care, 10 children, as of April 17, 2001, receive wraparound services, such as respite care, shopping, and housecleaning, which provide support to families so that the children can remain at home. Two full-time Clinicians coordinate support staff of eight, plus a pool of extra help, in order to provide services for the 10 children. 2000-2001 Mendocino County Grand Jury Final Report 10 Response (Mental Health): Agree: There are currently 12 families being served through Mendocino’s Family Strengths “Wraparound” Program. In all but one of these families there are other children and/or family members or care givers who have mental health issues who are benefiting from the intense services Wraparound provides. This unique program, funded through State Department of Human Services, allows complete flexibility to meet intensive service needs that have previously been met in a high level residential home or would currently require placement in a high level residential home at an average monthly cost of $12,000-$15,000. per child. There are two Family Strengths “Wraparound” teams, each consisting of 1 facilitator/clinician, 3 case managers, 1 human service worker and support for Parent Advocates. Each team (one in Willits and one in Ukiah) can serve 7-8 families depending upon the complexity and breadth of needs of those families. The staffing to provide a team for the coastal area has recently been approved by the Board of Supervisors. Response (Board of Supervisors): The Board agrees with this finding. The Board agrees with the response presented by the Mental Health Department.

Parents reported a need for wraparound services on the Coast where services are planned, but have not been provided. The staff position of parent advocate for the Coast has been vacant for the past year. Response (Mental Health): Agree. A team is planned for the Coast in the coming year. Funds are available to hire a person who is qualified for the position. There has been an ongoing effort to find a parent on the coast to fill the Parent Advocate position. However, in the interim, a PAN representative has been assigned and travels to the coast, out-of-county etc. to meet these needs. Response (Board of Supervisors): The Board agrees in part with this finding. The Board agrees with the response presented by the Mental Health Department, and notes that staff for a coastal Family Strengths team was recently approved.

Parents of children returning from out-of-home placement testified that Mental Health was negligent in providing services specified in an IEP, and did not make provisions for the child’s return to the community or assist adequately in finding another placement. Witnesses testified that because Deputy County Counsel was not available, Mental Health staff refused to attend a required emergency meeting attended by all other agencies involved in planning for immediate client services. Response (Mental Health): The needs of every child returning from out of home placement are reviewed by the IACMT in order to arrange for a variety of 2000-2001 Mendocino County Grand Jury Final Report 11 support services including wrap-around, Therapeutic Behavioral Services (TBS), outpatient treatment and/or school support. In most cases, if a new placement is required, the IACMT works with Mental Health Department case managers to locate an appropriate placement as quickly as possible. Regarding IEP meetings, Department staff has never knowingly missed a required meeting. Mental Health clinicians are only required to attend IEPs when placement is being discussed. Other IEPs, in which academic goals are being determined, are not the purview of Mental Health staff, and they likely would not attend. If lawyers are present representing parents or the School District, the Department prefers to also have legal counsel on hand. Staff is not in the position to make commitments such as financial agreements or timing of placements, for example, on behalf of the County, so having an attorney present can actually promote resolution of issues in these meetings. Response (Board of Supervisors): The Grand Jury did not provide sufficient information for the Board to either agree or disagree with this finding. The Board agrees with the response presented by the Mental Health Department.

System of Care promotes the idea that with appropriate support and intervention, all children remain at home. Response (Mental Health): Agree. Response (Board of Supervisors): The Board agrees with this finding. a. Out-of-home placement is not always detrimental. Former group home residents testified that placement in an out-of-county treatment program had been beneficial. Response (Mental Health): Agree. Response (Board of Supervisors): The Board agrees with this finding. b. Some children with severe behavior management problems need specialized school programs that are not currently provided in the County. Response (Mental Health): Agree. Response (Board of Supervisors): The Board agrees with this finding. School Services and Day Treatment Programs Background Information Mental Health operates Day-Treatment Programs and offers counseling services at school sites. Mental Health Clinicians provide mental health evaluations for IEPs 2000-2001 Mendocino County Grand Jury Final Report 12 when a team of school personnel and parents determine that a child’s mental health is interfering with education. School-based Mental Health Services: the Compendium, p. 18 states, “The mission/goal of program “To provide services to those students in outlying areas who qualify for mental health services.” Description of program/activity: Provides counseling with individuals and families at settings donated by school districts. Must meet Mental Health requirements of DSM IV [Diagnostic and Statistical Manual of Mental Disorders IV] diagnosis along with severity, duration and impairment in functioning as indicators of medical necessity.” Day Treatment Programs: the Compendium, p. 17, states, “Mission/goal of program: A psychiatric treatment program allied with special education instruction, to provide habilitative treatment to children in the least restrictive setting who are at risk for placement out-of- home and/or school failure. Description of program/activity: All children are assessed and determined to be Severely Emotionally Disabled. An Individual Education Plan is developed. Program combines special education, psychiatric treatment and intensive family therapy. Referral criteria: These students must be identified as qualifying for special education services, as well as qualifying for mental health services.” Findings

Mental Health staff states that the best way to provide services to children is through the schools. However, no clear list exists for school services available in the County. Response (Mental Health): Disagree. Several lists were provided. Response (Board of Supervisors): The Board disagrees with this finding. The Board agrees with the response presented by the Department of Mental Health.

There are contradictions between the Compendium and the information received in interviews with school personnel and Mental Health staff. The Compendium states that clients “Must meet Mental Health requirements of DSM IV diagnosis.” Most of the reviewed IEPs for children receiving services lacked a DSM IV diagnosis. Response (Mental Health): Disagree. Every child who has an IEP that is served by the Mental Health Department has a DSM IV diagnosis. The diagnosis is not 2000-2001 Mendocino County Grand Jury Final Report 13 kept in the school file but rather in the confidential Mental Health Chart. These charts were not reviewed by the Grand Jury. Response (Board of Supervisors): The Board disagrees with this finding. The Board agrees with the response presented by the Department of Mental Health.

Mental Health has not provided school districts with consistent written information regarding services available through Mental Health. The Compendium is not specific in listing services provided or how a district can obtain those services. Response (Mental Health): Disagree. A letter was sent out to every District in 1999 explaining the services of the Mental Health Department. Each year since then a Mental Health Clinician has made a presentation to the local SELPA Policy Council which includes the Special Education Directors from each district explaining in detail the services of the Department. Response (Board of Supervisors): The Board disagrees with this finding. The Board agrees with the response presented by the Department of Mental Health.

Mental Health reported: “Services to the schools are provided through contracts with local districts. The opportunity to purchase those services was made known to the SELPA (Special Education Local Plan Area) and through the Superintendent’s Council, as well as informal contacts by us to Principals and Special Education Directors.” Response (Mental Health): Agree. Response (Board of Supervisors): The Board agrees with this finding.

Mental Health provided three contracts with school districts to the Grand Jury. Contracts do not specify the programs to be provided or the evaluation of their outcomes. Response (Mental Health): Agree in part. Contracts do not describe services. Attachments to the contracts spell out all services. Attachments do not speak about outcomes. Response (Board of Supervisors): The Board agrees in part with this finding. While the Board agrees with the response presented by the Department of Mental Health, it is unfortunate that the Grand Jury did not review the “Scope of Work” which is customarily included as an attachment to County contracts. The Board is also concerned about outcomes and will ask the Department for clarification on how the school-based contracts are evaluated. 2000-2001 Mendocino County Grand Jury Final Report 14