advancing intensive in-home treatment practice: clinical ... · pro-social peers & activities...

Session 55:

Advancing Intensive In-Home Treatment Practice: Clinical

innovations, practice frameworks and supports

Presenters: Joseph Woolston, MD,, Yale

University; Richard Shepler, Ph.D., PCC-

S, David Hussey, Ph.D. & Bobbi Beale,

Psy.D. Case Western Reserve University

Introduction

• Intensive In-Home Treatment (IIHT) is designed to address the complex needs of youth with serious emotional disabilities (SED) who are at risk of out of home placement.

• IIHT is implemented in most states and is an integral part of comprehensive continuums of care.

•The IIHT workforce consists mainly of entry level Master’s level clinicians who are asked to serve the most complex and highest risk youth and families.

•These novice clinicians need additional supports that include in depth training, intensive supervision, and practice frameworks that helps them prioritize interventions and strategies to best meet the presenting needs of youth and families.

INTENSIVE HOME-BASED TREATMENT PRACTICE FRAMEWORK: MATCHING STRATEGIES AND TECHNIQUES TO YOUTH AND FAMILY NEEDS

RICK SHEPLER, PH.D., PCC-S

BOBBI BEALE, PSY.D.

DAVID HUSSEY, PH.D.

CENTER FOR INNOVATIVE PRACTICES

BEGUN CENTER FOR VIOLENCE PREVENTION

Intensive Home-Based Treatment

• IHBT is an intensive, time-limited behavioral health treatment for children and adolescents with significant behavioral health challenges and related functional impairments in key life domains.

• IHBT incorporates a comprehensive set of behavioral health services which are delivered in the home, school and community, with the purpose of stabilizing behavioral health and safety concerns, for youth who are at-risk of placement due to his or her behavioral health challenges, being reunified from placement, or require a high intensity of behavioral health interventions to safely remain in the home.

3/21/2018

Intensive Home-Based Service Delivery Model

Location of Service Home and Community

Intensity Frequency: 2 to 5 sessions per week

Duration: 4 to 8 hours per week

Crisis response & availability 24/7

Active safety planning & monitoring Ongoing

Small caseloads 4 to 6 families per FTE; no mixed caseloads

(e.g. Outpatient & IHBT)

Flexible scheduling Convenient to family

Treatment duration 3 to 6 months

Systemic engagement and community

teaming

Child and family teaming; skillful advocacy;

family partnering; culturally mindful engagement

Active clinical supervision & oversight 24/7 availability; field support; weekly team

meetings

Provider credentials Licensed Behavioral Health Professional: MA

level preferred.

Comprehensive service array: integrated

and seamless; single point of clinical

responsibility

Crisis stabilization, safety planning, skill building,

trauma-focused, family therapy, resiliency &

support-building, cognitive interventions

Cu

ltu

rall

y M

ind

ful E

ng

ag

em

en

t

an

d F

am

ily P

art

ners

hip

sHome-Based Service Delivery

Modality

Comprehensive Treatment

Array Matched to Needs and

Strengths

Cross-System Collaboration

and Service Coordination

Multidimensional Assessment

IHBT Model ComponentsR

esilie

ncy-O

rien

ted

Dev

elo

pm

en

tal P

ers

pec

tive

6

Youth and Families with Complex Needs and Challenges

Youth

SU Disorders

MH Disorders

Family and

Neighborhood

Violence;

Neg. Peers

Trauma

Developmental Factors

(Risk & Protective Factors)

Safety Needs

System Involvement Stressors

(Lack of Support & Connection,

Demands, Pressures, Burden)

Resource Poor

(financial,

transportation,

housing,

supports)

Disparities; Service Access

Language Barriers

Family Stressors, Conflicts,

& Challenges

Multiple Risks Require Multiple Interventions (Sameroff, Gutman, and Peck, 2003)

•Interventions need to be as complex as the multiplicity of risk factors and contexts

•Most interventions in single domains have not produced major reductions in problem behaviors

Most youth experience risks across multiple social contexts

Interventions need to address all the social contexts in which the risks occur

8

Conceptualization Tools

Multidimensional Assessment

I. Diagnoses: youth who meet the criteria for Mental Health Disorder and related symptom manifestation

II. Developmental Functioning: (cognitive, emotional, & behavioral maturity)

III. Contextual Functioning: Individual functioning in relevant life domains, including risk and protective factors, and risk and recovery environments

IV. Safety and Risk Factors: Self and other harm, personal, family, and community safety

10

11

Age Developmental

Assets, Milestones,

and Successes

Significant Life Events

(Trauma, Family,

Legal, School, Peers,

Physical)

Mental Health

Symptoms

Substance

Use

Behavioral Health Timeline

Contextual Assessment and Treatment

School

Family

Peers Community

Informal Supports

+

+

+

+

-

- -

-

Work

+

-

+

-Youth

+ = Protective Factors

- = Risk Factors12 Shepler and

Baltrinic, 2006

Intervention and Conceptualization Strategies

Resiliency

promotion

Crisis and

Safety

Skill Building Cognitive Family Ecological

Strategic

accommodations

Safety

Planning

Emotional &

physical

regulation

CBT Structural Child and

family

teaming

Pro-social peers

& activities

Risk

assessment

Problem solving Trauma-

focused

Solution

focused

Cross-system

collaboration

Strengths

identification

Active

monitoring

Communication MI Behavior

management

Youth and family

supports

24/7

response

Conflict

resolution

Relationship

building

Linkage to

mentors

Crisis

stabilization

Supervision and

Monitoring

Trauma-

focused

Asset building Coping skills

Futures

orientation

Comprehensive Treatment Array

Comprehensive service requires integrative treatment framework

•Services and supports are matched to each family’s presenting needs, strengths and circumstances

•A family need hierarchy is utilized to assist in assessing and prioritizing the youth’s and family needs

•Strategies and interventions are matched to the most salient need, progressing to more complex needs once the primary needs are met

•What key factors if not addressed will lead to relapse or increased behavioral health symptoms or decreased functioning in a key life domain?

15

Integrated and Comprehensive Treatment Matched to Need

Wellness &Resiliency

Eco-systemic Functioning

Basic Skills and Coping

Basic Needs, Safety, and Stabilization

Youth and Family Need Hierarchy (Shepler, 1991, 1999)16

Resiliency

Reduce Risk

Environments and

Behaviors

Increase

Protective Factors

in Multiple

Environments

Risk and Resiliency Focus (Mannes; Shepler)

Safety is FoundationalSafe environments for recovery and resiliency promotion

Establish Positive

Connections &

Functional Success

through Relational

Supports & Strategic

Accommodations

Asset Building,

Futures Orientation,

and Meaningful

Contribution

Basic Needs,

Resources, &

Validation18

(Shepler, 2011)

19

Contextual Functional Analysis

Youth

SU Disorder

MH Disorder

De-stabilizing

Event or Trigger

Risks Factors, Skills,

Resources, and Supports

Trauma Filter

Exacerbating

Response Salient

Behavior/

Symptom

Dispositional

Factors

Contextual & Relational Dynamics:

Family, Peers,

School, Community

Safety

Issue

Escalation Cycle

© 2011, Shepler,

Center for Innovative

Practices

20

Adaptive Systemic Response

Youth

SU Disorder

MH Disorder

Remove triggers

Coping skills and strategies

Emotional regulation skills

Stress reduction

Remove trauma

triggers; Safe

environments

Adaptive,

supportive

response

Coping

response

Health & Wellness:

Mindfulness, etc.

Contextual & relational supports

Behavioral redirection

Change the environment

Pro-social activities

De-escalation Cycle

© 2014, R. Shepler,

Center for Innovative

Practices

Domain Priority

Concerns/ Needs

Barriers Strengths Plan

Individual

Home/Family

School

Community/

Peers

Risk &

Safety

Issues

IHBT Conceptualization and Planning

Workforce Development

• Comprehensive and ongoing training

• Weekly clinical consultation from model developer

• Intensive clinical supervision including field supervision

• Inform clinicians: collect and disseminate outcomes.

• Yearly fidelity monitoring

• Think of this as a post-graduate fellowship experience

IHBT core competency areas

• Family systems

• Risk assessment and crisis stabilization

• Behavior management for children/adolescents with SED

• Cultural & linguistic competence

• Cross-system collaboration and coordination

• Trauma-informed care

• Resiliency-oriented, developmentally focused

• Skill building

• Educational and vocational functioning

• Youth and family engagement and partnering

• Strength-based assessment and treatment planning

• Co-Occurring Disorders

• Ethics in IHBT

• IHBT Supervision

For more Information on IHBT

Bobbi Beale: [email protected]

David Hussey: [email protected]

Rick Shepler: [email protected]

3/21/2018

mailto:[email protected]



Intensive, In-home Child &

Adolescent Psychiatric

Service

(IICAPS)

Structuring IHBT to Promote

Quality Improvement

Conflicts of Interest/Disclosures

• Woolston:

– Woolston, J.L., Adnopoz, J., Berkowitz, S.

IICAPS: A Home-Based Psychiatric

Treatment for Children and Adolescents, New

Haven: Yale University Press, 2007.

IICAPS Partnership

IICAPS Providers:19 sites, statewide in CT

IICAPS Services:

-training

-credentialing

-quality assurance

CT State

agencies:

-DCF

-DSS

Families

and

Children

© 2009 Yale University, Child Study Center, IICAPS

Not to be copied without permission of author

-data evaluation

What’s the clinical problem?

Version I: 10/1/2010• Children, 4-18, who have serious,

persistent, multi-domain, behavioral & emotional disturbances

• Who display behaviors that are dangerous to self & others causing high risk for requiring institutional based care

• Who have frequent & multiple “co-morbidities”: Axes I, II, III

• And who live in…



A Microsystem Characterized by

SED: “(MP)³ Syndrome”

• M-1: “Multi-problem” children with serious & persistent, out-of-control behavior that is dangerous to self and/or others

• M-2: Living in “multi-problem” multi-generational families

• M-3: Attending “multi-problem” schools and living in “multi-problem”neighborhoods”



Parental

stress

Out of

Control behavior

Child emotional &

behavioral problemsInstitutional

service use

Problems in school,

neighborhood,

access to resources

Compromised

Parenting &

Family Management

Practices

Biological, other

vulnerabilities (eg

PDD NOS)

Vicious cycle of (MP)³

Family Domain

School/Environment

Domains

Parental

disability

Child Domain

Ecological Systems Theory

Social Learning Theory

Problem Solving

Training Theory;

Goal Setting, Goal

Striving



IICAPS

• Intensive, in-home, relationship based tx, ecologically & family focused

• 2 person clinical team treats 8 families

• 3-4 teams in weekly Rounds co-led by CAP & senior mental health clinician

• Weekly team supervision: 15 min/case

• Manualized: Tools, Domains, Phases

• Funding: Medicaid, fee-for-service



IICAPS Service Provision

• Team provides each family approximately

5 hours/week of direct and indirect

services

• Average max. LOS= ~6 months

• Services are provided wherever indicated

to maximize engagement & improvement

in microsystem functioning

• Documentation structures are Medicaid

compliant

IICAPS Theoretical Constructs

• Social Learning Theory ( Bandura) and its

clinical application, Parent Management

Training (Patterson; Kazdin)

• Ecological Systems Theory (Bronfenbrenner)

• Problem Solving Training (D'zurilla)

• Goal Setting/Goal Striving (Oettingen;

Gollwitzer)

IICAPS Interventions

Child Emotional &

Behavioral Problems

Out of Control

Behavior

Institutional

Service Use

Parenting skills

& practices

Parental

Stress

Environmental

Stressors

Intensive Care Management

Problem Solving Training

Problem Solving Training Parenting Skill Building

Mobile Crisis Intervention

Psychiatric Evaluation

& Psychotherapy



Growth of the IICAPS Network

© 2010 Yale University, Child Study Center,

IICAPS. Not to be copied without permission of

author

372

579

974

1231

2069

22272340 2371 2309 2289 2246

39 71 100 116 127 140 145 145 142 144 141

14 16 18 19 20 20 20 20 20 20 190

500

1000

1500

2000

2500

20

07

20

08

20

09

20

10

20

11

20

12

20

13

20

14

20

15

20

16

20

17

Closed cases

# IICAPS teams

# IICAPS sites

Fiscal Year

IICAPS Network: Outcomes

Cases Closed between July 1, 2009-June 30, 2017

(FYs 09/10 – FY16/17)

N=17,082

Tx Completers (n=10,848; 67.5%)

Non-completers (n=5,216; 32.5%)

Evaluation Only (n=1,018)



author

IICAPS Outcomes Measures

Child Emotional &

Behavioral Problems

Out of Control

Behavior

Institutional

Service Use

Parenting & family

management skills

Parental

Stress

Environmental

Stressors

Service Utilization

Questionnaire (SUQ)

Main Problem Rating

Ohio Scales:

Problem Severity

& Functioning Domains

© 2009 Yale University, Child Study Center, IICAPS. Not

to be copied without permission of author

Ohio Problem Severity:Paired T-test, IICAPS Intake and Discharge

(Treatment Completers; N= 10,848)

Proportional Decrease, Parent Report: 37.6% (p<.0001)

Proportional Decrease, Youth Report: 34.7% (p<.0001)

Proportional Decrease, Worker Report: 36.5% (p<.0001)


IICAPS. Not to be copied without

permission of author

33.5

26.2

31.8

20.9

17.1

20.2

0

5

10

15

20

25

30

35

40

PARENT REPORT YOUTH REPORT WORKER REPORT

Intake Discharge

Clinical cutoff = 20

Decreases in Ohio Scales Problem Severity

Scores over Eight Fiscal Years

for Treatment Completers



author

37.5% 36.8% 34.9%

38.8% 38.4% 38.0% 38.2% 36.5%38.1% 37.8% 37.4%

38.7%

35.2% 34.2% 34.5% 32.9%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

2010 2011 2012 2013 2014 2015 2016 2017

Parent Report Worker Report

Fiscal Year

Ohio Child Functioning:Paired T-test, IICAPS Intake and Discharge

(Treatment Completers; N=10,848)

Proportional Increase, Parent Report: 23.7% (p<.0001)

Proportional Increase, Youth Report: 11.1% (p<.0001)

Proportional Increase, Worker Report: 26.9% (p<.0001)

© 2016 Yale University, Child Study

Center, IICAPS. Not to be copied

without permission of author

39.7

52.2

38.2

49.1

58.1

48.1

0

10

20

30

40

50

60

70

PARENT REPORT YOUTH REPORT WORKER REPORT

Intake Discharge

Clinical cutoff for

parent report = 51

Clinical cutoff for

youth report = 60Clinical cutoff for

worker report = 51

Increases in Ohio Scales Functioning Scores

over Eight Fiscal Years

for Treatment Completers



author

24.3% 24.1%22.2% 24.3% 23.4% 23.8% 24.2%

22.6%

26.5% 25.7%27.4% 27.1% 26.2%

24.7% 24.2% 22.9%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

2010 2011 2012 2013 2014 2015 2016 2017

Parent Report Worker Report

Fiscal Year

Main Problem Ratings & Scores

Defining Main Problem: co-construction of description of

behavior that puts child at risk for requiring institutional

treatment

Rating Main Problem: 10 point scale with behavioral

anchor points ranging from:

1 - Imminent risk of injury to self or others/gravely

disturbed

to:

10 - No disturbance






Main Problem Rating:Paired T-test Results

Measured at IICAPS Intake and Discharge

Mean Difference, Treatment Completers: 3.5 pts. (p<.0001)

Mean Difference, Non-completers: 1.2 pts. (p<.0001)

3.613.41

7.12

4.58

1

2

3

4

5

6

7

8

9

10

PLANNED DISCHARGES/ TREATMENTCOMPLETERS

UNPLANNED DISCHARGES/ NON-COMPLETERS

Intake Discharge

Imminent

Risk of Out-

Placement

No

Disturbance

Service Utilization Data

• Service Utilization Questionnaire (SUQ): created by the IICAPS developers

• Parent report; excellent validity when compared to claims payment data

• Administered at Intake to collect data on service utilization during the 6 months prior to IICAPS Intake

• Administered at Discharge to collect data on service utilization during the period of the IICAPS Intervention (time variable)



Service Utilization Data: Number of

Patients with a Treatment EventTreatment Completers

Proportional Decrease, Pts w/Psych Inpatient Admission: 54.6%

Proportional Decrease, Pts w/ED Visit: 40.3%




2873

3603

1305

2152

0

500

1000

1500

2000

2500

3000

3500

4000

PTS WITH PSYCHIATRIC INPT ADMISSION PTS WITH ED VISITS

6 mos prior to IICAPS Intake During IICAPS

Service Utilization Data: Total Days of

Psychiatric Inpatient StayTreatment Completers

Proportional Decrease, Days of Psychiatric Inpatient Stay: 65.6% © 2016 Yale University, Child Study Center, IICAPS


50977

17559

0

10000

20000

30000

40000

50000

60000

6 mos prior to IICAPS Intake During IICAPS

Decrease in Psychiatric Inpatient Admissions

and Days over Eight Fiscal Yearsfor Treatment Completers



author

56.9%

70.0% 69.4%64.9%

70.4%67.4% 68.5%

61.6%

49.2%

57.6%

51.1% 50.8%56.3% 56.1% 56.7% 54.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

2010 2011 2012 2013 2014 2015 2016 2017

Inpt Days Reduction Inpt Admission Reduction

Fiscal Year

New Tool; New Data;

New Understanding• Important Childhood Events (ICE) 2014

• Semi-structured activity with parent

involving 20 questions about caregiver’s

experience during childhood:

– 10 questions of adversity (ACE)

– 10 questions resilience (RCE)

• n= 5,213 (4,241 birth parents)

• 80% completion across sites

42.4

37.2

29.6

38.8

17.8

54

28.2

46.1

40.8

23.1

0 10 20 30 40 50 60 70 80 90 100

Emotional Abuse

Physical Abuse

Sexual Abuse

Emotional Neglect

Physical Neglect

Divorce/Separation

Domestic Violence

HH Substance Abuse

HH Mental Illness

HH Member Incarcerated

ACE Items Endorsed

Percent of Families with Endorsed Item

44.7

38.9

31.5

42.3

19

56.4

29.9

47.9

43.7

24.6

32.5

29.5

21.5

28.2

12.7

43.9

20.7

38.1

27.8

16.6

0 10 20 30 40 50 60 70 80 90 100

Emotional Abuse

Physical Abuse

Sexual Abuse

Emotional Neglect

Physical Neglect

Divorce/Separation

Domestic Violence

HH Substance Abuse

HH Mental Illness

HH Member Incarcerated

ACE Items Endorsed - Birth vs Other Parents

Non-birth parents

Birth parents

Percent of Families with Endorsed Item

0

10

20

30

40

50

60

Emotional

Abuse

Physical

Abuse

Sexual

Abuse

Physical

Neglect

Emotional

Neglect

Divorce/Sep HH

Substance

HH Mental Domestic

Volence

HH

Member

Incarcerated

Endors

ed (

Per

centa

ge)

ACEs by Study - IICAPS Birth Parents Only Kaiser/CDC (San Diego, CA)

Urban ACEs (Philadelphia, PA)

Homeless Mothers of 4-6 y/o children

IICAPS - Birth Parents

0

10

20

30

40

50

60

No ACEs 1-4 ACES 4+ ACEs

Endors

ed (

Per

centa

ge)

ACEs by Study - IICAPS Birth Parents Kaiser/CDC

Urban ACEs

Homeless Mothers

IICAPS - Birth Parents

IICAPS: 2016

version 2.0• Intensive, in-home, relationship based tx,

ecologically & family focused, attachment informed

• 2 person clinical team treats 8 families

• 3-4 teams in weekly Rounds co-led by CAP & senior mental health clinician

• Weekly team supervision: 15 min/case

• Manualized: Tools, Domains, Phases

• Funding: Medicaid, fee-for-service



Clinical problem (revised)

• But these children aren’t in isolation

• They live in families with multi-

generational trauma/adversity and in

broader microsystems with present and

historic compromised functioning at

multiple levels

• Consistent with Developmental Trauma

Disorder (van der Kolk et al, 2005, 2009)



Parental

stress

Out of

Control behavior

Child emotional &

behavioral problems

Ineffective

Parenting:

Compromised

RF &

attachment

Institutional

service useParental coping

problems

Ohio Scales

SUQ

Problematic

social environ

Traumatization

Mal-

treatment

Parental

Hx Child

Maltx

Main Problem

ICE

Problematic

school environ.

IICAPS Theoretical Constructs

• Attachment Theory (Bowlby; Ainsworth; Main );

and its clinical application, Mentalizing (Fonagy; Steele; Steele; Target)

• Social Learning Theory (Bandura)

• Ecological Systems Theory (Bronfenbrenner)

• Goal Setting/Goal Striving (Oettingen;

Gollwitzer)

• Problem Solving Training (D'zurilla)

IICAPS Interventions

Child Emotional &

Behavioral Problems

Out of Control

Behavior

Institutional

Service Use

Parenting skills

& practices

Parental

Stress

Environmental

Stressors

Intensive Care Management

Problem Solving Training

Problem Solving Training Parenting Skill Building; Enhancing Reflective Functioning

Mobile Crisis Intervention

Psychiatric Evaluation

& Psychotherapy

informed by

Developmental

Trauma



IICAPS Summary:

8 years of experience• Stat. & clin. significant improvements in:

• Ohio Symptom Severity

• Ohio Functioning

• Main Problem rating

• Stat. & clin. significant decreases in:

• Psychiatric hospitalization admissions and days

• ED visits for psychiatric reasons

• Parental childhood adversity is extremely

prevalent

© 2009 Yale University, Child Study Center, IICAPS Not to be copied without permission of author

What we’ve learned from our

research• 5 RCTs and 2 quasi-experimental design

studies of IHBT show trends indicating

efficacy

• Chronic school absenteeism is a

significant problem in IICAPS population

and may respond well to IICAPS

Next Steps

• Development & implementation:

– Family Cycle: a semi-structured, family activity

to enhance family acknowledgement of

impact of trauma & adversity;

– Clinician Observation Scale of Parental RF

• Latent Class Analysis of Treatment

Completers v. Non-Completers

• Exploratory Analysis of Relationship of

Goal Attainment and Ohio scores

Publications

• Barbot, B., et al. Changes in Mental Health Outcomes with the

Intensive In-Home Child and Adolescent Psychiatric Service: a

Multi-Informant, Latent Consensus Approach. Intern J Methods

Psychiat. Research. DOI:10.1002/mpr. 2015

• Moffett, S., et al. Intensive home-based programs for youth with

serious emotional disturbances: A comprehensive review of

experimental findings. Doi.org/10.1016/j.childyouth.2017.10.004

• Conway, C. A., et al., School functioning as an outcome in child

psychiatry: The effect of intensive home-based family therapy on

school absenteeism in a high-risk clinical population. Submitted for

publication

• Stob, V. et al., The Family Cycle: A Conceptual Tool for Clinicians

and Families. In preparation

Thank you

• IICAPS Services

– Liliya Katsovitch John Sayward, Cecilia Singh,

Joseph Woolston, Jean Adnopoz

• IICAPS Research Group

– Line Brotnow, Samantha Moffett, C. Andrew

Conway, Bridget Torres, Rebecca Kamody,

Kristen Pirog; Olivia Robertson, Jean

Adnopoz, Joseph Woolston

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