FASST: A residential program [Behavioral Healthcare]

Program's success shows wisdom of wraparound services concept

"Kevin" is a handsome young man of 14 with a 100 kilowatt smile and mischievous brown eyes who loves playing video games and roughhousing with his dog, Milo. Tragically, Kevin was brutally abused as a toddler by his mother's boyfriend, the same boyfriend who murdered his mother before his eyes when he was just four years old.

After subsequent placement in a foster home, Kevin alternatively lashed out violently at his foster parents and other foster children and withdrew into a sullen, silent shell. At age 8, he was hospitalized in a psychiatric facility after trying to drink bleach, sayhighewantedto be with his mom. From there, Kevin was sent to a children's residential facility in South Carolina, his home state, wherehe remained for two years.

At age 10, Kevin went to live with an aunt and uncle inSomerville, Mass. Kevin's aunt, "Elie Gooding," who was his mother's older half sister, had contacted the South Carolina child welfare agency to inquire about her nephew and was told that he was scheduled to leave residential care soon.

Elie and her husband "Thomas" applied to become Kevin's kinship foster parents, unsure what they were getting themselves into but knowing that they could not abandon Kevin to an unknown, uncertain future. Because ofKevin's continuing serious emotional difficulties, the Goodings were referred to the Massachusetts Department of Mental Health (DMH) for support and direction regarding his care.

A new beginning

The Goodings were referred to an unusual community program designed to help families keep a child with serious emotional disturbance (SED) at home and prevent further out-of-home placement. This program, the Family Advocacy, Stabilization and Support Team (FASST), was developed in the mid-1990s by the Guidance Center, a children's community mental health agency that is now a part of Riverside Community Care, Inc.

IheFASSTconceptwas bora in the early 1990s when Joan Mikula, Assistant Commissioner of Child and Adolescent Services at DMH attended a national conference presentation on "wraparound" services that could prevent the need for long-term residential treatment of children and youth with SED. This conceptltterally "wrapped" an array of services around a child and family to support the family's ongoing care and the stability of the child in the home.

In Massachusetts at the time, there were few community-based alternatives to residential placement of a child with SED. Plus, DMH was spending significant funds to maintain residential beds. So, thought Commissioner Mikula, what if the state redirected the funding needed for a few residential beds into a community-based wraparound services program?

In response to DMH s RFP for a "community residential program without beds," the Guidance Center developed the FASST program under the direction of Borja Alvarez de Toledo, M.Ed.

The FASST model

The use of FASST marked a major innovation in treatment for the most severely disturbed youngsters because, for the first time, the FASST model offered inparient and residential care as one element in an array of wraparound services, rather than as the primary mode of treatment for children with SED.

FASST is designed for children and youth, ages 3 to 19, and their families. It delivers services buutaround family strengths, driven by family-identified goals, and sensitive to cultural differences from an ethnically, racially and linguistically diverse staff.

Encouraging and supporting the family's voice in treatment planning is a key element in the FASST model. Wraparound services range in intensity from normative community resources such as Boys and Girls Clubs, YMCA and YWCAs, and local religious institutions, to the purchase ofbrief residential and respite placements facilitated by contract providers. FASST staffalso provides concrete goods using DMH flexible funds, including transportation vouchers, food vouchers, medical supplies, educational materials, and home appliances. These goods are included as part of a comprehensive package designed co address the needs of any family member whose functioning may affect the child or youth with SED. This array of goods and services is continually adjusted to build an individualized system of care that can sustain the child in the family and community over time.

If a youth is in a residential treatment center (RTC) or a short-terrn assessment unit when referred to FASST, the initial phase of the intervention focuses on family reunification. This involves workingwith the family from 4 to 6 weeks prior to the child's return home to insure that necessary services and supports are in place, as well as working closely with hospital or RTC staff and the youth to prepare the child for discharge. During this time, the family is engaged in family therapy with the FASST clinicians, child and staff at the residential facility.

Crisis management In FASST

Because of the often fragile and volatile psychosocial functioning of the children and youth served by FASST and the programs goal of preventing crisis-driven psychiatric hospitalizations, the model provides 24/7 response to families, 365 days a year.

When possible, triage by telephone is first carried out to assess the nature of the crisisj de-escalate the child or family members and determine the need for face-to-face contact. When placement becomes necessary, the FASST team can directly purchase various forms of brief, more intensive care, such as:

* in-home or out-of-home respite for the family,

* short-term residential placements (three months or less),

* therapeutic foster care in the community,

* therapeutic day or overnight camp, or,

* substance abuse assessment and treatment.

Outcomes

Since the inception of the FASST program, data have been collected on each child's level of functioning with the Child and Adolescent Functional Assessment Scale (CAFAS), a widely used, standardized instrument in children's mental health. On average, children who participate in the FASST program experience a 23 percent increase in their overall level of psychosocial functioning from program entry to termination as measured by the CAFAS.

The FASST program also collects preand post-treatment data on the Children's Global Assessment Scale (C-GAS), an observational scale used to rate psychosocial functioning of children underage 18. Average scores on this scale at FASST termination indicate that participating children have increased their psychosocial functioning to the point that they would generally not appear all that different from other children to an outside observer.

Finally, reflecting the FASST program goal of stabilizing children and youth with SED and preventing long-term out-ofhome placements, 84 percent of children in the FASST program are functioning at a stable level at home, school and in the community at treatment termination. The remaining 16 percent require a more structured setting or are in the custody of state child welfare authorities.

Conclusion

While community-based residential treatment without beds may not keep every child with SED out of long-term residential care, the FASST program has seen positive results: enhanced psychosocial functioning and greatly reduced placement lengths for most participants.

Kevin was one of those who benefited significantly from the individualized network of supports and services the FASST team put in place for him and his foster - now adoptive - family.

By participating in the FASST program, Kevin learned new ways to manage his feelings and behavior in social situations, acknowledged and developed strengths - including athletic ability and a love of animals, organized his schoolwork, and successfully met the educational demands at his local school.

With support and instruction from FASST clinicians, Kevin's parents were able to help him manage his feelings more appropriately by recognizing his behavioral triggers and taking steps to calm him before he erupts.

Recently, Mr. Goodingand Kevin started volunteering together on Saturday mornings at the local animal shelter. Mrs. Gooding laughingly says it's the only thing that can get Kevin out of bed before noon on the weekends - just like any other teenager.

Studies make clear the immediate and long-term benefits for children when they learn to function in a normative environment. ' Youth receiving communitybased mental healthcare report higher levels of satisfaction with their lives as well as with the services they have received as compared with those in traditional residential psychiatric settings. Higher Ufe satisfaction scores are associated with fewer behavior difficulties, increased family involvement and support, increased school attendance and community involvement.2

While there are no definitive state or federal data that compare the cost of treating a child with SED in the community rather than ina residential setting, it is clear that there are cost savings. Thus, programs such as FAAST represent both good public policy and good economic sense. Recently, when asked what he thought of the FASST program, Kevin responded that it was totally "church."

Members of FASST Team at Riverside Community Care, Dedham, Mass.

Lessons Learned

Our 20-year experience delivering wraparound services in the FASST program has taught use important lessons about how to prevent long-term, out-of-home placement of children with serious emotional and behavioral disturbances:

1. Early family engagement The earlier a family becomes a partner, either in helping to prevent the need for in-patient placement or in the process of ensuring a smooth return home, the more likely the chances of success.

2. Everyone needs a break. A successful wraparound program must provide respite care for all, whether an occasional "parents night out," a weekend away for the child in a treatment foster home, or a short-term in-patient stay when everyone needs a more structured break from one another.

3. Service mix must be situationspecific. The intensity, frequency and duration of wraparound services depend on the strengths, needs and circumstances of the child and the family.

4. Treatment is ecological and multisystemic. Members of the treatment team must be able to focus on the child in the family context, the family in the context of the community, and the community in the context of the larger cultural and social environment. They must also be able to engage multiple community providers in working toward the goal of stabilizing and maintaining the child at home and in the community.

5. Staff must be flexible in their roles. Successful wraparound treatment demands team members that can assume different roles at different times and with different family members: partner, educator, mentor, advocate, tutor, coach and therapist.

References

1. Burns, B. J. & Friedman, R. (1990). Examining the research base for child mental health services and policy. The Journal of Behavioral Health Services and Research, /7(1), 87-98; Manteuffel, B., Stephens, R. L., & Santiago, R. (2002). Overview of the national evaluation of theComprehensive Community Mental Health Services and ChildrenandtheirFamilies Program: Summary of current findings. Children's Services: Social Policy, Research, and Practice, 5(1), 3-20.

2. Burns, B. J., & Hoagwood, K. (Eds.) (2002). Community Treatment far Youth. New York: Oxford.

BY MARTHA M. DOME, PhD AND BOfUA ALVARBZ DC TOLEDO, MEd

Martha M. Dore PhD is Director of Research and Evaluation, and Borja Alvarez de Toledo, M.Ed., is Division Director for Child and Family Services at Riverside Community Care in Dedham, Mass.