The Institute for Innovation and Implementation

In recognition of National Children’s Mental Health Awareness Week, the Institute is sharing one story each day about the nationwide impact of its work on the mental health needs of our youth.

We’re using a strategy that incorporates youth input in the design of what the services look like, in the evaluation of how well we’re doing as providers, and making sure youth voice is centered throughout the process.

-- Blair Franklin, Executive Director, Youth Empowered Society (YES)

The funding opportunity? Serve adolescents struggling with substance misuse with well researched practices through a family-centered treatment approach.

The Institute’s approach? Support youth and young adults ages 14-25 in Baltimore City who are misusing substances, experiencing homelessness or housing instability, and may be pregnant or parenting with services that are youth-informed.

The federal government agreed and B’More SUCCEEDS (Success through Community-based Coordination, Empowerment, Evidence-based interventions, and Direct Supports) was born in October 2018!

B’More SUCCEEDS is led by The Institute in partnership with Youth Empowered Society (YES) Youth Drop-In Center, HARBEL Prevention and Recovery Center, Treatment Resources for Youth (TRY), Baltimore City Health Department, B’More for Healthy Babies, and the PACT’s Therapeutic Nursery at the Kennedy Krieger Institute, along with Behavioral Health System Baltimore, HealthCare Access Maryland, and the Baltimore Harm Reduction Coalition. It builds upon the intentional and focused work done over the past ten years in Baltimore City and across Maryland to end and prevent youth homelessness, including Youth REACH MD.

According to the latest data from Youth REACH MD, over 1,500 youth are experiencing homelessness in Baltimore City, with 32% reporting having children of their own and only 11% reporting that they received the support they needed.¹ At the core of B’More SUCCEEDS, the YES Drop-In Center serves approximately 250 youth and young adults who are experiencing homelessness in Baltimore annually. Youth experiencing homelessness are at increased risk for victimization, poor mental and physical health, and dropping out of school. For youth who are pregnant or parenting, these risks can also extend to their children, which is why it is so important we provide them with the support they need now.

B’More SUCCEEDS takes a two-generational approach to service design and delivery, recognizing that the youth are the experts on themselves and their children.

Youth experiencing homelessness are typically no longer connected with their parents or guardians and are frequently pregnant or parents themselves, so they are both the youth and the family in one. In this situation, youth are the heads of their own families and they are asking for support to help them give their children a better life than they have had. B’More SUCCEEDS takes a multigenerational approach to make sure that youth experiencing homelessness as well as their children are getting the supports they need.

-- Amanda Miller, B'More SUCCEEDS & Youth REACH Project Director, The Institute

The program is serving the needs of youth experiencing homelessness through the power of partnership and youth voice. B’More SUCCEEDS brings together service providers that do not normally have the opportunity to collaborate, such as those that address substance misuse and those that provide parent, infant, and early childhood care. The challenge for service providers is that addressing the needs of a newly-identified population does not always neatly align with the current practice. The project provides training to these organizations to address the holistic needs of youth and supports access to a range of services from housing to mental health services. Youth play a key role in shaping the project outcomes by providing ongoing feedback and helping partners evaluate their work as well as supporting their peers at YES.

Hearing the stories of a youth now who is getting support that they weren’t getting before, through a team that is working on different pieces of the puzzle—that’s really what we came here to do. The fact that less than six months in, we’re starting to hear these stories shows that we’re on the right track.

-- Amanda Miller, B'More SUCCEEDS & Youth REACH Project Director, The Institute

Although B’More SUCCEEDS only began its work late fall, youth are already beginning to provide feedback that they are receiving new, more coordinated services. This feedback will continue to guide the program in achieving its goals to help end youth homelessness in the City. The program partners, together with organizations across the State, including the Maryland Department of Housing and Community Development, continue to build momentum for this movement, as evidenced by the 250 youth and young adults, advocates, policymakers, and service providers who participated in the first Maryland Youth Homelessness Symposium on May 1 and 2.

This work requires us to dig in, recognize, and address the institutional and structural issues of poverty and racism in Baltimore City and how they impact the mental and physical health and well-being of youth and young adults and their families. At the end of the day? Our goal is to support youth and young adults so that they and their families are safe, healthy, and housed.

-- Deborah Harburger, Principal Investigator, B'More SUCCEEDS, The Institute

Find more information about The Institute's work on youth homelessness

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_{Funding for B’More SUCCEEDS comes from the Center for Substance Use Treatment, Substance Abuse & Mental Health Services Administration, U.S. Department of Health and Human Services under the Enhancement and Expansion of Treatment and Recovery Services for Adolescents, Transitional Aged Youth, and their Families funding opportunity.  Funding for Youth REACH MD and the Maryland Youth Homelessness Symposium comes from the Maryland Department of Housing & Community Development.}

_Resource

_{1. The data cited in this article will be published in the Youth Count 2018 Report due out June 2019. The previous reports and data is currently available online and can be accessed here: http://www.youthreachmd.com/publications/ . The 2018 report will be available at this same link.}

Everything’s big in Texas, especially The Institute’s work to address the needs of youth and their families. In the Institute’s Texas Center, we work with a process known as Wraparound that has a tremendous impact on families and communities. Through Wraparound, we are working to address the needs of youth with serious mental health challenges across the state.

Wraparound is centered on the idea that children do best with their families in their communities, and not in restrictive institutional settings. Youth with complex needs are often involved with more than one child-serving system, including schools, health care, child welfare, and juvenile justice. Each of these agencies may have its own expectations for the youth and it can be hard for families to keep track of all of the competing demands.

All families have strengths and all families deserve high quality, culturally-responsive care with family voice and choice at the heart of all of the work. Families have people in their lives that support and care for them and those folks are at the table in Wraparound, too. In Wraparound, a care coordinator works to bring child-serving agencies and service providers together with family, friends, neighbors, coaches, faith leaders, and other supports to one table, challenging them to understand the family’s full story and create one plan to meet the needs of these youth.

Care coordinators help the Wraparound team create a vision and a plan to achieve a brighter future. The youth and caregivers take the lead in defining and achieving the outcomes they want for themselves and their family; their voices and choices are at the heart of the work. Care coordinators are employed by a community-based organization, working with 10 to 12 teams at a time.

When Wraparound comes into local community systems, kids are able to stay in their homes, families feel more supported, community and state systems have a cost-efficient way to approach need. But, most importantly, kids are being helped.

-- Sarah Strader, National Trainer & Coach

Building a new model of community support across the state of Texas and training an entire cadre of care coordinators is no simple task. The state of Texas invited the National Wraparound Implementation Center and The Institute to support implementation of Wraparound across the state, including providing high-quality workforce training and coaching, as well as monitoring and evaluating their efforts to ensure success.

Monica Rodriguez works for Tropical Texas Behavioral Health, a local mental health authority, located on the Texas-Mexico border. Some feel Wraparound can’t be successfully implemented with Latino populations, but she has a different story to share.

We serve over 4,500 youth each year in 120 miles of Texas-Mexico border area. Like a lot of Texas, we have a lot of ground to cover and a lot of need. You can’t go from one end of our catchment area to another without stopping for fuel. This is a place in Texas that folks were very skeptical about implementing Wraparound as there are cultural barriers to engaging the Latino/Hispanic community around mental health. But it’s nothing that we can’t tackle through authentic engagement and meeting families where they are.

-- Monica Rodriguez, Family Support Partner, Tropical Texas Behavioral Health

Rodriguez (at left) was one of the first people to graduate from NWIC’s intensive Wraparound care coordinator training and become a certified coach herself. Rodriquez now trains care coordinators in an area of Texas where most folks thought Wraparound would never work. Her work demonstrates the importance of high quality, culturally-responsive care.

The Institute uses its knowledge and experience in implementing models like Wraparound on a large scale to create immediate and lasting impact for families. The success of each individual family team at the core of Wraparound depends on the collaboration of child-serving systems and community partners. The long-term success of Texas’s efforts to care for its youth relies on coaches like Rodriguez who operate with passion and with determination. With a clear-eyed commitment to quality training and continuous, thorough evaluation of practices, Rodriguez and her colleagues across the state will ensure that Texas’s youth reach their bright futures.

Find more information about The Institute's work in Texas on Wraparound

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I struggled for years with my daughter while demanding from her a life that she wasn’t able to give. In my perfect world, she would be who I wanted her to be. In 2008, I became a Family Support Partner. I never dreamed that I would gain so much from the many LGBTQ families that I work with. I finally began to understand what my daughter was experiencing. 

-- Linda, Family Support Partner, Steps2Connect, Pennsylvania

With a few encouraging words, Linda nudges broken-hearted families on a path toward healing. She plays a critical role in a pilot project designed to engage parents and guardians in affirming LGBTQ+ youth who have been placed in foster care. These parents are struggling to accept and support their children, as Linda once did. And, as a part of Steps2Connect, Linda, along with a therapist, is helping families reunify and create supportive bonds with these young people.

Steps2Connect in Pennsylvania is one of fourteen projects across four sites being designed, implemented, and evaluated in the National Quality Improvement Center on Tailored Services, Placement Stability, and Permanency for LGBTQ+ Children and Youth in Foster Care (QIC-LGBTQ+), a five-year federally-funded project led by the Institute.

For children and youth in foster care, life is precarious. Movement among schools, families of origin, foster families, and group homes all contribute to a sense of uncertainty and isolation. The mental health statistics for this population are known: high rates of anxiety, depression, and suicide. But what isn’t widely recognized is the soaring increase in these mental health challenges for one particular segment of foster youth over their peers—those with diverse sexual orientation, gender identities, and gender expressions.

LGBTQ youth are about twice as likely to attempt suicide compared to their peers and there are studies that show that percentage to be much higher. They are six times more likely to experience depression, and three times more likely to use illegal substances than their peers. Those numbers get a lot more stark when we break down that acronym of identities, particularly for youth who are transgender. If this was any other population in our society, people would be outraged.

-- Angela Weeks, Project Director, The Institute

LGBTQ+ youth are disproportionately represented in foster care. While they represent less than ten percent of the general US population, they make up more than twenty percent of youth in foster care.¹

And in the foster care system, they are far more likely to be mistreated, and far less likely to be adopted or fostered than their peers. Some LGBTQ+ youth experience upwards of twenty different placements before finally aging out of the system. This makes schooling, friendships, and reliable routines nearly impossible. And it also makes unlikely the acquisition of those coming-of-age skills that families routinely impart to young people: paying bills, applying for college, or getting an apartment.

With limited familial relationships and few life skills, young people who age out of foster care are left to meet basic needs on their own. This contributes to large numbers of LGBTQ+ youth experiencing homelessness. Studies report that almost half of youth homeless populations are LGBTQ+.² The experiences around homelessness also leads to higher rates of incarceration for crimes related to poverty, including vagrancy, sex trafficking, and property crime. Unfortunately, child welfare systems can play a role in LGBTQ+ young people not receiving culturally-responsive care and providing protection and support so these young people can successfully transition into adulthood with lifelong supports and a general belief that they are loved for who they are.

In 2016, the federal government funded the Institute to lead a five-year project to design, implement, and evaluate new innovations to support LGBTQ+ youth in foster care and their families. Just two and a half years into the project, the QIC-LGBTQ+ operates an astounding number of interventions across four states. These fourteen interventions are broadly focused on helping young people to improve self-esteem and coping skills when facing discrimination; working with families to move them from struggling with acceptance of their young person to a place of affirmation and support; increasing permanent connections with supportive and affirming adults; and determining successful methods for collecting data on diverse sexual orientation, gender identity and expression within the child welfare intake and assessment processes.

Linda and her peers, with relevant experience, are an important part of this process with both youth and parent peer support. Linda knows only too well the struggles of moving this work forward. Creating understanding and empathy among families who may not wish to discuss their struggles with an LGBTQ+ child is challenging because the family first has to identify themselves before the QIC-LGBTQ+ can reach them. The very services they might need to restore harmony in their household are the very ones they are unlikely to pursue. For those families hesitant to speak with a therapist, Linda presents a softer, more approachable opportunity for consultation and guidance. 

I have gained so much knowledge, understanding, and ability to love people for who they are and not for what I think they should be. All my daughter wanted from me as a mother was to love her for who she was. We lost so many years because I didn’t accept her but now we have the mother and daughter relationship that I have always dreamed of.

-- Linda, Family Support Partner, Steps2Connect, Pennsylvania

Some of the inventive ideas for meeting QIC project goals, like enlisting Family Support Partners, came from the valuable input of parents, like Linda, and of LGBTQ+ youth participating in the design and implementation of these interventions. Tapping into the ideas and expertise of those we serve and partnering with them to build well-informed solutions is our best opportunity for improving the lives of youth and families.

QIC-LGBTQ+ will continue to work with the sites to refine their interventions and move into the full implementation and final evaluation. Assessing and perfecting the effectiveness of these projects is critical because QIC is seeking a seismic shift in our culture. The QIC-LGBTQ+ strives to increase the likelihood that LGBTQ+ youth in foster care will have less instability while in care and receive well-informed supports to meet their unique needs. To accomplish these goals, they need proven successes that can be replicated nationally throughout the child welfare system. Nothing less will do.

Find more information about QIC-LTBTQ+.

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_{The National Quality Improvement Center on Tailored Services, Placement Stability and Permanency for Lesbian, Gay, Bisexual, Transgender, Questioning, and Two-Spirit Children and Youth in Foster Care (QIC-LGBTQ2S) is funded through the U.S. Department of Health and Human Services, Administration for Children, Youth and Families, Children’s Bureau, grant #90CW1145. The contents of this publication do not necessarily reflect the views or policies of the funders, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Department of Health and Human Services.}

_Resources:

_{1. Wilson, B.D.M., Cooper, K., Kastanis, A., & Nezhad, S. (2014). Sexual and Gender Minority Youth in Foster care: Assessing Disproportionality and Disparities in Los Angeles. Los Angeles: The Williams Institute, UCLA School of Law. http://williamsinstitute.law.ucla.edu/wp-content/uploads/LAFYS_report_final-aug-2014.pdf.}

_{2. http://truecolorsunited.org/our-issue/}

Being able to support primary relationships for young kids is just so important; that’s the glue that you return to throughout your life...every parent needs support once in a while. 

-- Kate Wasserman, Co-Director, The Institute

If seeing life through the eyes of a child can make one wise, then the work of the BRIDGE team is pure genius. In 2015, The Institute, together with a number of community partners, embarked on a four-year federally- funded project in southern Maryland to support parents and to improve the social and emotional well-being of children under the age of 5.

We think of anxiety, depression, and trauma as adult experiences, but the youngest among us are not immune. Even when highly verbal, very young children are limited in their ability to explain the logic behind their behavior. But, as anyone who has experienced a toddler meltdown knows, the behavior itself is a form of a communication. There is quite a big difference between the occasional temper tantrum and the kind of repeated behavior that alerts us when something is seriously wrong. And there are tools to know the difference.

Southern Maryland BRIDGE (Building Resilience from Infancy through Development and Early Childhood) is in rural Maryland: Charles, Calvert, and St. Mary’s Counties. A quickly growing region, its workforce is stretched to meet the needs of families in the region. These professionals have experience and skill in addressing a wide variety of challenges that their community faces, but, until recently, they did not have much access to specialized training in, and services for, the mental health and social and emotional needs of their youngest residents.

Our providers are coming to us very burnt out, very tired and saying they don’t know how to work with these very young children. We help them build the skills they need to not only work with one child but work with the whole classroom.

-- Kelly Hutter, Executive Director, The Promise Resource Center

Helping little kids who need help seems straightforward, but the BRIDGE team, which includes local health departments, community- and clinic-based mental health providers, and the Maryland Coalition of Families, face logistical challenges, and some misconceptions. Children who are not yet in school are often not in plain sight of those who can offer them help. Parents and caregivers may not identify the behavior of young children as anything other than a challenging developmental phase that they hope the child will outgrow. If they do seek support, or know where to ask for help, parents are often worried about formally diagnosing their child for fear that they might be labeled for years to come with a mental health challenge. The BRIDGE team works to spread the message that quite the opposite is true: addressing mental health needs early in life can have a profound positive impact on a child’s future.

If we catch challenging behaviors early, and we can get services in early, we improve the overall outcome for that child later on in life. We send the child ready to learn to school.

-- Kelly Hutter, Executive Director, The Promise Resource Center

With the input of families and the partnership of Maryland Family Network, BRIDGE launched a marketing campaign directed at parents with the slogan, Parenting is Hard. BRIDGE Can Help. They established a phone number to text or call and a parent with experience navigating the mental health system on behalf of their own young children answer the line. They provide callers with guidance on where to go if more support is needed, and provide support and access to resources including parenting skills training.

This campaign with its peer-to-peer parental “warmline” is reflective of The Institute’s commitment to elevating family voice and the practice of continuous quality improvement. This warmline, coupled with the availability of new and tailored services and focused trainings for professionals and parents, is an illustration of how the BRIDGE leadership acknowledged that family voice was missing, and worked to filled a gap.

Once a month (and often more) The Institute’s Parent, Infant, & Early Childhood (PIEC) co-directors, Kate Wasserman and Margo Candelaria, and their team make the drive to beautiful Southern Maryland to meet face-to-face with their partners in Charles, Calvert, and St. Mary’s Counties to continue building the network of relationships that has made BRIDGE successful. With services that now exist in southern Maryland, a trained workforce to address the needs of our youngest, and a place for parents to ask questions, the growing BRIDGE network is prepared to carry the work forward with well-researched tools and methods for serving parents and their young children.

Find more information about The Institute’s work in early childhood.

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_{Southern Maryland BRIDGE is funded through a cooperative agreement with the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Grant # 1U79SM062471-01.}

It’s in those moments when I hear about a kid feeling safe enough to talk about their life experience, or knowing that folks are using a tool we created that helps a kid tell their story …to me that’s beyond impactful.

-- Meredith Gunn, Director, Instructional Design & Media, The Institute

When we think of the word adoption, we often think about fulfillment: the child who now has a safe place to call home and the parents whose hearts are newly filled with love. The reality can be more complex and, surprisingly, often involves some grief and loss.

A new nationwide program—produced here at UMB and set to launch this fall—is designed to improve the experience of more than 130,000 children placed in adoptive homes across the US each year. Sixty percent of children arrive to their adoptive families through the child welfare, or foster care, system. Child welfare workers interact with each child and their family to negotiate and support the placement. But not a single graduate social work program in the US provides intensive training specific to the unique mental health needs of adopted children.

A child arriving in a new family experiences a severely disorienting sense of loss. Birth parents, siblings, extended family, friends, schools, foster families, familiar places, belongings, culture, language, food, and birth names are all at the core of one’s sense of self. Yet these are the very things that a child may lose. Adoption across racial and ethnic lines causes additional stress to a child who feels different from their new family and may not feel they can express their true self. Additionally, many youth who have experienced adoption have also encountered significant trauma in their lives. Adoptive parents may feel tremendous love for their new family member and need resources to support a child who has experienced these losses and trauma.

In 2015, the federal government identified a need for training for child welfare and mental health professionals so they would be better able to work with children and youth in a way that is sensitive to the experience of being adopted. The Center for Adoption Support and Education (CASE), a national leader in mental health services for the foster care and adoption community, leads this work in partnership with The Institute.  Together, the two institutions designed the National Adoption Competency Mental Health Training Initiative (NTI).

It was an awesome opportunity for CASE to ask us to be their partner. To transform a workforce that touches the lives of the most vulnerable populations of young people and their families is profound.

-- Marlene Matarese, Deputy Director, The Institute

There are almost 500,000 child welfare and mental health workers across the U.S., making an online training program the best way to deliver consistent, effective content. To produce such training, The Institute drew on its experience with engaging adult learners and utilizing data to develop and implement transformative online learning programs. NTI is designed with adaptive, cutting-edge technology that delivers interactive, multimedia content to teach a variety of learners. The Institute uses the principles of continuous quality improvement to evaluate and improve the training before, during, and after initial launch, including piloting the training in 2017 with 7,500 child welfare and mental health professionals across eight states. The Institute’s dedicated evaluation team uses data to recognize barriers to learning, evaluating knowledge gains through pre- and posttest results, and ensuring decisions are informed by the learning experiences of the intended audience.

The data have shown us that people are feeling more competent, both in their ability and in their knowledge base, at the end of the training. People are using the skills that were presented in the training.

--Tony Bonadio, Research Assistant Professor, The Institute

With its range of resources and practical tools, NTI builds skills for immediate use in a professional’s practice. It will be widely available in September. Although NTI training requires more than 25 hours to complete, the commitment of time and energy is well worth the effort to better serve the unique needs of children and adoptive families.

Find more information about NTI.

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_{The National Adoption Competency Mental Health Training Initiative is funded through the Department of Health and Human Services, Administration for Children and Families, Children’s Bureau, Grant #90CO1121.}