|The New York Foundling Forging History with Evidence|
|Tuesday, 27 April 2010 06:05|
The New York Foundling has been on the frontlines of child welfare since two Sisters of Charity took in the first baby abandoned on the steps of their Greenwich Village convent in 1869. During the next 40 years, The Foundling would offer refuge to more than 27,000 infants left by distraught and impoverished mothers with hopeful, if heartbreaking, notes pinned to their clothes.
Today, nearly a century and one half later, The New York Foundling continues to be at the cutting edge of services for children – now with an arsenal of new programs and evidence-based therapeutic approaches designed to heal and care for families as a whole.
The New York Foundling is one of the largest child welfare agencies in the city. It provides care for more than one thousand children living in foster boarding homes throughout the five boroughs. Its residential programs target the needs of another 150 youngsters, including 65 pregnant or parenting teens. Preventive programs designed to avoid out-of-home placement are helping to keep more than 900 families safely together at any given point in time.
Over the years, The New York Foundling has had more than its share of pioneering programs. It placed its first child with a goal of adoption as far back as 1873. In 1945, Dr. Joseph DiLeo opened the Child Developmental Clinic and began his groundbreaking analyses of children’s drawings as a diagnostic and assessment tool. In 1968, The Foundling launched New York City’s first private family day care program.
Under the direction of long-time Medical Director Dr. Vincent J. Fontana, The Foundling opened its Maria Lucadamo Crisis Nursery and Family Center in 1982. The Crisis Nursery -- in many ways an updated and family-focused variation of The Foundling’s earliest work -- allows troubled or overwhelmed parents to drop off their children for safe but temporary respite care as they get the help they need. The Crisis Nursery allows families to avoid serious risks of abuse or neglect without formal entry into the Child Welfare System. For several months after discharge, social workers follow up with families to ensure that the children are, once again, living in a safe, nurturing environment.
In 1999, The Foundling established a permanent vehicle to carry forward Dr. Fontana’s extraordinary vision and commitment with the creation of the Vincent J. Fontana Center for Child Protection. This unique institution supports The Foundling’s mission through a combination of research, training, education and advocacy on a wide range of child welfare issues.
A Time of Change
When CEO Bill Baccaglini, Jr. arrived in May 2003, following a long career at the NYS Office of Children and Family Services in Albany, The Foundling -- along with every other provider in New York City -- was about to embark on a major transformation of the child welfare system. Administration for Children’s Services Commissioner John Mattingly was determined to reduce the number of children placed in foster care. And, he believed, those who were placed in care should live in family-based settings rather than large and often remote institutional programs.
For much of the subsequent seven years, Baccaglini has guided The Foundling through this challenging and often perilous transition. “We have kept our core businesses but have become more thoughtful about engaging in long range planning,” he says. “We have tried to see the direction that the system – all the systems – are moving and put those sorts of programs in place. Agencies like The Foundling, with its size and history, have to look forward and perhaps influence the direction of the field.”
In 2005, Baccaglini closed a 175-bed residential program that The Foundling had operated at its St. Agatha’s Campus in Rockland County. “We saw ACS moving away from residential care and the real estate market was good, so we wound up selling most of the property there to the Nanuet School District,” he explains. “We were very, very fortunate.” Proceeds from the sale are now helping to finance several new Foundling initiatives.
Looking forward, The Foundling then began to move aggressively into the bold new world of evidence-based service models. While at OCFS, Baccaglini had played a key role in building the State’s commitment to using research-driven, family-based therapies – particularly Multi-Systemic Therapy (MST) -- with youth coming out of upstate juvenile justice facilities.
MST uses highly trained therapists, with a maximum caseload of six families, to work at home with the entire family over six to twelve months. Therapists visit the home multiple times per week and are also available by phone 24 hours a day. The youth’s entire social network is considered and relied upon to assist the youth and family in making positive changes. Therapists use a tightly prescribed regimen of cognitive, behavioral, and family therapies to address issues relating to substance abuse, family dysfunction, negative peer influences, and poor school attachment. Data from 30 years of randomized trials with juvenile offenders suggests that MST produces a 25-70% decrease in rates of re-arrest at a cost significantly lower than that of placement.
When ACS began contracting for evidence-based, intensive preventive service programs for adolescents in 2007, The Foundling launched an MST-based program of its own.
If one evidence-based therapy is good, however, three are likely to be better.
In February 2007, The Foundling began working with ACS on a new Juvenile Justice Initiative (JJI) designed to reduce the numbers of New York City youth being placed in upstate facilities operated by OCFS. The “Blue Sky Project”, as it is now known, took the unprecedented step of integrating three evidence-based, family- and community-based treatment models– MST, Functional Family Therapy (FFT), and Multidimensional Treatment Foster Care (MTFC) – into a single, continuum of care. The unique Blue Sky approach was designed by the Annie E. Casey Foundation and the developers of the three evidence-based treatments.
Blue Sky only takes cases where a youth would otherwise be going to placement. “These are kids who have been arrested, adjudicated and the investigation report by the Department of Probation recommends placement. Then we can consider the case,” says Dr. Sylvia Rowlands, the Director overseeing Blue Sky and The Foundling’s mental health clinic. “We have 60 families at any point in time and an average length of time in the program of 4.5 months. So, we serve over 150 families a year.”
The arsenal of therapeutic approaches – each one strictly defined following decades of clinical testing -- offers Blue Sky some significant advantages.
“Because we have the continuum, we can take kids that a stand alone program can’t,” says Rowlands. Each of the models offers a particular focus and various strengths with specific youth and families. Youth and families can move from one modality to another depending on their needs as they move through the program.
“We use the psychiatric adaptation of MST, rather than the standard, so we can take kids who have conduct disorders plus bi-polar, thought disorders, even some Axis II disorders,” says Rowlands. “The MST Therapists carry a caseload of four families and they have a much shorter engagement period with the family and immediately go to doing interventions.”
Functional Family Therapy (FFT), on the other hand, proceeds through a series of phases, beginning with a process of engagement and motivation with the family, before moving on to modifying behavior. FFT is primarily focused on the structure of family relationships in the home. “The FFT team tends to take a lot of the family violence kinds of cases,” says Rowlands. “If there are more pressing external risk factors in the community, we would use MST.” FFT teams work with caseloads of eight families at a time. Data from prior clinical trials indicate that FFT reduces recidivism by 25 to 60%.
For youth who cannot stay at home due to safety or other concerns -- but would be badly served by a stint in an upstate institution – Blue Sky uses Multidimensional Treatment Foster Care (MTFC). Another highly researched and rigorously delineated treatment model, MTFC places youth in foster homes – one child at a time with specially trained and compensated foster parents – for a limited period of time.
“Foster parents are required to run a point level, behavior modification system,” says Rowlands. “At the same time, they are trained not to get into escalating a situation with kids. They are not the disciplinarian; the program supervisor is. Kids and foster parents have a really supportive relationship.”
MTFC uses a daily report system in which a trained caller phones the foster parent and asks whether the youth has experienced any of 37 different behaviors and how stressful the behaviors were. “Research has shown that after three calls with six or more stressful behaviors, a kid is going to blow out of foster care,” says Rowlands. “So, we get in there really fast and do an intervention. We can graph behaviors and know if our treatment is effective and we provide weekly skills training to the foster parents on how to deal with those behaviors.”
MTFC appears to veer from current consensus in thinking that foster parents and birth parents have no contact. “We avoid all kinds of triangulation that way,” says Rowlands. “Our experience is that when they get together you get alignment in a way that is not healthy. Also, when you let a biological parent get comfortable with a foster parent, the urgency to get that kid home is removed. We keep the tension up on the family.”
However, kids in MTFC are home for visits quickly and often according to a defined schedule. “Beginning in week three, kids are home for a family session,” says Rowlands. “Next week they are there for four hours, then eight hours, then an overnight. After that it is a weekend and then for four days. We debrief back at the foster home; we debrief with the bio parent. Kids are never denied home visits. They are never a privilege. It is where you are going. You have work to do; let’s get it done.”
Blue Sky uses MST Therapists to work with birth families while the youth are in MTFC and to help with the transition home. “They are making sure the integration happens and that the parents have the behavior modification skills necessary to address anti-social behaviors,” says Rowlands. “Then we fade out.”
The highly structured therapeutic approach works. “For the majority of our families – 75% of them – kids are back home in about 4.5 months,” says Rowlands. “Ours is a little faster than the standard MTFC model because we have the MST Therapist attached.”
The Blue Sky blending of three different evidence-based practices into a single program is unique – and did not happen without enormous challenges. “We are the only agency that the developers have sanctioned doing this at the current time,” says Rowlands. Numerous foreign researchers have wanted to visit. New Zealand recently came for a look, as did Norway.
Developers of evidence-based treatments are notoriously strict in requiring total adherence to the model as developed and tested. “If you don’t do the model exactly this way, then it is not connected to the research,” explains Rowlands, “and the reason you brought it in was to get those outcomes demonstrated in the research.”
For Blue Sky, Rowlands has a regular one-hour weekly conference call with the developers of all three therapeutic models – the “Blue Sky Faculty”. “They oversee all the adaptations on the ground,” she explains.
Now, The Foundling and “Blue Sky Faculty” want a full-blown clinical trial to test the results of the new approach. The obstacle has been the need for random selection of youth either for treatment or a control group. “Judges have gotten used to the idea that Blue Sky is here,” explains Rowland. “If they want it for a particular youth, they want it.”
In the meantime, however, the Robin Hood Foundation has stepped forward with a $1.1 million grant to ACS which will support a Foundling expansion of JJI focusing on youth with serious mental health diagnoses. The program will utilize the psychiatric adaptation of MST. “Robin Hood funds only the best and brightest initiatives to combat the root causes of poverty,” said David Saltzman, Executive Director of the Robin Hood Foundation. “We are excited to partner with Children’s Services and The New York Foundling – who have expertly collaborated on the successful Juvenile Justice Initiative -- to bring this innovative service to New York City for the first time.”
Follow the Evidence
“There have been some ripple effects from Blue Sky,” says Baccaglini in what seems to be an understatement.
The program’s success in avoiding juvenile justice institutional placement for some of New York’s most challenging youth by providing families with intensive, but relatively brief, therapeutic services seemingly has implications for all child welfare services. Baccaglini is determined to learn from this experience and begin applying evidence-based service models in other Foundling programs.
In September, The Foundling transitioned its entire preventive services program in northern Manhattan -- 130 slots – to a new variation of Functional Family Therapy now being called FFT-CW.
“We are trying to see if FFT as a modality can work within the context of traditional preventive services here in New York,” says Baccaglini. There have been bumps along the way, he admits, as staff work out tensions between the child welfare model with its primary focus on child safety and FFT’s traditional juvenile justice focus on the development of effective relationships which result in family safety.
Baccaglini is convinced the new approach will work and that the benefits will be enormous. ACS is already pressing preventive service providers to limit family lengths of service to 12 months – versus historic levels of up to two years or more. Baccaglini points to FFT’s demonstrated Blue Sky track record of effectively serving difficult youth and families in just 4.5 months.
“That is what best practices do,” says Baccaglini. “They get out all the noise. Case workers want to be all things to all people. That is what leads to two and three year lengths of stay. We need to focus on what this family needs and move forward.”
“Our FFT-CW length of stay is already down now to 13.5 months,” says Rowlands who provides clinical oversight to the project. “If we can get it to six months, we are saving the City 75% on the cost of services.”
To make the program work financially for The Foundling, however, Baccaglini will have to convince ACS to pay for preventive services by the total number of families served rather than the number of service slots available at any single point in time.
Similarly, The Foundling has applied an evidence-based service model – Brief Strategic Family Therapy (BSFT) – at a new Article 31 outpatient mental health clinic in Harlem.
“The change has been amazing,” says Rowlands, who also oversees this program. “Our length of stay is 12-16 months. Other mental health clinics experience lengths of service of two, four, ten years. As a result, we never have a waiting list. Our length of time from intake to therapist is 1.2 days.”
The clinic, which opened last year, takes clients through a variety of contracts and referral sources. “We provide family treatment for juvenile youthful offenders,” says Rowlands. “We work with kids who have placement disruptions in foster care. We have a contract with Turnaround for Children, which goes into failing NYC schools and does a total culture change. We do the crisis conference calls at the school so that 911 isn’t called anymore. It helps keep those kids in school.”
The Foundling has not implemented any of the new evidence-based practices in its traditional foster care or residential programs – at least not yet.
“I think we as a system have to bring to bear much better intervention strategies on our foster care population,” says Baccaglini. “We have to be much more focused on the way we do business with our families.”
If Blue Sky’s Multidimensional Treatment Foster Care (MTFC) can reunite some of New York’s most challenged youth and families in less than five months, it should also be applicable to the broader foster care population, says Rowlands. She notes that while MTFC is primarily geared to older youth, Patty Chamberlain, MTFC’s developer, has a similar evidence-based model called Early Intervention Foster Care (EIFC) for younger children.
One major Foundling initiative designed to better meet the needs of children in foster care is Mott Haven Academy Charter School – a unique charter school now in its second year of operation.
“We know that urban public schools are not organized in ways that can accommodate the chaotic lives of kids in foster care,” says Baccaglini. Foster care children face an enormous array of educational challenges, including the intense emotional and behavioral turmoil associated with family separation as well as frequent school transfers as they move through various stages of the foster care system. “Research will tell you that by the fourth grade, foster care kids are one-and-one-half years behind other students,” says Baccaglini. “That is a recipe for dropping out of school.”
In response, Baccaglini developed the vision for a school attuned to meeting the specialized needs of foster care children and two other high risk groups – families receiving preventive services and children applying from the broader Mott Haven community, each of which make up one third of the total school enrollment. “It is the poorest Congressional District in the country,” says Baccaglini. “Nobody can accuse us of creaming. If anything, we are taking kids with the most challenges anywhere in the system.” Following last month’s charter school lottery, Haven Academy had a wait list of over 180 applicants for next year’s 15 community student slots.
Haven Academy opened last year with a kindergarten and first grade. This year, students advanced as the school added a second grade and admitted a new kindergarten class. “In order to create your own school culture, you have to start at the beginning and then add one new grade a year,” says Baccaglini. “That way, by the time you are fully established, the older kids serve as role models for the younger children.”
Unlike other schools, Haven Academy offers a range of services for its high need and child welfare-associated students. Turnover has been extremely low, due in part to the school’s willingness to arrange transportation for foster care and/or preventive children who are forced to move during the school year. “We run three different yellow bus routes within a five-mile radius,” says Principal Jessica Nauiokas. “For students who fall outside of those bus zones, we run two private transportation services.”
Haven Academy also has two MSW-level social workers for counseling and school psychology interns help with assessments and counseling several days per week. The school also works closely with The Foundling’s Bronx foster care and preventive services staff.
Next year, this collaboration is likely to grow stronger when Haven Academy moves out of shared space in a NYC public school to a brand new 55,000 sq. ft. facility across the street. “It will be home to the charter school as well as The Foundling’s entire child welfare infrastructure in the Bronx,” says Baccaglini.
So far, the academic outcomes for children at Haven Academy appear to be extremely positive. “Last year, we felt very confident that we were sending our kindergarteners to first grade with the skills they needed to be successful,” says Nauiokas. For the first graders, who came with less preparation, Haven Academy is making a difference. “About 80% of that cohort is at grade level,” says Nauiokas. “For the other 20%, we have special education services, at-home tutoring and summer interventions. They just need more time with the academic instruction they didn’t have before they got here.”
In addition, The Foundling operates a number of other large and important human service programs. The agency is home to 175 adults with developmental disabilities living in the Bronx and Rockland County. A $10 million Head Start program serves 1,200 families in Puerto Rico. And, The Foundling recently became a provider of Supportive Housing for youth with mental health or other chronic disabilities who have aged out of foster care.
For The Foundling – like most providers of child welfare services – the next several years are likely to be challenging. Baccaglini expects that recently announced reductions in future ACS reimbursement for foster care services under a new round of contracts could cost the agency several million dollars next year alone. That hurts, even for an organization with an annual budget approaching $100 million and a $60 million endowment.
At the same time, Baccaglini sees at least some silver lining in the cloud. “I am excited about the opportunity this gives to examine our businesses,” he says. “Are there efficiencies to achieve? In flush times, people are less inclined to examine critically the way they go about their business.”
Baccaglini remains strongly committed to advancing the use of evidence-based practices in the child welfare field – even to the extent of funding expensive evaluations of the FFT-CW prevention model and Mott Haven Academy Charter School. “We owe it to ourselves and to the rest of the child welfare community to be able to say that what we are doing actually works.”