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Dr. Lindsey is assistant professor, School of Social Work and School of Medicine, University of Maryland, Baltimore, 525 W. Redwood St., Baltimore, MD 21201 (e-mail: firstname.lastname@example.org). Dr. Lee is assistant professor, School of Social Work, University of Maryland, Baltimore. Mr. Sullivan is executive director, Anne Arundel County Mental Health Agency, Inc., Annapolis, Maryland.
Treating youths with serious mental health needs without separating them from their families and communities has been a goal for over two decades. However, there is a dearth of innovative and evidence-based interventions that provide long-term, family-based in-home services. Maryland's In-Home Intervention Program for Children (IHIP-C) is a new endeavor that is guided by systems-of-care principles and aims to prevent out-of-home placement for youths with serious mental health needs, including conduct disorders, oppositional defiant disorder, major depression, and bipolar disorder.
The IHIP-C is the result of a confluence of a developing vision of how to better serve youths with serious mental health issues and the opportunity provided by the closing of a regional psychiatric facility, Crownsville Hospital Center in Maryland. Mental health administrators and service providers from five jurisdictions most affected by this closure had noted that children with serious psychiatric disorders served by the public health system were consistently being referred to residential treatment centers. A lack of other community-based alternatives cultivated an overreliance on these treatment centers, resulting in a waiting list for families seeking treatment for their children's mental health needs. State mental health administrators realized that high-cost residential services were consuming a large share of the financial resources for children's mental health care. In addition to the financial inefficiency, concerns were raised about the effectiveness of group placements for youths with mental health needs.
In considering a family-focused, community-based intervention for youths, state mental health administrators and service providers envisioned a program where families could receive in-home services and support that were available 24 hours a day, seven days a week, and that were strengths-based, supportive services in situ as an adjunct to outpatient counseling and psychiatric treatment. The result of this vision was the IHIP-C, launched in January 2005.
The program employs four tenets in serving children and adolescents with mental illnesses and at risk of out-of-home placement: provide intervention services around-the-clock that are evidence based, family focused, multijurisdictional, community based, and in the home; ensure that services are individualized, coordinated, and built on the family's strengths and resilience; either reduce admissions to more costly and more restrictive institutional placements by providing clinical services to families or assist families with reunification after an out-of-home placement; and link children and adolescents to an outpatient therapist throughout their tenure in the program. A mental health clinician is part of each service team and provides direct services. Anne Arundel County Mental Health Agency, Inc., was designated as lead agency for the five-county collaborative project. The IHIP-C is primarily funded through the state-supported psychiatric rehabilitation program.
The target population for the IHIP-C is youths who are deemed high-end users of the public mental health system through institutional care (that is, hospitalization or residential treatment centers) and foster care children, ranging from ages eight to 18. Children and families can be served by the IHIP-C for as long as 15 months—a substantially longer period than comparable alternative community-based intervention programs (such as multisystemic therapy) that target similar risk groups. Families transition from the program as their treatment goals are met—a determination jointly made by IHIP-C clinical staff and the outpatient clinician of record. Program success is defined as improved pre-post assessments of family functioning and when problematic child and adolescent behaviors are contained within the natural ecologies of family and community, thus mitigating the potential that a youth will make contact with a residential treatment center.
Each family is assigned an in-home behavioral interventionist who is primarily responsible for service delivery. This individual conducts an initial assessment and provides weekly clinical services to the child and family (seven to ten hours during the initial 45 days in the program; two to two-and-a-half hours thereafter), in addition to being available to families for crisis intervention as needed. The behavioral interventionist provides short-term family support, parent training and skills enhancement to better manage their child's behavior, and service coordination and empowerment regarding the continued use of outpatient mental health services.
Future research plans include subjecting the IHIP-C to a clinical trial to determine its efficacy as an alternative clinical practice for youths with persistent mental health problems or high-end users of the most intensive services. Results from such a trial might further answer the question of whether this novel practice can prevent more costly and intrusive out-of-home placement.
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