Trends and shifting ecologies: part II

Child Adolesc Psychiatric Clin N Am 12 (2003) 779 – 793 Trends and shifting ecologies: part II Andres J. Pumariega, MDa,*, Nancy C. Winters, MDb a Department of Psychiatry and Behavioral Sciences, James H. Quillen College of Medicine, East Tennessee State University, Box 70567, Johnson City, TN 37614, USA b Child and Adolescent Psychiatry Residency Program, Department of Psychiatry, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, DC-7P, Portland, OR 97201, USA Children and adolescents are embedded in the ecologic context of their families, schools, neighborhoods, and other social systems (such as child welfare and juvenile justice) responsible for their care. Contextual factors are particularly relevant to child and adolescent mental health emergencies. Generally, a child’s parents or other responsible adults decide when the child’s emotional or behavioral problems are beyond their control and require emergency services. The timing of the acute presentation is as likely to result from impairment in the adults’ functioning (or capacity to contain the child’s behavior) as from a worsening of the child’s psychopathology. In a review of factors related to inpatient hospitalization for children and adolescents, Gutterman et al [1] concluded that hospitalization was chosen when a youth’s behavior was perceived as out of control or when efforts to increase the coping abilities of the youth and family were unsuccessful. It is important for emergency services to address not only a child’s psychopathology but also how those problems interact with the resources and vulnerabilities of the child’s caregivers. Approaches that address these factors are most likely to be successful not only in resolving the crisis but also in reducing future risk. While a child’s ecologic context influences the timing, nature, and severity of the crisis, the organization of emergency mental health services in the ecology of the health care system may influence the outcome of the crisis. In communities that lack an organized system of care, traditional hospital-based emergency services may become the ‘‘default’’ mental health crisis system. Such settings are poorly equipped to address the contextual nature of children’s mental health crises. Typically, they emphasize screening for psychiatric hospitalization rather * Corresponding author. E-mail address: [email protected] (A.J. Pumariega). 1056-4993/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S1056-4993(03)00033-6 780 A.J. Pumariega, N.C. Winters / Child Adolesc Psychiatric Clin N Am 12 (2003) 779–793 than crisis intervention. Emergency services unaffiliated with outpatient mental health programs are unable to provide suitable referrals for outpatient mental health treatment. For patients who are referred to outpatient follow-up from hospital emergency departments, noncompliance is known to be a substantial problem [2]. Little evidence exists that psychiatric hospitalization itself lowers the risk for subsequent crises [3], perhaps related to its emphasis on the child’s psychopathology rather than the family and systemic contextual factors implicated in the crisis. The system of care model was developed to address the needs of children and adolescents with the most serious mental disorders who are at high risk of presenting with acute and emergent symptoms. This article describes the shifting ecologies of emergency services within organized systems of care, which offer community-based and ecologically oriented approaches to child psychiatric emergencies. Contextual perspective of child mental health emergencies Typology of emergencies At one point or another, all child-serving agencies face a common set of child mental health and psychiatric emergencies. These emergencies can be summarized as follows: (1) the child is dangerous to self or others, either through selfdestructive or suicidal impulses or aggressive (or even homicidal) impulses; (2) the child is in danger from others (from abuse, victimization, or severe neglect), with associated mood or anxiety symptomatology; (3) the child is unable to maintain his or her own safety and use environmental supports (through temporary impairment of mental status or severe or acute developmental regression); (4) the child or adolescent engages in serious drug or alcohol use or abuse that endangers his or her life, either through intoxication and behavioral effects of such (eg, delirium or psychosis), through medical complications from the drug(s) themselves (or interaction with prescribed agents), or through accidental overdose; (5) severe environmental stressors adversely impact the family system and render the child vulnerable to heightened stress (either through impairment of the child or the parent/caretaker); (6) environmental supports (family, community, services) break down to point that they are unable to provide critical safety and supports for child. The loss of environmental supports often may determine timing of the emergency presentation, just as they may have forestalled an earlier or more acute presentation. Contributing contextual factors In considering a contextual approach to different child psychiatric emergencies, one also must consider the multifactorial nature of such emergencies. Several important innate, transactional, and environmental factors are often A.J. Pumariega, N.C. Winters / Child Adolesc Psychiatric Clin N Am 12 (2003) 779–793 781 operative in any such emergency situation. Such factors include (1) the child’s innate vulnerability to mental illness or developmental disability (which may have been masked by contextual factors before the crisis), (2) the child’s degree of exposure to drugs and alcohol, (3) the family’s psychosocial functioning (including parental adaptation and mental illness and availability of social supports), (4) the adequacy of the physical, educational, and financial resources of the family, (5) the resources of the extended family, kinship network, or community (which can vary based on socioeconomic, cultural, and geographic factors), and (6) the adequacy of formal community-based services to ameliorate the previous factors, including clinical and formal support services. Application of community systems of care principles to address child psychiatric emergencies Traditional response to child mental health emergencies Traditional community mental health crisis services tend to operate in a standard manner, often regardless of whether the patient is a child or adult and frequently regardless of a child’s individual needs. The child is most often seen at a crisis intervention office or a hospital emergency room, at times with a parent but infrequently with all relevant family members. (If the crisis call is initiated at school, parents might not even be present.) If the crisis can be defused during the crisis visit, the child is referred for follow-up outpatient services, often not even intensive outpatient services. If the child continues to be a danger to self or others, he or she is most often removed from family and natural supports and sent to a range of out-of-home placements, from youth shelters to inpatient facilities and even long-term residential treatment facilities. Categorical services are often duplicated in the intervention and follow-up process, such as multiple case managers if the child is involved with multiple agencies (such as mental health and child protection). When a child is treated in such an institutional environment, the family often receives limited services (mostly infrequent family therapy sessions at the institutional facility, if they are fortunate enough to be able to travel to this setting). Little in the way of intensive intervention is provided in the home and community environment where problems (and solutions) reside. The transition of treatment from the institutional setting to community services is often limited at best despite studies that point to this being the critical factor in the success of this treatment. The literature offers little support for the use of either inpatient or residential treatment programs [4,5]. The traditional approach to crisis intervention has other unintended adverse consequences. Families often feel usurped of their primacy in the child’s life when ‘‘experts’’ take over, especially at a critical point in the child’s life. A large share of resources is used for inpatient and residential services, whereas resources are shifted away from community-based treatment and maintenance services. 782 A.J. Pumariega, N.C. Winters / Child Adolesc Psychiatric Clin N Am 12 (2003) 779–793 Few resources are devoted to prevention of crises, whereas most services are reactive to acute disruptions. Relevance of community-based systems principles The community-based systems of care model promotes several important principles that are readily translated to a totally different approach to child psychiatric and mental health crisis services. This model promotes services that are child focused and family driven and are designed to meet an individual child and family’s needs. It promotes an interdisciplinary and interagency team approach, with close coordination of services by different agencies with which the child and family are involved. There is a focus on strength-based approaches in which natural supports are mobilized and enhanced. Services are delivered in the least restrictive environment and in the child’s community. Treatment in out-ofhome settings (inpatient or residential) is either avoided or the child is rapidly returned to the home, family, and community. In this model, service intensity is separated from service restriction, with intensive services delivered in the child’s home wherever possible (such as intensive behavioral interventions, family or individual therapy, and even pharmacologic treatment with nursing and psychiatric services) [6]. Restrictive services are reserved for when the child or community is in danger; they can even be created in the community with flexible services (such as in-home staffing for safety and behavioral management). The family (and the child, if appropriate) is in charge of crisis and follow-up services, driving the selection of interventions and clearly expressing not only the special needs that they need addressed but also the strengths and resources that they can bring to resolving the crisis and longer term problems. This is often done in child and family teams in which the family, child, and other extended family and kinship network members participate in services selection and planning. Services are culturally competent and are oriented to the values and beliefs of diverse cultures and special needs of minority children and families (see the article on cultural considerations elsewhere in this issue). Community systems of care promote the development of preventive services that are oriented to prevent psychiatric crises and acute services. These can include school-based and community-based preventive services (such as suicide and violence prevention programs) and even early intervention services that have long-term impact on highrisk populations (such as families of children who are abused or are at risk of conduct disturbances). Evidence-based, community-based interventions The wraparound approach Developed over the past 15 years, wraparound has been defined as a ‘‘planning process involving the child and family that results in a unique set of community A.J. Pumariega, N.C. Winters / Child Adolesc Psychiatric Clin N Am 12 (2003) 779–793 783 services and natural supports individualized for that child and family to achieve a positive set of outcomes’’ [7]. The wraparound approach emphasizes individualized and strength-based services, family empowerment, cultural competence, unconditional care, and achievement of outcomes [8]. Flexible funding is used to achieve a balance of formal and informal interventions, with an emphasis on nontraditional services, such as in-home providers, respite care, therapeutic foster care, and services by paraprofessionals [9]. Service effectiveness studies suggest that nontraditional services (especially case management, home-based services, and therapeutic foster care) are effective in altering service use outcomes, including change in placements, and use of high intensity services, such as hospitals [10]. In their review of multiple uncontrolled studies of case management using a wraparound approach, Burns et al [7] found emerging evidence for the effectiveness of wraparound, especially in achieving placement stability. Intensive case management New York has several intensive case management models that have been effective for crisis-prone, high-risk youth populations. In a study of the children and youth intensive case management model, case managers were assigned to high-risk youth populations for as long as necessary. Case managers’ activities were based primarily in the community, and they included advocacy, direct support, and service coordination. They were available to clients at all times and had access to flexible funds. When compared with a matched comparison group, children and youth intensive case management led to a decrease in inpatient use and high-risk behaviors [11]. The family-centered intensive case management model is a team case management approach described by Evans et al [12]. Family-centered intensive case management uses parent advocates and flexible funds to purchase economic and social supports, along with in-home respite care. The family-centered case manager’s aim is to support the skills of family members in functioning as the natural case manager for the child. Evans et al [12] compared family-centered intensive case management with a case management approach in children approved for foster care placement. The children who remained in their homes with familycentered intensive case management had better clinical and functional outcomes than the group placed in foster care, which received a comparison case management intervention. Crisis service models Crisis services typically include rapid evaluation and assessment services, crisis intervention services, and follow-up services. After intervening immediately, they provide intensive treatment for the child and family and link them to community support services, averting the use of more costly emergency room and inpatient services. In community-based programs and systems of care, however, the traditional crisis services (such as hotlines, walk-in clinics, and emergency room 784 A.J. Pumariega, N.C. Winters / Child Adolesc Psychiatric Clin N Am 12 (2003) 779–793 services) and emergency room-based services have been replaced by three models of crisis services: mobile crisis teams, short-term residential services (many of these in therapeutic foster home settings), and home-based crisis services. Mobile crisis services Mobile crisis teams have the advantage of meeting the child and family where the crisis is occurring. Milwaukee, Wisconsin serves as an example of a community with mobile crisis teams that are integrated into a continuum of community-based mental health services. Mobile urgent treatment teams are publicly funded, cityoperated teams available on a 24-hour, 7-day-a-week basis to all Milwaukee County residents regardless of insurance status. Child psychologists, psychiatric nurses, and psychiatric social workers staff mobile urgent treatment teams. Two clinicians from the team go out to the home and evaluate whether the child or adolescent can be maintained in the home or needs a higher level of care. They first attempt to resolve the crisis, but they have access either to a county-run inpatient program or crisis respite beds if a 24-hour secure setting is not needed. They provide short-term wraparound services and case management linking to outpatient resources, such as in-home and other intensive services. They can arrange for quick outpatient psychiatric assessment by child psychiatrists employed at the county mental health agency. With these crisis and emergency services, the county has been able to decrease inpatient admissions dramatically [13]. Another model for mobile crisis services is the youth emergency services program in New York, which has demonstrated prevention of emergency room visits and out-of-home placements in evaluation studies [14]. Home-based interventions Several home-based interventions specifically address the ecologic context of children’s mental health crises. Multisystemic therapy (MST) is a family- and community-based intervention developed for antisocial youth at high risk of outof-home placement [15]. MST draws on systems and social ecologic theories, which posit that individual development and behavior are actively influenced by interconnected social systems, both familial and extrafamilial (eg, school, peers, community, cultural institutions). MST identifies and addresses the multiple risk and protective factors that operate in these systems to lower the youth’s risk for out-of-home placement and serious delinquency. Consistent with ecologic theory, treatment is individualized and delivered in the youth’s natural environment. MST is a time-limited intervention implemented for 3 to 5 months per family. Therapists work with four to five families at a time, offering treatment at times that are convenient for the family. Frequency of treatment is determined by individual need and response to treatment. Specific MST interventions are problem focused and chosen from those with empirical support. In multiple randomized, controlled studies, MST has been shown to reduce out-of-home placement and recidivism rates in youth with serious antisocial behavior [16]. MST also has been modified for use with youths who present with psychiatric emergencies. In a randomized, controlled trial that compared MST A.J. Pumariega, N.C. Winters / Child Adolesc Psychiatric Clin N Am 12 (2003) 779–793 785 with hospitalization, MST had comparable effectiveness to psychiatric hospitalization in reducing externalizing and internalizing symptoms and was able to prevent hospitalization in 57% of the participants [17,18]. The authors noted that additional clinical resources, especially child and adolescent psychiatrists, had to be added to the MST intervention for this severely disturbed population. The Yale Intensive In-home Child and Adolescent Psychiatric Service is a home-based, intensive intervention for children and adolescents with serious emotional disturbance who are at risk for psychiatric hospitalization, are unable to benefit from traditional outpatient treatment, are returning home from psychiatric hospitalization, or are unable to be discharged from a psychiatric hospital [19]. The Yale Intensive In-home Child and Adolescent Psychiatric Service makes use of a consistent treatment team to provide comprehensive assessments, case management, individual and family treatment, and crisis intervention. Intervention is informed by a synthesis of the medical model, developmental psychopathology, systems theory, and wraparound concepts. Although no controlled trials have yet been reported for the Yale Intensive In-home Child and Adolescent Psychiatric Service, it is a promising home-based intervention. A similar program, the homebased crisis intervention program in New York, provides in-home short-term intensive emergency services as an alternative to traditional emergency services or hospitalization. Data on this program from a sample of more than 700 youth served over a 4-year period show that, after an average service episode of 36 days, more than 95% of youth served were enrolled in other less restrictive services [20]. Therapeutic foster homes Therapeutic foster care is a form of foster care that provides intensive support and treatment services in a foster home placement that provides a nurturing environment. Foster parents are trained in the emotional and behavioral management of children and youth with severe emotional and behavioral problems. Therapeutic foster homes usually have a low census, usually only one to two children or youth. Case managers who oversee these homes also have low caseloads, which allows them provide more oversight, training, and care coordination to therapeutic foster parents. These services may include in-home interventions or crisis interventions. Four randomized, controlled studies of therapeutic foster care programs have been conducted, and they demonstrated that therapeutic foster care improved behavior, decreased the use of institutional care, and lowered costs compared with other settings for previously hospitalized youth [21 –23]. In a review of 18 reports of uncontrolled trials, Kutash and Rivera [24] found that 60% to 90% of youth treated in therapeutic foster home were discharged into less restrictive settings, with most youth able to remain in these settings for substantial periods of time. Partial hospitalization and day treatment Day treatment programs are designed to be more intensive than traditional outpatient services but less restrictive than inpatient care. These programs may be 786 A.J. Pumariega, N.C. Winters / Child Adolesc Psychiatric Clin N Am 12 (2003) 779–793 located in schools, hospitals, clinics, or other community settings. They offer a range of services, including individual, family, and group therapy, behavioral programming, and educational interventions. Children and youth can spend up to 8 hours a day in these programs and are able to return home in the evening (or can be placed in foster homes if necessary). Day treatment programs are used as alternatives to hospitalization for children and youth with crises who require significant intervention but can be managed outside of the hospital. For other youth, day treatment programs may serve as a transition from the hospital back to a community setting and community-based treatments. Most studies on day treatment programs show positive results; most are uncontrolled but a few are controlled. These studies show an improvement in youth behavioral symptoms and family functioning, and more costly and restrictive services (inpatient and residential) were reduced [25,26]. Level of care determination: CALOCUS In this era of decreasing resources, providing the right level of care to youth who experience mental health crises has become increasingly important. Objective methods for determining level of care needs are essential in helping clinicians to make these often difficult decisions. The CALOCUS is one such tool that assesses six clinical domains relevant to treatment planning: (1) risk of harm, (2) functional status, (3) comorbidity, (4) recovery environment (including environmental stress and environmental support), (5) resiliency and treatment history, and (6) treatment acceptance and engagement. The CALOCUS conceptualizes level of care as service intensity, as opposed to the more traditional concept of placement setting. It outlines different mechanisms for achieving each level of care using communitybased and wraparound services. For example, residential treatment level care might be achieved through a combination of intensive home-based services, respite care, and family-centered wraparound interventions. The initial psychometric data on CALOCUS are particularly promising. On a national multisite trial, it has shown high levels of reliability that do not vary significantly with the level of training and experience of the user. It also has demonstrated good reliability when compared with the Children’s Global Assessment Scale and the Child and Adolescent Functional Assessment Scale, especially the subscales that are related to child functionality [27]. Other field trials are currently underway, but the CALOCUS is already in use in many clinical settings and public mental health systems. It is recommended for more frequent re-administration with children in crisis or at high levels of care to determine acute level of care needs and the rapid changes in such needs on the implementation of treatment interventions [28]. Preventive services Preventive interventions have developed an impressive evidence base over the past two decades. They have two primary areas of focus: (1) long-term prevention A.J. Pumariega, N.C. Winters / Child Adolesc Psychiatric Clin N Am 12 (2003) 779–793 787 with high-risk children and youth through early infant and childhood interventions and (2) short-term prevention of highly disruptive and dangerous behaviors, such as violence and suicide. Early infant and childhood interventions have proven to be effective in the prevention of conduct disturbances among the children of economically disadvantaged first-time mothers, such as the Elmira project [29], and prevention of abuse among the children of mothers reported for child abuse and neglect, such as the New Orleans programs by Zeanah et al [30]. School-based intervention projects, such as the Primary Mental Health Project, with children from grades K through 3 [31], school- and community-based interventions developed for youth at risk of suicide and self-injurious behaviors, [32 – 34], and school- and community-based preventive interventions for youth at risk of violent behaviors [35] have demonstrated effectiveness in reducing highrisk behaviors that contribute to child and adolescent mental health crises. Barriers and challenges to community-based approaches to child crisis and emergency services Practitioner issues Some barriers to an effective system of care orientation originate in practitioner attitudes. There is the inertia and bias toward addressing emergencies and crises in a centralized ‘‘specialized’’ location to where the child and family must be brought for assessment, intervention, or disposition. Some of this stems from real fears around risks and liability, some from the comfort with staying in the ‘‘office’’ or primary mental health setting. It is often harder to address crises outside of the child and family’s natural setting, however, with lack of access to critical observational information and critical natural supports that could help resolve the crisis. Another point of resistance arises from lack of practitioner skills in crisis intervention or not being able to mobilize the most experienced clinicians to the field to deal with the most difficult situations. The latter problems have been resolved by the greater availability of expert consultation by phone or even by mobile telecommunication and by better training in ecologic model and wraparound approaches. System organization issues The strengths of true community-based crisis services are the 24-hour, 7-dayper-week availability, the ability to go to where the children and adolescents are, and the availability of mental health-trained staff to perform assessment and short-term crisis intervention. Also important is the ability to link to intensive community-based interventions. Underuse of hospitalization is a possible risk in community-based approaches, however, particularly in settings in which the wraparound philosophy is associated with ‘‘anti-hospital’’ attitudes or is used to rationalize not spending the money to hospitalize. There also is the risk of not 788 A.J. Pumariega, N.C. Winters / Child Adolesc Psychiatric Clin N Am 12 (2003) 779–793 having adequate resources for emergency medical evaluation (eg, physical examinations, laboratory tests to rule out drug toxicity or medical causes) or limited availability of psychiatric hospitalization for patients who need hospitalization. It is important that medical and developmental perspectives are integrated into the community-based treatment model and that psychiatric leadership and supervision are available to develop the most clinically appropriate plan for the individual child or adolescent. System pressures are available to minimize the use of resources by resisting the deployment of crisis intervention services on site and centralizing these for greater economies of scale. The savings from the latter often can be offset by the limited options available when dealing with a mental health crisis around a child out of the context of the family and community, in which the only option available is often out-of-home removal (which ends up being the most costly option in the long run). The role of managed care Managed care and organized systems of care share the objective of minimizing the unnecessary use of restrictive and expensive services. Savings then can be reinvested in community-based services, thus providing an opportunity to develop an organized system of crisis services. Although this is commonly stated as the primary aim of managed care, managed care implementations have been uneven in developing organized crisis systems for children and adolescents. There have been several barriers. Early managed care models based on restriction of benefits led to underuse and, paradoxically, overuse of psychiatric hospitalization. An example of the latter was in Tennessee’s TennCare, in which inadequate risk adjustment for funding of services to the seriously mentally ill led to loss of outpatient services and resulted in increased use of hospitalization [36]. Managed care models designed primarily for adult mental health needs have not invested in development of wraparound services or in the interagency collaborative structures necessary for children in crisis situations. Strength-based approaches central to the wraparound model do not fit easily into the medical necessity criteria used in managed care as stipulated by federal Medicaid regulations. The medical model continues to operate in many managed care systems, limiting more family-centered or ecologic approaches [18,37]. Even when managed care is able to lower hospital use, it is not always clear that quality of care is improved. In 1992, Massachusetts implemented a private managed care program for its Medicaid population. Several studies examined the impacts of private managed care specifically on emergency services for children and adolescents. Nicholson et al [38] reported that the percentage of dispositions to home and psychiatric hospitals decreased after managed Medicaid. These decreases were offset by a significant increase in referral to crisis stabilization settings, such as 24-hour, staffed, community-based services, acute residential treatment programs, and respite care. Callahan et al [39] also found significant reductions after the managed Medicaid implementation. For children and adolescents, however, they found A.J. Pumariega, N.C. Winters / Child Adolesc Psychiatric Clin N Am 12 (2003) 779–793 789 increased rates of readmission within a 30-day period. These findings raise questions as to whether the right children and adolescents are being hospitalized and whether the decreased hospitalization and shorter lengths of stay may result in longer term costs if children’s needs are not being met with an appropriately timed hospital admission. As suggested by Nicholson et al [40], to really assess quality of care, outcomes should be assessed using a framework of criteria based on the Child and Adolescent Service System Programs (CASSP) concepts of individualized, least restrictive, and community-based care. Case studies Two case examples illustrate the contextual nature of mental health crises in children and the benefit of community-based approaches. The first case, which presented to the pediatric emergency department of a university-based hospital, illustrates the traditional approach. The second case involves a youth who was a client in a wraparound program. It illustrates a more proactive, home-based approach consistent with the system of care model. Case 1: Jimmy Rose Jimmy, a 9-year-old boy in foster care, was brought by his foster father to a pediatric emergency department late on a Sunday evening. For 3 weeks, Jimmy had shown an escalating pattern of aggression in school and at home and was threatening to kill himself and his foster siblings. His foster parents felt they could no longer manage his behavior after Jimmy revealed his plan to hurt someone in the home with a weapon he had fashioned. Jimmy had been removed from the care of his biological mother because of neglect 9 month earlier and was placed in a foster home in which 14 people were living. Jimmy’s difficulties had escalated since his biological mother missed a planned visit after having no contact with him for a long period of time. A counselor in a community mental health agency had followed Jimmy for depression since his placement in foster care. During this period, his primary care physician prescribed him an antidepressant. A psychiatrist had not yet seen him; his first psychiatric appointment at the mental health agency was still 3 weeks away when he presented to the emergency department. As Jimmy’s threats and aggressive behavior escalated, the counselor and child welfare worker tried to manage his behavior on an outpatient basis. They had discussed the possibility of a psychiatric admission but had not yet initiated a referral. When Jimmy presented to the emergency department, neither the child welfare worker nor the mental health agency was available for consultation. The emergency department was located in a hospital without its own child psychiatric unit, and Jimmy was placed on a general pediatric unit, where he received no mental health services, until a bed in a community hospital became available. While on the medical unit, Jimmy voiced repeated complaints about his living situation and resentment toward the other foster children in the home. 790 A.J. Pumariega, N.C. Winters / Child Adolesc Psychiatric Clin N Am 12 (2003) 779–793 This case example illustrates the consequences of a mental health system with inadequate crisis services for children. None of the systems involved with Jimmy— child welfare, mental health, and special education—had mobilized an intensive response to his escalating symptoms. The mental health agency continued to offer standard office-based outpatient services and failed to make psychiatric assessment and treatment available as his symptoms became more serious. His mental health provider had no crisis services available over the weekend, and Jimmy was brought to a hospital-based emergency department that was not well equipped to perform crisis intervention. A different outcome might have resulted if Jimmy lived in a community with an organized system for responding to children’s mental health emergencies. As Jimmy’s symptoms worsened, he would have benefited from short-term case management similar to the Milwaukee mobile urgent treatment teams model, linking him to psychiatric evaluation and intensive in-home services to address the contextual issues underlying the worsening of his symptoms. The escalation of Jimmy’s symptoms after a missed visit with his mother is not atypical for children in foster care, many of whom experience placement disruptions caused by attachment problems and emotional and behavioral problems [41]. In-home crisis services for Jimmy would have explored whether these foster parents were able to meet Jimmy’s emotional needs, given the large number of children in the home. An emergency respite bed for Jimmy would have been accessed while these and other contextual factors were being addressed. Case 2: Gina Tran Gina, the daughter of Southeast Asian immigrants, had remained in her home country to live with elderly grandparents when the rest of the family emigrated. She joined her family in the United States 4 years later when she was 13 years old. Gina’s adjustment to rejoining her family in a new country was not an easy one. She experienced significant conflict with her uncle, who was the father figure of the extended family. At age 14, she was hospitalized after threatening to kill herself after an argument with her uncle. While in the hospital, Gina was diagnosed with depression and parent-child relational problems; she was discharged to a short-term residential treatment program. After leaving residential treatment, Gina was enrolled in a case management program that offered wraparound services. In-home therapy services were started, but the family was slow to engage in treatment because they were not comfortable with open discussion of conflict. Several months later, in the context of another serious argument with her uncle, Gina ran away from home. She was found later that night in the neighborhood, again threatening to kill herself. Her family once again brought her to the local emergency department. Although the emergency department staff felt that Gina needed hospitalization because of her significant suicidal ideation, the emergency department staff contacted the case manager before deciding on a disposition. A.J. Pumariega, N.C. Winters / Child Adolesc Psychiatric Clin N Am 12 (2003) 779–793 791 The case manager, aware of the role that family dynamics played in the crisis, used flexible funds to place Gina in an emergency respite bed for 5 days in lieu of another hospitalization. The in-home therapist received consultation from another clinician experienced in working with Gina’s ethnic group to help her understand the cultural factors underlying the family dysfunction. The therapist’s increased cultural awareness helped the family to become more engaged in treatment. The therapist also consulted with school personnel, who reported that Gina’s extreme fear of being disciplined at home if she received poor grades was interfering with her ability to be academically productive and develop normal peer relationships. They responded by putting her on an individualized education plan with added emotional and behavioral support to help with her anxiety about school performance. The in-home therapist and case manager then worked with the family to identify natural supports for future respite needs. In this case example, the availability of intensive case management, timely access to an emergency respite bed, and wraparound interventions were central to meeting the needs of Gina and her family during this emergency. With culturally competent in-home therapy services, the complex cultural issues that contributed to Gina’s emergency presentations were sorted out, and further emergencies and hospitalizations were averted. Summary Community-based systems of care offer some promising ecologically based approaches to child psychiatric emergencies. More community-based effectiveness research is needed on child and adolescent mental health crisis services. To meet the needs of real-world children with serious emotional disorders and their families, however, research should include integration of multiple evidence-based modalities (such as psychopharmacology, behavioral, and cognitive approaches) and the effectiveness of single modalities. Funding priorities in mental health systems also should shift significantly to support community-based crisis services over more restrictive approaches that have a less solid evidence base. References [1] Gutterman EM, Markowitz JS, LoConte JS, Beier J. 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